Procedure

Chordal transfer for repair of anterior leaflet prolapse

Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA

^* Corresponding author: ^* Tel.: +1-216-445-8841, fax: +1-216-444-0777. Email: gillinom{at}ccf.org

	Summary

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Chordal transfer is a reliable technique for correction of anterior leaflet prolapse. In most cases, normal chordae and a strip of leaflet tissue are transferred from the posterior leaflet to the free edge of unsupported anterior leaflet; the posterior leaflet is repaired as after a quadrangular resection with either a sliding repair or a standard repair. Occasionally, secondary anterior leaflet chordae may be transferred from the undersurface of the anterior leaflet to its unsupported free edge, effecting a rapid and effective repair. After chordal transfer, annuloplasty completes the mitral valve repair.

Key Words: Mitral valve repair • mitral prolapse • anterior leaflet • mitral valve surgery • chordal transfer

	Introduction

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Although repair is feasible in approximately 95% of patients with degenerative mitral valve disease, correction of anterior leaflet prolapse is more challeng-ing than is reconstruction of the posterior leaflet [1, 2]. In recent years, however, there has been considerable progress in the development of techniques for anterior leaflet repair. Surgeons have reported good results with multiple strategies, including chordal transfer, creation of artificial chordae, limited anterior leaflet resection, and the edge-to-edge technique [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14]. In order to ensure the ability to correct anterior leaflet prolapse in a wide variety of situations, the surgeon should master more than one of these techniques. At The Cleveland Clinic, we have extensive experience with chordal transfer for correction of anterior leaflet prolapse, reserving a modified edge-to-edge technique and creation of artificial chordae for selected situations. Introduced by Carpentier, chordal transfer provides a secure method for anterior leaflet repair with proven long-term durability [15].

	Surgical technique

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After induction of general endotracheal anesthesia, a transesophageal echo probe is placed. A detailed echocardiographic assessment is performed, including careful examination of the mitral valve to determine the severity and mechanism(s) of mitral regurgitation (Video 1).

Click on image to view video Video 1 Transesophageal echo demonstrating isolated anterior leaflet prolapse.

View larger version (122K): [in this window] [in a new window]   Schematic 1 Partial upper sternotomy ‘T'd’ into left 4th intercostals space.

Chordal transfer: posterior leaflet to anterior leaflet
This technique is used when a large region of the anterior leaflet is unsupported and there are insufficient secondary anterior leaflet chordae available for transfer (Videos 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14).

Click on image to view video Video 2 Identification of unsupported region of anterior leaflet. The region of unsupported anterior leaflet is identified, and stay sutures passed around normal anterior leaflet chordae on each side of the elongated or ruptured chordae. These stay sutures identify the region of unsupported anterior leaflet.

Click on image to view video Video 3 Determination of segment of posterior leaflet to transfer. The next step is to identify normal chordae to be transferred to the free edge of the anterior leaflet. This is accomplished by identifying a normal segment of posterior leaflet opposite the unsupported region of the anterior leaflet; this is generally the middle scallop, or P2 segment, of the posterior leaflet. This portion of the posterior leaflet will be transferred to the anterior leaflet. Sutures are passed around the first chordae that will be left with the posterior leaflet.

Click on image to view video Video 4 Beginning of chordal transfer. 4-0 sutures are passed from the anterior leaflet to the posterior leaflet at the edges of the planned chordal transfer.

Click on image to view video Video 5 Detachment of posterior leaflet for chordal transfer. The segment of posterior leaflet with its attached chordae is detached from the posterior annulus. Excess leaflet tissue may be trimmed from the piece of posterior leaflet to be transferred.

Click on image to view video Video 6 Completion of chordal transfer. The segment of posterior leaflet and its attached chordae is affixed to the free edge of the anterior leaflet with multiple, interrupted 4-0 braided sutures.

Click on image to view video Video 7 Posterior leaflet detachment for sliding repair. The extent of posterior leaflet resection mandates a sliding repair for reconstruction of the posterior leaflet. The posterior leaflet is detached from the annulus from commissure to commissure.

Click on image to view video Video 8 Annuloplasty suture placement. Annuloplasty sutures are easily placed after detachment of the posterior leaflet.

Click on image to view video Video 9 Reattachment of posterior leaflet to annulus. The posterior leaflet remnants are reattached to the mitral annulus. Spacing is adjusted to account for the resected area. If posterior leaflet height is greater than 1.5 cm, deep bites in the posterior leaflet reduce the height and eliminate the risk of SAM.

Click on image to view video Video 10 Reapproximation of posterior leaflet remnants. The 2 posterior leaflet remnants are affixed to each other with a running 5-0 braided suture.

Click on image to view video Video 11 Sizing annuloplasty band. The annuloplasty band is sized according to the surface area of the anterior leaflet.

Click on image to view video Video 12 Placement of annuloplasty band.

Click on image to view video Video 13 Static valve testing. Valve competence is assessed by injecting saline into the left ventricle and, simultaneously, administering antegrade cardioplegia to pressurize the left ventricle.

Click on image to view video Video 14 Post-repair transesophageal echocardiogram. The post-repair transesophageal echocardiogram confirms repair success, with only trace residual mitral regurgitation.

View larger version (24K): [in this window] [in a new window]   Schematic 2 Repair of limited anterior leaflet prolapse by transfer of anterior leaflet secondary chord.

	Results

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	References

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1. Gillinov AM, Cosgrove DM, Blackstone EH, Diaz R, Arnold JH, Lytle BW, Smedira NG, Sabik JF, McCarthy PM, Loop FD. Durability of mitral valve repair for degenerative disease. J Thorac Car-diovasc Surg 1998;116:734–743[Abstract/Free Full Text]
2. Smedira NG, Selman R, Cosgrove DM, McCarthy PM, Lytle BW, Taylor PC, Apperson-Hansen C, Stewart RW, Loop FD. Repair of anterior leaflet prolapse: chordal transfer is superior to chordal shortening. J Thorac Cardiovasc Surg 1996; 112:287–292[Abstract/Free Full Text]
3. Sousa Uva M, Grare P, Jebara V, Fuzelier JF, Portoghese M, Acar C, Relland J, Mihaileanu S, Fabiani JN, Carpentier A. Transposition of chordae in mitral valve repair. Mid-term results. Circulation 1993:88:II35–38
4. Salati M, Scrofani R, Fundaro P, Cialfi A, Santoli C. Correction of anterior mitral prolapse. Results of chordal transposition. J Thorac Cardiovasc Surg 1992;104:1268–1273[Abstract]
5. Salati M, Moriggia S, Scrofani R, Santoli C. Chordal transposition for anterior mitral prolapse: early and long-term results. Eur J Cardiothorac Surg 1997;11:268–273[Abstract]
6. Duran CG. Repair of anterior mitral leaflet chordal rupture or elongation (the flip-over technique). J Card Surg 1986;1:161–166[Medline]
7. David TE, Omran A, Armstrong S, Sun Z, Ivanov J. Long-term results of mitral valve repair for myxomatous disease with and without chordal replacement with expanded polytetrafluoro- ethylene sutures. J Thorac Cardiovasc Surg 1998;115:1279–1286[Abstract/Free Full Text]
8. Von Oppell UO, Mohr FW. Chordal replacement for both minimally invasive and conventional mitral valve surgery using premeasured gore-tex loops. Ann Thorac Surg 2000;70:2166–2168[Abstract/Free Full Text]
9. Zussa C. Artificial chordae. J Heart Valve Dis 1995:4:S249–S256
10. El Khoury G, Noirhomme P, Verhelst R, Rubay J, Dion R. Surgical repair of the prolapsing anterior leaflet in degenerative mitral valve disease. J Heart Valve Dis 2000;9:75–81[Medline]
11. Fucci C, Sandrelli L, Pardini A, Torracca L, Ferrari M, Alfieri O. Improved results with mitral valve repair using new surgical techniques. Eur J Cardiothorac Surg 1995;9:621–627[Abstract]
12. Alfieri O, Maisano F, DeBonis M, Stefano PL, Torracca L, Oppizzi M, La Canna G. The double-orifice technique in mitral valve repair: A simple solution for complex problems. J Thorac Cardiovasc Surg 2001;122:674–681[Abstract/Free Full Text]
13. Spencer FC, Galloway AC, Grossi EA, Ribakove GH, Delianides J, Baumann FG, Colvin SB. Recent developments and evolving techniques of mitral valve reconstruction. Ann Thorac Surg 1998;65:307–313[Abstract/Free Full Text]
14. Grossi EA, Galloway AC, LeBoutillier M 3rd, Steinberg B, Baumann FG, Delianides J, Spencer FC, Colvin SB. Anterior leaflet procedures during mitral valve repair do not adversely influence long-term outcome. J Am Coll Cardiol 1995;25:134–136[Abstract]
15. Carpentier A. Cardiac valve surgery – the "French correction". J Thorac Cardiovasc Surg 1983; 86:323–337[Medline]
16. Cosgrove DM, Gillinov AM. Partial sternotomy for mitral valve operations. Operative Techniques in Cardiac and Thoracic Surgery 1998;3:62–72
17. Perier P, Stumpf J, Gotz C, Lakew F, Schneider A, Clausnizer B, Hacker R. Valve repair for mitral regurgitation caused by isolated prolapse of the posterior leaflet. Ann Thorac Surg 1997;64:445–50[Abstract/Free Full Text]
18. Gillinov AM, Cosgrove DM, Lytle BW, Taylor PC, Stewart RW, McCarthy PM, Smedira NG, Muehrcke DD, Apperson-Hansen C, Loop FD. Reoperation for failure of mitral valve repair. J Thorac Cardiovasc Surg 1997;113:467–475[Abstract/Free Full Text]