Preoperative determination of artificial chordae tendineae length by transoesophageal echocardiography in totally endoscopic mitral valve repair

Abstract

<jats:title>Abstract</jats:title> <jats:p /> <jats:sec> <jats:title>OBJECTIVES</jats:title> <jats:p>Artificial chordae tendineae are widely used for surgical repair in patients with mitral regurgitation due to floppy mitral valve/mitral valve prolapse. Expanded polytetrafluoroethylene has been used to construct these artificial chordae; however, the determination of the optimal length of the chordae prior to surgery has been an issue. For this reason, such a method was developed and the results of its use are presented.</jats:p> </jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>Forty-seven consecutive patients with significant mitral regurgitation due to floppy mitral valve/mitral valve prolapse who underwent totally endoscopic mitral valve surgery were studied. The chordae length was predetermined using transoesophageal echocardiography. The length between the top of the fibrous body of the papillary muscle and the coaptation line of the 2 leaflets of the mitral valve was measured and used to define the length of the chordae to be used for repair. Then under stereoscopic vision, a total endoscopic mitral valve repair was performed.</jats:p> </jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>The predicted mean length of chordal loops was 19.76 ± 0.71 mm (median 20, range 16–28) and the actual mean length of chordal loops used was 19.68 ± 0.74 mm (median 20, range 16–26) demonstrating an excellent correlation between the two (r = 0.959). The mean number of chordae loops used per patient was 5.12 ± 0.62 (median 4, range 2–12). All patients at the time of discharge had no or trivial mitral regurgitation on transoesophageal echocardiography.</jats:p> </jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>The chordae length used for mitral valve repair can be determined prior to surgery using transoesophageal echocardiography with a high degree of accuracy. Further, total endoscopic repair in this group of patients provides excellent results. For these reasons, it is expected that this method will replace most traditional approaches to cardiac surgeries in the years to come.</jats:p> </jats:sec>

Totally Endoscopic Aortic Valve Replacement with Concomitant Trans-Aortic Mitral Valve Repair for Mitral Regurgitation

“…A successful surgical technique of TEAVR and concomitant totally endoscopic mitral valve repair via a trans-aortic approach is presented. When stand-alone endoscopic mitral repair is performed, this is usually done through a more lateral thoracotomy incision through the 4th ICS [2]. In order to perform a combined aortic valve replacement and a mitral repair through a standard left atriotomy incision, we can place our working incision through the 3rd ICS in the middle clavicular line, which is a compromise for both the endoscopic aortic valve replacement and the mitral repair through a left atriotomy.…”

“…a) marked mitral annular dilation -better managed with an annuloplasty procedure through a left atriotomy [4] and b) P1 or P3 or commissural ail/prolapse -better managed with the loop technique through a left atriotomy [2,4] (through a median sternotomy incision if combined with aortic valve disease).…”

“…Here we present our technique of TEAVR and concomitant trans-aortic mitral valve repair for primary or secondary MR. In cases with primary MR (Video 1), arti cial chordae tendineae were used to repair the prolapsing/ ail mitral valve in which the length was calculated preoperatively by transesophageal echocardiography (TEE), as previously reported [2]. In cases of secondary MR (Video 2), the edge-to-edge repair method was used [3].…”

Mitral commissural prolapse

“…Commissural prolapse is present in approximately 20% of patients operated for mitral leaflet prolapse or flail 3 . The lesion responsible for commissural prolapse is variable and may involve the leaflet tissue, chords, or papillary muscle.…”

“…In the majority of cases, patients' commissural prolapse was associated with another leaflet disease. 3 In a Korean study by Kim and colleagues, isolated commissural prolapse was more frequent (25% of cases) and posteromedial was approximately twice as common as anterolateral prolapse. 5,6 Posteromedial was three times more common than anterolateral prolapse in a large japanese study, and similar results were obtained in a German study.…”