Ann Thorac Surg 2001;72:1515-1519
© 2001 The Society of Thoracic Surgeons
Original article: cardiovascular
Chordal plication and free edge remodeling for mitral anterior leaflet prolapse repair: 8-year follow-up
Pino Fundarò, MD*a,b,c,
Andrea Moneta, MDa,b,c,
Emmanuel Villa, MDa,b,c,
Marco Pocar, MDa,b,c,
Michele Triggiani, MDa,b,c,
Francesco Donatelli, MDa,b,c,
Adalberto Grossi, MDa,b,c
a Divisione di Cardiochirurgia, IRCCS Ospedale Maggiore di Milano, Milan, Italy
b Istituto di Malattie dell’Apparato Cardiovascolare e Respiratorio, Milan, Italy
c Università degli Studi di Milano, Milan, Italy
Accepted for publication June 22, 2001.
* Address reprint requests to Dr Fundarò, Divisione di Cardiochirurgia, IRCCS Ospedale Maggiore di Milano, Via Francesco Sforza, 35, 20122 Milan, Italy
e-mail: grossil{at}mailserver.unimi.it
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Abstract
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Background. Chordal suture plication and free edge remodeling represent a personal technique for the repair of anterior leaflet prolapse. We report the results of an 8-year experience.
Methods. Sixty-one patients with degenerative mitral regurgitation caused by prolapse of the anterior leaflet (11) or both leaflets (50) underwent anterior leaflet prolapse repair. Twenty patients who had associated cardiac procedures are included.
Results. There were two perioperative deaths. Postoperative mitral regurgitation fell to 0.4 ± 0.7 versus 3.7 ± 0.4 preoperative (p < 0.0001). Mean follow-up was 40.5 months. There were 3 late deaths and 3 mitral reoperations (1 of 3 repairs, 2 of 3 replacements). Thromboembolism and endocarditis occurred in 1 patient each. Actuarial overall survival, freedom from cardiac death, and freedom from mitral reoperation at 92 months were 85.1% ± 7.9%, 88.9% ± 7.7%, and 94.6% ± 3.0%, respectively.
Conclusions. Our technique of anterior leaflet prolapse repair appears effective, safe, and durable at mid- to long-term follow-up, and may be used in the presence of extensive disease of both leaflets.
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Introduction
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Repair of anterior leaflet prolapse (ALP) remains more demanding than that of the posterior leaflet and produces less predictable results [1–3]. A variety of surgical techniques are currently used for the repair of ALP [4] but the optimal treatment is not clearly defined.
Since 1993 a personal technique for ALP repair, consisting of chordal suture plication and free edge remodeling (FER), has been developed by our group [5]. Mid- to long-term results are analyzed in this study.
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Material and methods
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Patients
Between July 1993 and December 2000, 61 patients underwent FER for the treatment of severe degenerative (myxomatous) mitral regurgitation (MR). During this period FER was applied to more than 90% of patients with ALP by a single surgeon (PF). All patients underwent preoperative and pre-discharge transthoracic echocardiography (TTE). Intraoperative transesophageal echocardiography (TEE) was performed routinely before and after valve reconstruction. The degree of MR (1 to 4) was recorded according to standard echocardiographic criteria. Coronary angiography was performed in patients older than 50 years. Etiology of mitral valve disease was degenerative in 58 patients and mixed (ie, degenerative and ischemic) in 3 patients. Five patients presented a previous history of endocarditis. Preoperative characteristics and valve pathology are shown in Tables 1 and 2.
Operative technique
The operation is performed using standard cardiopulmonary bypass with bicaval venous cannulation, systemic moderate hypothermia, and cold cardioplegic arrest. The mitral valve is approached through a right-sided left atriotomy. The prolapsing portion of the anterior leaflet, the amount of chordal elongation, and the presence of interchordal redundancy are evaluated. Two stay sutures are placed on the anterior leaflet free edge, often in a paracommissural position, to mark the margins of the diseased area. A 5–0 nonabsorbable running suture (or multiple figure-of-eight stitches) is fashioned between the stay sutures. The suture involves the chordal-cusp junction of the prolapsing portion and plicates the rough zone on the ventricular aspect, thus strengthening the chordae and remodeling the leaflet’s free edge (Figs 1A, B, 2). Only the rough zone should be included in the suture, because bites involving the leaflet’s body may excessively warp the cusp. The chordae are included in the suture for a variable length (2 to 5 mm), depending on the degree of elongation. As a result, leaflet mobility is greatly reduced, interchordal redundancies are eliminated, and the chordal-cusp junction appears reinforced and more regular. In the presence of bileaflet prolapse concomitant quadrangular resection of the posterior leaflet is performed. The repair is completed by a posterior suture annuloplasty reinforced with an autologous pericardial strip or, more recently, a Gore-Tex band (W. L. Gore & Assoc, Flagstaff, AZ) [6, 7]. Early in our experience, associated chordal transfer was performed for ALP repair in 3 patients. Surgical techniques used for mitral valve reconstruction are summarized in Table 3.
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Fig 1. The suture includes the rough zone and a limited portion of the elongated chordae (A) resulting in plication on the ventricular aspect and fit coaptation (B).
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Fig 2. Free edge remodeling with the suture tied (left) and exact positioning of suture bites (right) as seen by the surgeon’s perspective.
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Concomitant cardiac procedures were performed in 20 patients (32.8%) as described in Table 4. In the presence of coronary artery disease, all distal anastomoses of bypass grafts were completed before mitral valve repair (MVR). Associated tricuspid and aortic valve procedures or atrial septal repair were performed after MVR.
Patients were reevaluated by TTE 3 months after hospital discharge and annually thereafter. Oral anticoagulation was administered for 3 months postoperatively. Patients in sinus rhythm were then switched to antiplatelet therapy. Follow-up was 96.6% complete (2 of 59 survivors were lost at the most recent evaluation). Average follow-up was 40.5 months (range, 3–92). Clinical status of patients was determined by hospital records or telephone interviews.
Statistical analysis
Data were analyzed using a statistical software program (SPSS for Windows 10.0.1, SPSS Inc, Chicago, IL). Continuous variables are expressed as mean ± standard deviation. Actuarial analysis of event-free rates was accomplished using the Kaplan-Meier method. The 
2 test was used for comparison of data. A p value less than 0.05 was considered statistically significant.
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Results
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Intraoperative TEE and TTE at hospital discharge demonstrated successful MVR (trivial or no residual regurgitation) in all patients with morphological ALP correction and fit leaflet coaptation below the annular plane. Mean MR fell significantly after repair to 0.4 ± 0.7 versus 3.7 ± 0.4 before repair (p < 0.0001). One patient who underwent isolated MVR showed transient mild left ventricular outflow tract obstruction caused by mitral systolic anterior motion (peak systolic gradient = 15 mm Hg) at intraoperative TEE. Embolism to the left upper limb, treated with heparin infusion, occurred perioperatively in 1 patient.
Mortality
There were two hospital deaths (3.2%) and three late deaths. The causes of death were not related to MVR. Death was caused by refractory ventricular fibrillation secondary to perioperative myocardial infarction after MVR and coronary artery bypass grafting in 1 patient, and massive postoperative bleeding from the aortic cannulation site in an 83-year-old patient who underwent MVR and aortic valve replacement. Causes of late death were bilateral pneumonia (at 10 months), malignancy (at 28 months) and myocardial infarction (at 67 months).
Including in-hospital mortality, overall survival was 94.9% ± 2.9%, 92.5% ± 3.7%, and 85.1% ± 7.9%. Freedom from cardiac death was 96.7% ± 2.3%, 96.7% ± 2.3%, and 88.9% ± 7.7%, at 12, 60, and 92 months, respectively (Figs 3, 4).
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Fig 3. Actuarial overall survival (± standard error) at 92 months in 61 patients who underwent free edge remodeling. Patients at risk are reported along the bottom.
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Fig 4. Actuarial freedom from cardiac death (± standard error) at 92 months in 61 patients who underwent free edge remodeling. Patients at risk are reported along the bottom.
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Early and late mitral reoperation
Three patients required mitral valve reoperation, with 1 patient who had reoperation twice after initial MVR. In the first patient, TTE showed recurrent ALP 6 days after MVR. At reoperation, the remodeling running suture had broken, probably cut by the needle itself. No chordal rupture was detected and FER was used again for ALP re-repair. The patient initially had an uneventful recovery but underwent valve replacement 2 months later for hemolytic anemia caused by high-speed jet regurgitation. In the second patient, partial disinsertion of the annuloplasty Gore-Tex band was observed and the mitral valve was replaced 8 days after MVR. The third patient underwent mitral valve replacement at another hospital 26 months after MVR for recurrence of severe MR.
Actuarial freedom from valve reoperation at 12, 60, and 92 months was 96.6% ± 2.4%, 94.6% ± 3.0%, and 94.6% ± 3.0%, respectively (Fig 5).
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Fig 5. Actuarial freedom from reoperation (± standard error) at 92 months in 59 operative survivors. Patients at risk are reported along the bottom.
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Clinical follow-up
Among the 51 patients alive in March 2001 with their native valve repaired, 44 of 51 (86.3%) are in New York Heart Association class I, 6 of 51 patients are in class II (11.8%), and 1 patient is in class III. The latter patient developed dilated cardiomyopathy 48 months after operation despite stable mild MR. No late thromboembolic event was recorded. One patient suffered late bacterial endocarditis treated with intravenous antibiotics. At TTE evaluation, mild to moderate MR, when present (5 patients), was stable in all but 1 patient who underwent mitral valve replacement 26 months after MVR, as previously described. No evidence of late anterior leaflet fibrosis or valve stenosis was detected.
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Comment
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A variety of techniques, including chordal transfer [7–9], chordal shortening [9–11], insertion of artificial chordae [3, 12, 13], leaflet resection [10, 14], apposition of anterior and posterior leaflets [15], transfer of posterior tricuspid leaflet and chordae [16], and posterior papillary muscle repositioning [11], are currently available for ALP repair. Apparently, all techniques have produced good results in selected patients, but the optimal treatment and long-term durability of the various techniques have not been clearly defined. Comparisons between techniques are difficult because populations of patients are often evaluated regardless of etiology and morphofunctional mechanisms of MR [1, 14, 17]. In addition, data that are usually used for the evaluation of systolic left ventricular function are difficult to assess. It should also be pointed out that the prevalence of ALP varies widely (from 12.3% to 48.1%) in different series [12, 17], probably reflecting lack of uniformity in the definition of ALP or selection of patients, or both.
Free edge remodeling, introduced in 1993, is based on the anatomical standpoint that competence of the mitral valve with correct leaflet coaptation depends on the appropriate length and extension of structures anatomically located between the mitral annulus and the apex of the papillary muscle, namely, the leaflet body, the leaflet rough zone, and the chordae. In degenerative myxomatous mitral valve disease, leaflets are enlarged and redundant (predominantly in the rough zone) and chordae are elongated. This results in tissue excess when compared with the distance between the annulus and papillary muscle apex. Excess of cusp tissue also occurs between adjacent chordal insertions resulting in interchordal prolapse with deformity of the free margin profile and leaflet coaptation area. These anatomic features result in functional changes that are easy to observe by TTE (ie, excess of mobility of the prolapsing anterior leaflet, loss of leaflet coaptation) and ultimately produce severe MR. In addition, chordae are exposed to enhanced tensile stress during ventricular systole, resulting in a higher risk of chordal rupture; this is partially caused by the lack of coaptation itself and partially by the excess of leaflet area, which determines increased pressure on the cusp tissue, thus increasing chordal tension (termed the parachute effect).
With the more commonly used techniques for ALP correction, chordal repair (ie, shortening, transposition, replacement) is considered mandatory, whereas cusp tissue redundancy is usually not addressed in the repair. Only the technique of triangular resection [10, 14] includes cusp tissue reduction. Free edge remodeling, consisting of suture resuspension of the prolapsing portion of the anterior leaflet, reduces the extension of the rough zone (ie, the suture plicates it on the ventricular aspect) and shortens the elongated chordae with plication at the level of the leaflet’s free edge. Free edge remodeling normalizes tissue excess between the papillary muscle apex and annulus. At the same time, redundancy between adjacent chordal insertions (interchordal prolapse) is easily included in the suture, resulting in uniform, fit leaflet coaptation.
In the present series of consecutive patients undergoing FER, clinical results have been gratifying. The operative mortality was 0% for isolated MVR and 4.8% when MVR was combined with other procedures. Actuarial freedom from cardiac death was 88.9% ± 7.7% at 92 months. Fifty of 51 surviving patients were in New York Heart Association class I or II, which compared favorably with reports describing functional results of other techniques [3, 9, 14]. All series described patients requiring reoperation for recurrent mitral valve dysfunction. For patients with ALP, reported actuarial freedom from reoperation rates using different techniques are 85% to 96% at 5 years for chordal transfer [7, 9], 74% to 79% at 5 years for chordal shortening [2, 9], and 92% at 2 years and 86% to 94% at 10 years for implantation of artificial chordae [12, 13, 18]. In our experience 3 patients required reoperation, resulting in a 92-month actuarial freedom from reoperation rate of 94.6% ± 3.0%. Durability of FER is reflected by the fact that only 1 patient required late valve replacement for recurrence of severe MR.
The presumption exists that elongated chordae of the myxomatous valve are predisposed to further elongation and rupture, resulting in a potential lack of long-term durability of repair techniques [3, 9, 12]. Degenerative myxomatous valves undoubtedly show weakened chordae, but we believe this is not the determinant of late repair failure. Our late results confirm that myxomatous chordae, despite structural weakening, are not prone to rupture after repair and may be safely used to obtain durable results, as reported also for myxomatous transferred chordae. Also, we believe that FER produces a more even distribution of tension among chordae and a reduction of chordal tensile stress. This is the result of exclusion of tissue redundancy between adjacent chordal insertions and achievement of a more uniform free edge and leaflet coaptation [19]. We consider anterior leaflet chordal rupture (or extreme thinning) a relative contraindication for FER if used alone to correct ALP.
In conclusion, our experience confirms that ALP repair, which is generally considered to be associated with a higher complexity and difficulty, may be accomplished using FER in the majority of patients. Provided that chordal quality is sufficiently preserved, FER is effective, straightforward, and durable in the midterm to long-term. It is not intended to replace other successful procedures but rather to increase the number of surgical options for the improvement of overall results of MVR techniques. Because the optimal technical indication for the treatment of multiple lesions giving rise to ALP remains to be elucidated, a flexible approach is advised.
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Abstract
Introduction
