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J Thorac Cardiovasc Surg 2007;134:551-552
© 2007 The American Association for Thoracic Surgery

Letter to the Editor

Ring, string, chordal cutting: All or nothing?

Georges Fayad, MD, Thomas Modine, MD, Henri Warembourg, MD

Hôpital Cardiologique, CHRU de Lille, France

To the Editor:

We read with interest the article by Langer and Schäfers.1Go We congratulate the authors for performing this study regarding this on-focus topic. This new procedure described is a step forward in the surgical treatment of ischemic mitral regurgitation (IMR). Nevertheless, we would like to point out the following issues.

The first issue is regarding the patient population; indeed, 12 patients presenting with severe IMR (≥level III) were included in the study. Unfortunately, the follow-up showed unfavorable evolution of the mitral regurgitation despite the surgery in this category of patients.2Go It is therefore difficult to evaluate the benefit of this procedure in such a patient population. We believe that moderate IMR at rest worsened on exercise could be the best indication.

Second, the nature of IMR treated is highly important to point out. Acute IMR with a high troponin level should be distinguished from chronic IMR to correctly analyze the outcomes. The benefit of mitral surgery in comparison with myocardial revascularization is difficult to evaluate in acute IMR.

The third remark is related to the nature of the tenting mechanism itself: Was it an anterior or anterior and posterior mitral valve tenting phenomenon?

The interpretation of echocardiographic results is also of great importance. The short-term reported results are interesting. Residual mitral regurgitation varied between levels 0 and I by combining the "ring and string" procedure. Nevertheless, these results should be evaluated on exercise for 2 reasons. First, the myocardial behavior on effort could be different than at rest, despite myocardial revascularization.3Go Second, the small diameter of mitral rings used in this study (average of 28 mm) needs to be evaluated on exercise to measure the gradients and to eliminate any tendency to mitral stenosis that could be associated to the small diameter of used rings.

Inspired by Messas and colleagues’ work,4Go we previously reported the first clinical case of chordal cutting through aortotomy5Go (Figure 1). Since then, we have performed this procedure in patients using the same method with and without associating annuloplasty in chronic IMR with anterior leaflet tenting. In all cases this procedure considerably reduced the tenting phenomenon. All patients were evaluated postoperatively by exercise treadmill echocardiography protocol, showing favorable results. Therefore, "chordal cutting" should be considered as an effective technique to treat IMR because our results show the feasibility, the effectiveness (consistent reduction of IMR), the absence of secondary marginal chordal rupture, and the absence of delayed ejection fraction alteration. One of the explanations for this favorable effect could be the avoidance of undersizing mitral annulus strategy that we have adopted, allowing optimal opening of the anterior mitral leaflet.


Figure 1
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  		Figure 1. Operative view, before chordal cutting procedure, through aortotomy showing the retracted anterior mitral valve and the anterior (A) and posterior (B) basal chordae (1). The coronary and noncoronary aortic leaflets (stars).

 
The main advantage of the "string" technique is to offer a "seat belt" for the left ventricle, limiting deleterious remodeling. Therefore, this technique could be considered complementary to the "chordal cutting," especially because both could be achieved through aortotomy.

The multiplication of surgical treatment options offered in case of IMR clearly shows that it is still a difficult and highly debated subject that is far from being closed. None of the isolated reported techniques are subject to consensus to date. The factors involved in the postoperative regression of IMR are too complex and numerous to be attached to a given procedure. Thus, the association of all these techniques may represent the best approach to treat this pathology. We should not forget that some colleagues would still be partisan of the "nothing" technique, preferring to implant the mitral prosthesis with chordal conservation instead of multiplying the techniques.

References

  1. Langer F, Schäfers HJ. Ring plus string: papillary muscle repositioning as an adjunctive repair technique for ischemic mitral regurgitation. J Thorac Cardiovasc Surg 2007;133:247-249.[Free Full Text]
  2. Gillinov AM, Wierup PN, Blackstone EH, Bishay ES, Cosgrove DM, White J, et al. Repair preferable to replacement for ischemic mitral regurgitation?. J Thorac Cardiovasc Surg 2001;122:1125-1141.[Abstract/Free Full Text]
  3. Lancellotti P, Lebrun F, Pierard L. Determinants of exercise-induced changes in mitral regurgitation in patients with coronary artery disease and left ventricular dysfunction. J Am Coll Cardiol 2003;42:1921-1928.[Abstract/Free Full Text]
  4. Messas E, Guerrero JL, Handschumacher, MD, Conrad C, Chow CM, Sullivan S, et al. Chordal cutting: a new therapeutic approach for ischemic mitral regurgitation. Circulation 2001;104:1958-1963.[Abstract/Free Full Text]
  5. Fayad G, Modine T, Le Tourneau T, Al-Ruzzeh S, Ennezat PV, Decone C, et al. Chordal cutting technique through aortotomy: a new approach to treat chronic ischemic mitral regurgitation. J Thorac Cardiovasc Surg 2005;129:1173-1174.[Free Full Text]

Related Article

Reply to the Editor
Frank Langer and Hans-Joachim Schäfers
J. Thorac. Cardiovasc. Surg. 2007 134: 552-553. [Extract] [Full Text] [PDF]




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