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J Thorac Cardiovasc Surg 1994;107:321-322
© 1994 Mosby, Inc.
LETTERS TO THE EDITOR |
Department of Surgery
State University of Londrina Medical School
Londrina, Parana, Brazil
To the Editor:
In 1989 we introduced a new technique for shortening of elongated chordae tendineae.
1 It is particularly suitable for shortening the chordae tendineae in patients in whom the papillary muscles are either thin or deeper than usual. The shortening, performed above the anterior leaflet of the mitral valve, is quite feasible because of the accessible surgical site and easy quantification of the elongation of the chordae tendineae to be corrected.
Twenty-two patients, ranging from 5 to 51 years old (average 24 years) with mitral insufficiency (eight also had mitral stenosis) were operated on sequentially. Eighteen patients had rheumatic disease and four patients had myxoid degeneration. Eleven patients were in New York Heart Association functional class III and 11 were in functional class IV.
Preoperative left cineventriculogram showed grade III and IV mitral regurgitation in 19 patients and grade II regurgitation in three patients (these patients also had mitral stenosis). The average mitral transvalvular gradient was 6.1 mm Hg. Right cineventriculogram showed tricuspid regurgitation in 11 patients. Aortic insufficiency was observed in the aortograms of three patients. Echocardiograms showed the patients to have various degrees of anterior prolapse of the mitral valve.
All patients underwent cardiac catheterization at discharge from the hospital and were reassessed both clinically and echocardiographically 1 to 24 months after operation (average 14 months).
After installing a hypothermic bypass, we opened the left atrium and visualized the mitral valve. All patients had anterior mitral leaflet prolapse, and four also had a posterior leaflet prolapse. Elongation of one or more leaflet chordae was observed in all cases.
Once the elongated chordae were identified, the anterior leaflet was exposed and an orifice about 2 to 3 mm wide was made near the insertion of the elongated chordae (Fig. 1). After that procedure, the elongated chorda was pulled through the orifice with a nerve tractor (Fig. 2) or even a thick cotton thread so that the anterior leaflet was lowered to an appropriate level, resulting in a satisfactory coaptation of the leaflets. The orifice was sutured with interrupted 5-0 polypropylene sutures. This suture also fastened the chorda to the atrial surface of the anterior leaflet of the mitral valve (Fig. 3).
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2 thus correcting the posterior dilatation of the mitral valve anulus. In addition, comissurotomies were performed in eight patients with double mitral lesion. A partial resection of the anterior leaflet of the mitral valve was performed in one patient and a partial resection of the posterior leaflet was performed in four patients. Three patients underwent aortic valves replacement. All of the patients survived. At the postoperative examination, 20 patients were without symptoms, despite the use of digoxin, and two patients were in functional class III. Twelve patients (54.5%) had no murmurs, eight patients (36.4%) had faint systolic murmurs at the mitral area, one patient (4.5%) a moderate systolic murmur at the mitral area, and one patient (4.5%) had an important systolic murmur at the mitral area. The last two patients were operated on again 3 and 4 months after original operation, and the surgical aspect suggested rheumatic activity (functional class III). No thromboembolic phenomena occurred.
The postoperative left cineventriculogram showed absence of mitral regurgitation in 14 patients, slight mitral regurgitation in eight patients, and important regurgitation in two patients. In 18 patients, the mitral valve gradient was less than 4 mm Hg. The average mitral transvalvular gradient was 3.4 mm Hg.
The echocardiographic findings showed adequate coapta tion of the leaflets in all but two patients. The Doppler revealed absence of regurgitation in 12 patients, slight regurgitation in eight patients, and marked regurgitation in two patients.
One patient with rheumatic activity had a slight mitral regurgitation after operation. A hemodynamic study showed the mitral transvalvular gradient to be 15 mm Hg and the Doppler echocardiogram showed it to be 10.5 mm Hg. At present, this patient is free of symptoms and a nonradiating slight murmur can be heard at the mitral area. Another patient (who underwent a concomitant partial resection of the anterior leaflet) was without symptoms 6 months after the operation, but both the Doppler echocardiogram and the cardiac catheterization revealed a mitral transvalvular gradient measurement of 13 mm Hg.
The clinical results, the laboratory findings, and the technical advantages of this surgical approach allowed us to conclude that this technique is useful in the conservative surgical treatment of mitral insufficiency caused by elongation of the chordae tendineae of the anterior leaflet.
References
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