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• W1965629088 abstract "A technique is described for correction of mitral regurgitation when the posterior leaflet has a reasonable length (approximately 10 mm), but its movements are limited by thickened and short chords. To avoid further retraction when a band or a ring is positioned to force leaflets coaptation, native chords are replaced by artificial chords (leaving 10 mm of extra length), which are then cut. In 6 patients, after 6 months of follow-up, the results are good. A technique is described for correction of mitral regurgitation when the posterior leaflet has a reasonable length (approximately 10 mm), but its movements are limited by thickened and short chords. To avoid further retraction when a band or a ring is positioned to force leaflets coaptation, native chords are replaced by artificial chords (leaving 10 mm of extra length), which are then cut. In 6 patients, after 6 months of follow-up, the results are good. Rheumatic valve disease is often accompanied by severe disease of the subvalvular apparatus, which prevents any possibility of correction. However, in some cases of pure mitral regurgitation (MR), the anterior leaflet is prolapsing for chordal elongation. Conventional techniques can be successfully used, even if durability of the repair can be a concern.In some cases the pathology is mainly on the posterior leaflet (PL), which can be retracted, with lack of tissue. In other cases, the PL is tethered by thickened and short chords, and can be classified as type IIIb mitral regurgitation, according to Carpentier's classification [1Carpentier A. Cardiac valve surgery: the “French correction.”.J Thorac Cardiovasc Surg. 1983; 86: 323-337PubMed Google Scholar]. The anterior leaflet moves normally and its length is adequate, but it appears prolapsing (Fig 1) both for some chordal elongation (if any) and for reduced movement of the PL (pseudoprolapse). Herein, we describe a technique that can be used in such cases to obtain a competent mitral valve.TechniqueThe mitral valve was approached through the interatrial septum. The PL appeared hypomobile, due to short and thick chords (Fig 2A). After having checked the length (approximately 10 mm), artificial chords (2 chords = 1 suture, 4.0 Gore-Tex [Ethicon, Somerville, NJ]) were passed in the appropriate tips of the anterolateral and posteromedial papillary muscles (generally 1 suture for P1, 2 for P2, and 1 for P3). A nerve hook was used to pull up as much as possible of the border of the scallop, and the chords were tied 10 mm over the maximum height reached (Fig 2B). The native chords (both the primary and the secondary ones) were then exposed and cut (Fig 2C). The scallops were preferably sewn together to facilitate the global stability of the leaflet. The mobility and the length of the posterior leaflet were then checked, and, if adequate, the anterior leaflet prolapse (if present) was corrected. Finally a 40-mm band (SMB40 [Sorin Biomedica, Saluggia, Italy]), implanted from trigone to trigone, was used to reduce the annulus and to obtain a good coaptation (Fig 3).Fig 2(A) The short and thickened chords limit the movement of the posterior leaflet. (B) An artificial chord is implanted on the papillary muscle and it is tied 10 mm over the maximum extension of the free border of the leaflet, obtained after having pushed it by means of a nerve hook. (C) The native primary and secondary chords are then cut.View Large Image Figure ViewerDownload (PPT)Fig 3Transesophageal echocardiography. The posterior leaflet is fixed in a vertical position and offers a huge surface of coaptation to the anterior leaflet.View Large Image Figure ViewerDownload (PPT)During 2010, this technique was used in 6 patients (mean age, 23 ± 6; mean ejection fraction: 56% ± 10. In all cases MR was severe. The mean length of the PL at P2 level was 10.2 ± 1.2, being 9 mm only in two cases. None of the cases had diffuse or focal calcification of the PL, which could be a potential contraindication. After surgery, no MR was detected in 5 patients and only 1 showed mild MR. The echocardiographic evidence remained unchanged after a mean follow-up of 6 ± 2 months. The mean effective valvular area was 3.1 ± 0.6 and the mean gradient was 3.5 ± 0.5.CommentSurgery for MR, due to the consequences of rheumatic disease, can be challenging because of the complex pathologic patterns showed by the valvular and subvalvular apparatus [2Kumar S.A. Talwarb S. Saxenab A. Singhc R. Velayoudamb D. Results of mitral valve repair in rheumatic mitral regurgitation.Interactive Cardiovasc Thorac Surg. 2006; 5: 356-361Crossref PubMed Scopus (41) Google Scholar, 3El Oumeiri B. Boodhwani M. Glineur D. et al.Extending the scope of mitral valve repair in rheumatic disease.Ann Thorac Surg. 2009; 87: 1735-1740Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar]. Kalangos and colleagues [4Kalangos A. Beghetti M. Vala D. et al.Anterior mitral leaflet prolapse as a primary cause of pure rheumatic mitral insufficiency.Ann Thorac Surg. 2000; 69: 755-761Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar] reported a series of patients in which MR could possibly be corrected with conventional techniques, and this is the most favorable pattern. When the PL is involved, the surgical strategy includes augmentation of the leaflet with a pericardial patch [5Chauvaud S. Jebara V. Chachques J.C. et al.Valve extension with glutaraldehyde-preserved autologous pericardium Results in mitral valve repair.J Thorac Cardiovasc Surg. 1991; 102: 171-177PubMed Google Scholar, 6Zegdi R. Khabbaz Z. Chauvaud S. Latremouille C. Fabiani J.-N. Deloche A. Posterior leaflet extension with an autologous pericardial patch in rheumatic mitral insufficiency.Ann Thorac Surg. 2007; 84: 1043-1044Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar]. However, when the length of the PL is reasonable (approximately 10 mm) and the hypomobility is mainly related to thick and short chords, the technique described herein can be helpful to make the PL mobile. Suturing the scallops together is useful, as it forces the PL to move as a unique structure in such a way that every segment will support the adjacent one, reducing the margin of error. Reshaping the annulus with a short band will then maintain the PL in vertical position, assuring a long coaptation [7Calafiore A.M. Di Mauro M. Iaco' A.L. et al.Overreduction of the posterior annulus in surgical treatment of degenerative mitral regurgitation.Ann Thorac Surg. 2006; 81: 1310-1316Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar]. Without PL chordal cutting, annuloplasty will increase the tethering of the PL, failing to force the two leaflets to coapt. The decision to tie the artificial chords 10 mm higher than the maximal extension of the stretched leaflet came from clinical experience, but it was somehow arbitrary. In an article of ours [8Calafiore AM, Scandura S, Iacò AL, et al. A simple method to obtain the correct length of the artificial chordae in complex chordal replacement. J Card Surg 1008;23:204-6.Google Scholar], we reported that tying a new chord 5 mm over the maximum extension of a prolapsing segment of the anterior leaflet was enough to reduce its excess of movement. We then thought that as the PL was shorter than normal and tethered by retracted native chords, this extra length (5 mm) had to be doubled to restore a mobility similar to normal. After this reasoning, we tied the new chords 10 mm over the maximal extension of the border, where it was implanted with good echocardiographic results (Fig 3).Being the anatomic pattern of rheumatic MR variable, it is not possible to use a single technique to correct the regurgitation. Posterior chordal cutting, alone or together with other maneuvers, can he helpful to reach this goal. Rheumatic valve disease is often accompanied by severe disease of the subvalvular apparatus, which prevents any possibility of correction. However, in some cases of pure mitral regurgitation (MR), the anterior leaflet is prolapsing for chordal elongation. Conventional techniques can be successfully used, even if durability of the repair can be a concern. In some cases the pathology is mainly on the posterior leaflet (PL), which can be retracted, with lack of tissue. In other cases, the PL is tethered by thickened and short chords, and can be classified as type IIIb mitral regurgitation, according to Carpentier's classification [1Carpentier A. Cardiac valve surgery: the “French correction.”.J Thorac Cardiovasc Surg. 1983; 86: 323-337PubMed Google Scholar]. The anterior leaflet moves normally and its length is adequate, but it appears prolapsing (Fig 1) both for some chordal elongation (if any) and for reduced movement of the PL (pseudoprolapse). Herein, we describe a technique that can be used in such cases to obtain a competent mitral valve. TechniqueThe mitral valve was approached through the interatrial septum. The PL appeared hypomobile, due to short and thick chords (Fig 2A). After having checked the length (approximately 10 mm), artificial chords (2 chords = 1 suture, 4.0 Gore-Tex [Ethicon, Somerville, NJ]) were passed in the appropriate tips of the anterolateral and posteromedial papillary muscles (generally 1 suture for P1, 2 for P2, and 1 for P3). A nerve hook was used to pull up as much as possible of the border of the scallop, and the chords were tied 10 mm over the maximum height reached (Fig 2B). The native chords (both the primary and the secondary ones) were then exposed and cut (Fig 2C). The scallops were preferably sewn together to facilitate the global stability of the leaflet. The mobility and the length of the posterior leaflet were then checked, and, if adequate, the anterior leaflet prolapse (if present) was corrected. Finally a 40-mm band (SMB40 [Sorin Biomedica, Saluggia, Italy]), implanted from trigone to trigone, was used to reduce the annulus and to obtain a good coaptation (Fig 3).Fig 3Transesophageal echocardiography. The posterior leaflet is fixed in a vertical position and offers a huge surface of coaptation to the anterior leaflet.View Large Image Figure ViewerDownload (PPT)During 2010, this technique was used in 6 patients (mean age, 23 ± 6; mean ejection fraction: 56% ± 10. In all cases MR was severe. The mean length of the PL at P2 level was 10.2 ± 1.2, being 9 mm only in two cases. None of the cases had diffuse or focal calcification of the PL, which could be a potential contraindication. After surgery, no MR was detected in 5 patients and only 1 showed mild MR. The echocardiographic evidence remained unchanged after a mean follow-up of 6 ± 2 months. The mean effective valvular area was 3.1 ± 0.6 and the mean gradient was 3.5 ± 0.5. The mitral valve was approached through the interatrial septum. The PL appeared hypomobile, due to short and thick chords (Fig 2A). After having checked the length (approximately 10 mm), artificial chords (2 chords = 1 suture, 4.0 Gore-Tex [Ethicon, Somerville, NJ]) were passed in the appropriate tips of the anterolateral and posteromedial papillary muscles (generally 1 suture for P1, 2 for P2, and 1 for P3). A nerve hook was used to pull up as much as possible of the border of the scallop, and the chords were tied 10 mm over the maximum height reached (Fig 2B). The native chords (both the primary and the secondary ones) were then exposed and cut (Fig 2C). The scallops were preferably sewn together to facilitate the global stability of the leaflet. The mobility and the length of the posterior leaflet were then checked, and, if adequate, the anterior leaflet prolapse (if present) was corrected. Finally a 40-mm band (SMB40 [Sorin Biomedica, Saluggia, Italy]), implanted from trigone to trigone, was used to reduce the annulus and to obtain a good coaptation (Fig 3). During 2010, this technique was used in 6 patients (mean age, 23 ± 6; mean ejection fraction: 56% ± 10. In all cases MR was severe. The mean length of the PL at P2 level was 10.2 ± 1.2, being 9 mm only in two cases. None of the cases had diffuse or focal calcification of the PL, which could be a potential contraindication. After surgery, no MR was detected in 5 patients and only 1 showed mild MR. The echocardiographic evidence remained unchanged after a mean follow-up of 6 ± 2 months. The mean effective valvular area was 3.1 ± 0.6 and the mean gradient was 3.5 ± 0.5. CommentSurgery for MR, due to the consequences of rheumatic disease, can be challenging because of the complex pathologic patterns showed by the valvular and subvalvular apparatus [2Kumar S.A. Talwarb S. Saxenab A. Singhc R. Velayoudamb D. Results of mitral valve repair in rheumatic mitral regurgitation.Interactive Cardiovasc Thorac Surg. 2006; 5: 356-361Crossref PubMed Scopus (41) Google Scholar, 3El Oumeiri B. Boodhwani M. Glineur D. et al.Extending the scope of mitral valve repair in rheumatic disease.Ann Thorac Surg. 2009; 87: 1735-1740Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar]. Kalangos and colleagues [4Kalangos A. Beghetti M. Vala D. et al.Anterior mitral leaflet prolapse as a primary cause of pure rheumatic mitral insufficiency.Ann Thorac Surg. 2000; 69: 755-761Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar] reported a series of patients in which MR could possibly be corrected with conventional techniques, and this is the most favorable pattern. When the PL is involved, the surgical strategy includes augmentation of the leaflet with a pericardial patch [5Chauvaud S. Jebara V. Chachques J.C. et al.Valve extension with glutaraldehyde-preserved autologous pericardium Results in mitral valve repair.J Thorac Cardiovasc Surg. 1991; 102: 171-177PubMed Google Scholar, 6Zegdi R. Khabbaz Z. Chauvaud S. Latremouille C. Fabiani J.-N. Deloche A. Posterior leaflet extension with an autologous pericardial patch in rheumatic mitral insufficiency.Ann Thorac Surg. 2007; 84: 1043-1044Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar]. However, when the length of the PL is reasonable (approximately 10 mm) and the hypomobility is mainly related to thick and short chords, the technique described herein can be helpful to make the PL mobile. Suturing the scallops together is useful, as it forces the PL to move as a unique structure in such a way that every segment will support the adjacent one, reducing the margin of error. Reshaping the annulus with a short band will then maintain the PL in vertical position, assuring a long coaptation [7Calafiore A.M. Di Mauro M. Iaco' A.L. et al.Overreduction of the posterior annulus in surgical treatment of degenerative mitral regurgitation.Ann Thorac Surg. 2006; 81: 1310-1316Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar]. Without PL chordal cutting, annuloplasty will increase the tethering of the PL, failing to force the two leaflets to coapt. The decision to tie the artificial chords 10 mm higher than the maximal extension of the stretched leaflet came from clinical experience, but it was somehow arbitrary. In an article of ours [8Calafiore AM, Scandura S, Iacò AL, et al. A simple method to obtain the correct length of the artificial chordae in complex chordal replacement. J Card Surg 1008;23:204-6.Google Scholar], we reported that tying a new chord 5 mm over the maximum extension of a prolapsing segment of the anterior leaflet was enough to reduce its excess of movement. We then thought that as the PL was shorter than normal and tethered by retracted native chords, this extra length (5 mm) had to be doubled to restore a mobility similar to normal. After this reasoning, we tied the new chords 10 mm over the maximal extension of the border, where it was implanted with good echocardiographic results (Fig 3).Being the anatomic pattern of rheumatic MR variable, it is not possible to use a single technique to correct the regurgitation. Posterior chordal cutting, alone or together with other maneuvers, can he helpful to reach this goal. Surgery for MR, due to the consequences of rheumatic disease, can be challenging because of the complex pathologic patterns showed by the valvular and subvalvular apparatus [2Kumar S.A. Talwarb S. Saxenab A. Singhc R. Velayoudamb D. Results of mitral valve repair in rheumatic mitral regurgitation.Interactive Cardiovasc Thorac Surg. 2006; 5: 356-361Crossref PubMed Scopus (41) Google Scholar, 3El Oumeiri B. Boodhwani M. Glineur D. et al.Extending the scope of mitral valve repair in rheumatic disease.Ann Thorac Surg. 2009; 87: 1735-1740Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar]. Kalangos and colleagues [4Kalangos A. Beghetti M. Vala D. et al.Anterior mitral leaflet prolapse as a primary cause of pure rheumatic mitral insufficiency.Ann Thorac Surg. 2000; 69: 755-761Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar] reported a series of patients in which MR could possibly be corrected with conventional techniques, and this is the most favorable pattern. When the PL is involved, the surgical strategy includes augmentation of the leaflet with a pericardial patch [5Chauvaud S. Jebara V. Chachques J.C. et al.Valve extension with glutaraldehyde-preserved autologous pericardium Results in mitral valve repair.J Thorac Cardiovasc Surg. 1991; 102: 171-177PubMed Google Scholar, 6Zegdi R. Khabbaz Z. Chauvaud S. Latremouille C. Fabiani J.-N. Deloche A. Posterior leaflet extension with an autologous pericardial patch in rheumatic mitral insufficiency.Ann Thorac Surg. 2007; 84: 1043-1044Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar]. However, when the length of the PL is reasonable (approximately 10 mm) and the hypomobility is mainly related to thick and short chords, the technique described herein can be helpful to make the PL mobile. Suturing the scallops together is useful, as it forces the PL to move as a unique structure in such a way that every segment will support the adjacent one, reducing the margin of error. Reshaping the annulus with a short band will then maintain the PL in vertical position, assuring a long coaptation [7Calafiore A.M. Di Mauro M. Iaco' A.L. et al.Overreduction of the posterior annulus in surgical treatment of degenerative mitral regurgitation.Ann Thorac Surg. 2006; 81: 1310-1316Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar]. Without PL chordal cutting, annuloplasty will increase the tethering of the PL, failing to force the two leaflets to coapt. The decision to tie the artificial chords 10 mm higher than the maximal extension of the stretched leaflet came from clinical experience, but it was somehow arbitrary. In an article of ours [8Calafiore AM, Scandura S, Iacò AL, et al. A simple method to obtain the correct length of the artificial chordae in complex chordal replacement. J Card Surg 1008;23:204-6.Google Scholar], we reported that tying a new chord 5 mm over the maximum extension of a prolapsing segment of the anterior leaflet was enough to reduce its excess of movement. We then thought that as the PL was shorter than normal and tethered by retracted native chords, this extra length (5 mm) had to be doubled to restore a mobility similar to normal. After this reasoning, we tied the new chords 10 mm over the maximal extension of the border, where it was implanted with good echocardiographic results (Fig 3). Being the anatomic pattern of rheumatic MR variable, it is not possible to use a single technique to correct the regurgitation. Posterior chordal cutting, alone or together with other maneuvers, can he helpful to reach this goal." @default.
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• W1965629088 title "Posterior Chordal Cutting in Rheumatic Mitral Regurgitation Due to Hypomobility of the Posterior Leaflet" @default.
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