Replacement of chordae tendineae with polytetrafluoroethylene (PTFE) sutures in mitral valve repair: early and long-term results (original) (raw)
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Chordae replacement versus leaflet resection in minimally invasive mitral valve repair
Annals of cardiothoracic surgery, 2013
For many years, the quadrangular resection technique first proposed by Carpentier has become the gold standard for repair of posterior leaflet prolapse of the mitral valve (MV). Although this "resection" technique and its modifications are safe and very effective, they do not respect the anatomy of the MV and the physiological role of the posterior leaflet. Therefore some new techniques, aiming to preserve MV leaflets to a different extent, have been proposed. With the use of expanded polytetrafluoroethylene (ePTFE), neochordae leaflet preserving techniques for posterior MV prolapse treatment have emerged. The aim of these techniques is to support the free edge of the prolapsing segments and thereby restore the physiologic function of the MV. A simplified modification of this technique using premeasured ePTFE loops ("loop technique") was successfully introduced to ease the implantation of neochordae, especially in the setting of minimally invasive MV surgery. Whi...
The Annals of Thoracic Surgery, 2012
Mitral valve repair is considered the procedure of choice for correcting mitral regurgitation in myxomatous disease, providing long-term results that are superior to those with valve replacement. The use of artificial chordae to replace elongated or ruptured chordae responsible for mitral valve prolapse and severe mitral regurgitation has been the subject of extensive experimental work to define feasibility, reproducibility, and effectiveness of this procedure. Artificial chordae made of autologous or xenograft pericardium have been replaced by chordae made of expanded polytetrafluoroethylene (PTFE), a ma-terial with the unique property of becoming covered by host fibrosa and endothelium. The use of artificial chordae made of PTFE has been validated clinically over the past 2 decades and has been an increasing component of the surgical armamentarium for mitral valve repair. This article reviews the history, details of the relevant surgical techniques, long-term results, and fate of artificial chordae in mitral reconstructive surgery. (Ann Thorac Surg 2012;93:684 -91) T here is strong evidence that mitral valve repair for degenerative valve disease is superior to mitral valve replacement [1, 2]. Very long-term results of mitral valve repair have shown that this procedure, maintaining both valvular tissue and the subvalvular apparatus, has a lower operative mortality, with better preservation of left ventricular function and superior survival rates, than does prosthetic valve replacement [3]. These results suggest an indication for early mitral valve repair in asymptomatic patients and in patients without signs of left ventricular dysfunction [4]. Techniques for mitral valve repair have been popularized by the pioneering work of Carpentier [5], who described various methods of mitral valve reconstruction based on a new pathophysiologic classification. Among these methods, particular attention was given to the treatment of elongated or ruptured chordae, which is a common pathologic finding in patients with both fibroelastic deficiency and those with more complex Barlow disease of the mitral valve [6]. The techniques of leaflet fixation on secondary chordae, chordal transposition, and chordal shortening that Carpentier proposed [5] were undoubtedly appealing, but also technically quite demanding and not easily reproducible. Furthermore the reported results generated conflicting opinions about the effectiveness of these techniques [7, 8], particularly because the repaired chordae are still diseased and may again elongate or rupture with time, leading to recurrent mitral regurgitation. For this reason, there has been recent renewed interest in the use of artificial sutures to replace diseased native mitral chordae. This paper reviews the history, surgical techniques, and long-term results for such chordal replacement, and discusses the fate of artificial chordae on the basis of available pathologic data.
A 20-year experience with mitral valve repair with artificial chordae in 608 patients
The Journal of Thoracic and Cardiovascular Surgery, 2008
Objective: Mitral valve repair with artificial chordae for degenerative mitral regurgitation is widely adopted. We evaluated long-term results of mitral repair with expanded polytetrafluoroethylene sutures (GORE-TEX CV-5; W. L. Gore & Associates, Inc, Flagstaff, Ariz). Methods: Between November 1986 and November 2006, 608 consecutive patients underwent mitral repair with artificial neochordae. Mean age was 55 6 11 years (15-85 years); 433 (71.2%) were male. Valve disease was purely degenerative in 555 patients (91.3%). Prolapse of anterior, posterior, or both leaflets was present in 47 (7.7%), 308 (50.7%), and 253 (41.6%), respectively. Atrial fibrillation was associated in 117 (19.2%). In 125 cases (20.5%), additional surgical procedures were performed. Follow-up was complete at a median of 5.7 years (interquartile range 2.2-9.8 years, range 0-19.4 years). Results: In-hospital mortality was less than 1% (6 deaths). Overall and cardiac late mortalities were 6.6% and 3.9% (34 and 24 deaths). Kaplan-Meier survival at 15 years was 84% (95% confidence interval 75%-90%). Freedoms from endocarditis, thromboembolic events, reoperation, and recurrent mitral regurgitation at 15 years were 97% (95% confidence interval 93%-99%), 92% (87%-95%), 92% (88%-95%), and 85% (78%-91%), respectively. Sinus rhythm was restored in 75% (33 patients) after surgical atrial fibrillation correction. Calcification of GORE-TEX neochordae was never reported. Conclusion: Mitral valve repair with GORE-TEX artificial chordae is effective, safe, and associated with low operative mortality and low rates of valve-related complications at long-term follow-up. Artificial chordae showed excellent biologic adaptation, retaining flexibility and tension with time.
Neo-chordae length adjustment in mitral valve repair
European Journal of Cardio-Thoracic Surgery, 2006
Appropriate length adjustment of neo-chordae using PTFE sutures for mitral valve repair in degenerative valve disease has a crucial impact on both early and late outcomes of the repair. Herein we describe an adjuvant approach to facilitate the length adjustment.
Midterm results of mitral valve repair with artificial chordae in children
The Journal of Thoracic and Cardiovascular Surgery, 2005
We have used artificial chordal replacement with expanded polytetrafluoroethylene sutures for mitral valve repair in children and reported favorable early clinical results. In this article we evaluate the midterm results of mitral valve repair with expanded polytetrafluoroethylene sutures in 39 children.
Outcomes of mitral valve repair using artificial chordae
OBJECTIVES: The use of artificial chordae techniques has increased the number of mitral valve lesions which are amenable to repair. Artificial chordae can be adapted for a wide range of mitral valve pathologies including restricting the motion of overly mobile 'floppy' Barlow disease leaflets, replacing diseased chordae and improving coaptation in degenerative disease. There is continuing concern about the long-term performance of artificial chordae, which become endothelialized over time and may exhibit complications during the early or late follow-up period.
Improved results with mital valve repair using new surgical techniques
European Journal of Cardio-Thoracic Surgery, 1995
From January 1987 to July 1994, 299 consecutive patients ranging from 4 to 80 years of age underwent mitral repair for pure valve insufficiency due to degenerative disease (59 %), rheumatic disease (23 %), endocarditis (12%) or ischemic heart disease (6%). During the initial period, a variety of reparative methods were used following the principles originally described by Carpentier. More recently, in our institution other surgical techniques have been introduced: specifically, prolapse of the anterior leaflet was corrected either by replacing the chordae with polytetrafluoroethylene (PTFE) sutures or simply by anchoring the prolapsing free edge to the facing edge of the posterior leaflet ("edge-to-edge" technique). Chordal transposition has also been used occasionally to correct the prolapse of the anterior leaflet. The hospital mortality rate was 1.3%. According to actuarial methods, the overall survival rate was 94 % at 7 years, and freedom from reoperation was 86 %. Significant incremental risk factors for reoperation were: no use of prosthetic ring, correction of the prolapse of the anterior leaflet by triangular resection or chordal shortening and ischemic etiology of the mitral insufficiency (freedom from reoperation at 7 years was 61%, 56% and 51%, respectively). In the late postoperative period (mean follow-up 3.6 years), 95 % of the patients were in NYHA class I or II; four patients had thromboembolic episodes, two hemorrhagic complications and two endocarditis. No patient in whom the prolapse of the anterior leaflet was corrected by the recently introduced technique has required reoperation. The anterior mitral leaflet prolapse was therefore neutralized as an incremental risk factor for reoperation and this has contributed to the improved overall results of mitral valve repair.