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J Thorac Cardiovasc Surg 1994;107:635-0635
© 1994 Mosby, Inc.

Letters to the Editor

Grafting of chordae tendineae: A new technique for the repair of mitral insufficiency caused by ruptured chordae of the anterior leaflet

Francisco Gregori, Jr., MD, Samuel S. da Silva, MD, Marcos P. Goulart, MD, Octávio Canesin, MD, Sergio S. Hayashi, MD

From the Department of Surgery
State University of Londrina Medical School
Londrina, Parana, Brazil

To the Editor:

We propose an alternative approach to correct the valve prolapse caused by ruptured chordae tendineae of the anterior leaflet. This approach consists of grafting chordae tendineae from the tricuspid valve into the mitral valve. By performing a graft, we avoid valve replacement or implantation of foreign material as a substitute for chordae tendineae. We operated on two patients.

CASE 1
A 38-year-old woman in New York Heart Association functional class IV was admitted with a grade 5/6 systolic murmur at the mitral area and marked cardiomegaly caused by a left atrial and left ventricular enlargement and bulging of the pulmonary artery arch and left atrium.

Marked mitral insufficiency with a systolic pressure measurement of 30 mm Hg in the pulmonary artery, a ratio of pulmonary artery systolic pressure to aortic systolic pressure of 0.33, and an average pulmonary wedge pressure measurement of 10 mm Hg without a mitral valvular gradient were revealed during the hemodynamic evaluation.

At operation, the appearance of the mitral valve strongly suggested a rheumatic basis. The mitral anulus was dilated anteroposteriorly, leaflets were intact, and two thirds of the chordae tendineae joining the posterior papillary muscle to the anterior leaflet were ruptured. After a right atriotomy, the tricuspid valve was visualized. The anterior leaflet had an appropriate texture and the chordae tendineae had an adequate papillary support. We cut a piece of tissue (1 cm2) of the anterior leaflet containing chordae tendineae joined to one of the halves of the sectioned papillary muscle, which would be used as a graft (Fig. 1, A). The two edges of the anterior leaflet were joined with interrupted 5-0 polypropylene sutures (Fig. 1, B). The intraoperative test showed the tricuspid valve to be competent. The leaflet part of the graft was sutured to the anterior leaflet of the mitral valve on its ventricular surface with 5-0 polypropylene sutures. The papillary part of the graft was sutured to the stump of papillary muscle of the mitral valve in the fibrous part. To correct the anteroposterior dilatation of the mitral valve anulus, we implanted an open prosthetic ring.Go 1 The bypass time was 67 minutes, and the crossclamp time was 43 minutes. The patient had an uneventful recovery and was discharged 10 days after operation.



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  		Fig. 1. Drawing of anterior leaflet of tricuspid valve. A, Removal of a fragment of the leaflet and papillary muscle with intact chordae tendineae. B, The tricuspid valve is repaired with interrupted 5-0 polypropylene sutures.

 
The patient underwent hemodynamic evaluation 30 days after operation. This evaluation showed a systolic pressure measurement of 30 mm Hg in the pulmonary artery, a ratio of pulmonary artery systolic pressure to aortic systolic pressure of 0.27, and an average pulmonary wedge pressure of 10 mm Hg. No mitral valvular gradient was detected. The left cineventriculogram revealed no mitral regurgitation (Fig. 2, A). The right cineventriculogram revealed a faint tricuspid regurgitation (Fig. 2, B). The echocardiogram showed appropriate mobility of the anterior leaflet of the mitral valve without prolapse, and the Doppler echocardiogram showed no signs of regurgitation in the mitral and tricuspid valves. The patient was evaluated 1 year after the operation and at that time had no symptoms and no murmurs.



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  		Fig. 2. Postoperative left cineventriculogram (case 1). A, Absence of mitral regurgitation. B, faint regurgitation through the tricuspid valve.

 
CASE 2
A 27-year-old man in New York Heart Association functional class III had a grade 4/6 systolic murmur at the mitral area and cardiomegaly, caused mainly by enlargement of the chambers on the left side.

Cardiac catheterization showed a systolic pressure measurement of 39 mm Hg in the pulmonary artery, a pulmonary wedge pressure of 25 mm Hg, and an end-diastolic pressure of 15 mm Hg in the left ventricle. The left cineventriculogram showed marked mitral valve regurgitation and prolapse of the anterior leaflet.

The intraoperative appearance of the mitral valve suggested myxoid degeneration. There was marked anterior leaflet prolapse caused by rupture of chordae tendineae from the posteromedial papillary muscle. Anteroposterior dilatation of the mitral anulus was noticeable. Through a right atriotomy, the posterior leaflet and its bundle of chordae tendineae and papillary muscle were resected to obtain a graft, and the tricuspid valve was turned into a bicuspid valve through plication of the valve anulus (Fig. 3). The papillary muscle of the graft was sutured to the mitral stump of the mitral posteromedial papillary muscle. The leaflet from the tricuspid valve was sutured to the free border of the anterior leaflet of the mitral valve (Fig. 4). The suture extended from the leaflet midpoint up to the posteromedial commissure. We performed annuloplasty with an open prosthetic ring.Go 1 The bypass and crossclamp times were 107 and 75 minutes, respectively.



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  		Fig. 3. Drawing shows removal of posterior leaflet of the tricuspid valve. This leaflet will be grafted into the mitral valve, thus supplying the anterior leaflet with chordae tendineae.

 


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  		Fig. 4. Drawing shows anterior leaflet of mitral valve after grafting of chordae tendineae from tricuspid valve.

 
As with the previous patient, we reassessed the hemodynamic values 30 days after operation. The systolic pressure in the pulmonary artery was found to be same as before the operation (39 mm Hg). There was a reduction in the pulmonary wedge pressure (6 mm Hg) and in the left ventricular end-diastolic pressure (6 mm Hg). The cineventriculogram showed a competent mitral valve and a faint tricuspid regurgitation. The patient was clinically evaluated 9 months after and had no symptoms and no murmurs. The echocardiogram showed no leaflet prolapses or mitral stenosis and the Doppler echocardiogram revealed competent mitral and tricuspid valves (Fig. 5).



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  		Fig. 5. Postoperative Doppler echocardiogram of patient who underwent grafting in which we used the posterior leaflet of the tricuspid valve. The adequate junction of the mitral valve leaflets (inferior) and absence of mitral and tricuspid regurgitation (superior) are noticeable.

 
Use of the anterior leaflet for grafting is most feasible because that leaflet alone contains the appropriate papillary muscles and the largest number of chordae tendineae, which aids in the suturing to the mitral valve papillary muscle. An alternative approach is the complete removal of the posterior leaflet. It is not advisable to use the septal leaflet because cardiac rhythm disturbances may appear at the time of valvular repair as a result of traction of the conductive bundle.

These techniques offer the possibility of physiologic opening and closure of the mitral valve, thus dispensing with such foreign materials as polytetrafluoroethylene and biologic tissues as substitutes for chordae tendineae.Go 2

Grafting of chordae tendineae of the mitral valve anterior leaflet can also be done in the event of mitral stenosis caused by localized calcification of the anterior leaflet and concomitant damage of chordae tendineae. In this case, both the chordae tendineae and part of the anterior leaflet are replaced, avoiding a valve replacement.

The excellent results obtained in both cases recommend this procedure as an alternative, conservative treatment of mitral insufficiency caused by ruptured chordae tendineae of the anterior leaflet.

References

  1. Gregori F Jr, Silva SS, Baba K, et al. Um novo modêlo de anel protético para pacientes com insuficiência valvar mitral: relato de dois casos. Arq Bras Cardiol 1988;50:417-20.[Medline]
  2. Frater RW, Gabbay S, Shore D, et al. Reproducible replacement of elongated or ruptured mitral valve chordae. Ann Thorac Surg 1983;35:14-9.[Abstract]



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