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J Thorac Cardiovasc Surg 2007;133:1490-1492
© 2007 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Discussion

Dr D. Craig Miller (Stanford, Calif). Thank you, Dr Borger. That was a nice presentation. I don’t want anyone in this room to run home and try this, however. Despite how great it looks on the surface, it looks too good to be true and probably is too good to be true.

Let me reframe the controversy for the audience. Robert Levine’s MGH group has shown in acute and chronic sheep models of IMR that if you cut the second-order chords there is more leaflet area for coaptation and the valve is more competent. My concern has always been what cost do you pay in terms of ventricular systolic function when you cut the second-order chordae? Indeed, it is ironic that the senior author on this paper is the very one and same Tirone E. David who first convincingly demonstrated in a canine experimental preparation 23 years ago that cutting the chordae tendineae was bad for left ventricular systolic function. Further, these are sick ventricles. To paraphrase the Gorman brothers: IMR is not a valvular disease, it’s a ventricular disease, and these are sick ventricles crying out for help. If we impair their LV contractile performance more, we actually may be harming patients even if there is less postoperative recurrent IMR.

Congratulations for proving in the first sizable clinical series that cutting second-order chordae is feasible and safe with no apparent early side effects. I remain unconvinced, however, that the putative mechanism responsible for less recurrent MR was actually due to what you did. I also am skeptical that you actually did not impair left ventricular systolic function by cutting the chords.

Why am I unconvinced? First, you do not have the proper concurrent control group -- similar patients with IMR undergoing CABG alone -- but none of . . . [Full Text of this Article]

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Initial results of the chordal-cutting operation for ischemic mitral regurgitation

Michael A. Borger, Patricia M. Murphy, Asim Alam, Shafie Fazel, Manjula Maganti, Susan Armstrong, Vivek Rao, and Tirone E. David
J. Thorac. Cardiovasc. Surg. 2007 133: 1483-1492. [Abstract] [Full Text] [PDF]