Association of tethering of the second‐order chords and prolapse of the first‐order chords of the anterior leaflet: A risk factor for early and late repair failure

Calafiore, Antonio M.; Totaro, Antonio; Testa, Nicola; Sacra, Cosimo; Calvo, Eugenio; Mauro, Michele Di

doi:10.1111/jocs.14469

Cited by 7 publications

(13 citation statements)

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“…We have termed this surgical approach “surgical mitral plasticity.” 48 To complete what nature could not, the AL has to be augmented and lengthened (by an autologous glutaraldehyde‐treated or heterologous pericardial patch or any biological patch) and the second‐order chords have to be cut to increase the effective AL length and area (Figure 11). It is worth emphasizing the necessity of second‐order chords transection, as the fibrotic process, once started, can be progressive 49 . Moreover, by eliminating apical tethering, the AL can recover its normal curvature by removal, or reduction, of the tenting area.…”

Section: Resultsmentioning

confidence: 99%

“…It is worth emphasizing the necessity of second-order chords transection, as the fibrotic process, once started, can be progressive. 49 Moreover, by eliminating apical tethering, the AL can recover its normal curvature by removal, or reduction, of the tenting area. In selected cases, when the AL is sufficiently long, it is not necessary to augment it, but chordal cutting, performed through aortotomy, is sufficient ( Figure 12).…”

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The secret life of the mitral valve

et al. 2020

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In secondary mitral regurgitation, the concept that the mitral valve (MV) is an innocent bystander, has been challenged by many studies in the last decades. The MV is a living structure with intrinsic plasticity that reacts to changes in stretch or in mechanical stress activating biohumoral mechanisms that have, as purpose, the adaptation of the valve to the new environment. If the adaptation is balanced, the leaflets increase both surface and length and the chordae tendineae lengthen: the result is a valve with different characteristics, but able to avoid or to limit the regurgitation. However, if the adaptation is unbalanced, the leaflets and the chords do not change their size, but become stiffer and rigid, with moderate or severe regurgitation. These changes are mediated mainly by a cytokine, the transforming growth factor-β (TGF-β), which is able to promote the changes that the MV needs to adapt to a new hemodynamic environment. In general, mild TGF-β activation facilitates leaflet growth, excessive TGF-β activation, as after myocardial infarction, results in profibrotic changes in the leaflets, with increased thickness and stiffness. The MV is then a plastic organism, that reacts to the external stimuli, trying to maintain its physiologic integrity. This review has the goal to unveil the secret life of the MV, to understand which stimuli can trigger its plasticity, and to explain why the equation "large heart = moderate/severe mitral regurgitation" and "small heart = no/ mild mitral regurgitation" does not work into the clinical practice.

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Section: Resultsmentioning

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The secret life of the mitral valve

et al. 2020

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“…AML tethering in patients with PML prolapse was demonstrated to be associated with unfavorable postprocedural residual MR after surgical repair ( 21 ). Moreover, regional leaflet tethering can coexist with prolapse in AML and/or PML and, more importantly, could also affect surgical repair as a risk factor for MR occurrence ( 10 , 11 , 22 ). Hence, tenting volume may be an integrated factor to evaluate the tethering severity of the entire MV leaflet to predict residual MR 2+ immediately after interventional EE repair.…”

Section: Discussionmentioning

confidence: 99%

Impact of Leaflet Tethering on Residual Regurgitation in Patients With Degenerative Mitral Disease After Interventional Edge-to-Edge Repair

Pan

et al. 2021

Front. Cardiovasc. Med.

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Background: Grade 2+ residual mitral regurgitation (MR 2+) is associated with the recurrence of MR and a lower survival rate in interventional mitral valve (MV) edge-to-edge (EE) repair. We sought to determine the MV anatomic factors affecting residual MR 2+ during interventional EE repair with the ValveClamp system in patients with degenerative MR (DMR).Methods: In this multicenter study, 62 patients with significant (grade 3+ to 4+) DMR underwent ValveClamp implantation across eight centers from July 2018 to December 2019. Patient clinical, anatomical, and procedural characteristics were prospectively collected and retrospectively analyzed.Results: A single clamp was implanted in 59 patients, and two clamps were implanted in three patients. Residual MR 2+ was found in 14 patients (22.6%) immediately after the ValveClamp procedure. Patients with residual MR 2+ showed significantly larger preoperative tenting sizes and annular dimensions than the residual MR ≤1+ group. Multivariate analysis identified tenting volume as the major determinant of residual MR 2+ after ValveClamp procedures (odds ratio, 1.410 per 0.1-mL/m2 increase; 95% confidence interval, 1.167–1.705; P < 0.001). Receiver operating characteristic curves identified a tenting volume index ≥0.82 mL/m2 as the optimal cutoff point to predict residual MR 2+ (area under curve, 0.84). Patients with a tenting volume index ≥0.82 mL/m2 were more likely to develop recurrent 3+ MR or undergo MV surgery during short-term follow-up (P < 0.001).Conclusions: Preoperative assessment of the tenting volume index will help to predict intraoperative residual MR 2+ in patients with DMR receiving EE-based interventional repair. Improvements in the interventional strategy are warranted for sustained MR reduction in patients with DMR with unfavorable anatomy.

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“…Experimentally, it was demonstrated that MR, created by making a hole in the PL, was able to induce AL remodelling 33 . Moreover, tethering of the second-order chordae have been demonstrated in patients with prolapse of the PL 34,35 and prolapse or chordal rupture of the AL 36 .…”

Section: When To Cut the Second-order Chordaementioning

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Cutting the Second Order Chords During Mitral Valve Repair

Calafiore

Prapas²,

Totaro

et al. 2022

Preprint

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The chordae tendinae connect the papillary muscles to the mitral valve. While the first-order chordae serve to secure the leaflets to maintain valve closure and prevent mitral valve prolapse, the second-order chordae are believed that they play a role in maintaining normal LV size and geometry. The papillary muscles, from where the chordae tendinae originate, function as shock absorbers that compensate for the geometric changes of the left ventricular wall. The second-order chordae connect the PMs to both trigons under tension. The tension distributed towards the second-order chordae has been demonstrate to be more than three-fold that in the first-order counterpart. Cutting the second-order chordae puts all the tension on the first-order chordae, that can go closer to their rupture point. However, it has been experimentally demonstrated that the tension where the first-order chordae break is 6.8 N, by far higher than the maximal tension reached, that is 0.4 N. Even if the clinical reports have been favorable, the importance of cutting the second-order chordae to recover curvature of the anterior leaflet and increasing the coaptation length between the mitral leaflet has been slowly absorbed by the surgical world. Nevertheless, there are progressive demonstrations that chordal tethering affects the anterior leaflet not only in secondary, but also in primary mitral regurgitation, having a not negligeable role in the long-term outcome of mitral repair.

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Association of tethering of the second‐order chords and prolapse of the first‐order chords of the anterior leaflet: A risk factor for early and late repair failure

Cited by 7 publications

References 7 publications

The secret life of the mitral valve

The secret life of the mitral valve

Impact of Leaflet Tethering on Residual Regurgitation in Patients With Degenerative Mitral Disease After Interventional Edge-to-Edge Repair

Cutting the Second Order Chords During Mitral Valve Repair

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