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J Thorac Cardiovasc Surg 2009;137:504-506
© 2009 The American Association for Thoracic Surgery

Brief Communication

Late rupture of polytetrafluoroethylene neochordae after mitral valve repair

^a Division of Cardiac Surgery, Department of Cardiothoracic Surgery, Brigham & Women's Hospital, Boston, Mass
^b Department of Surgery, Brigham & Women's Hospital, Boston, Mass
^c Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women's Hospital, Boston, Mass

Received for publication January 31, 2008; accepted for publication February 13, 2008.

^_* Address for reprints: Robert Saeid Farivar, MD, PhD, 200 Hawkins Dr lowa city, IA 52242. (Email: robert-farivar{at}uiowa.edu).

Mitral valve repair is the procedure of choice to correct mitral regurgitation. The introduction of polytetrafluoroethylene (PTFE) sutures was an important contribution by David¹ and Zussa and colleagues² for the treatment of chordal shortening or for chordal replacement during mitral valve repair. This report describes a patient with acute-onset hematuria 11 years after mitral valve repair who was found to have fractured PTFE neochordae necessitating mitral valve replacement.

Clinical Summary

A 57-year-old man was transferred to our hospital with acute onset of hemoglobinuria. A transesophageal echocardiogram revealed a mobile density attached to the mitral leaflet with severe mitral regurgitation. His history was notable for a mitral valve repair in 1996 (11 years previously) by one of the authors (L.H.C.), with PTFE neochordae created for the anterior leaflet for myxomatous disease and the placement of a 30-mm Cosgrove-Edwards annuloplasty ring (Edwards Lifesciences LLC, Irvine, Calif). The patient's myxomatous anterior leaflet had had six ruptured native chordae that were resected, along with a portion of the anterior leaflet. Two PTFE neochordae were then created from the posteromedial and anterolateral papillary muscles in mattress fashion, anchoring the chordae on the papillary muscles with polytetrafluoroethylene pledgets. The patient had been well for 11 years after that procedure, with no cardiovascular symptoms since his initial mitral valve repair and normal results of repeated echocardiograms.

Intraoperative transesophageal echocardiography revealed a flail anterior leaflet with 4+ insufficiency ( Figures 1 and 2). The mitral valve was approached through a full sternotomy with ascending aortic cannulation, bicaval venous cannulation, and antegrade blood cardioplegia. The Sondergäard groove was developed to approach the left atrium. Valve inspection revealed the two PTFE neochordae in the anterior leaflet to be thickened, stiffened, and fractured midshaft. The native anterior leaflet was diffusely myxomatous, variably thickened, and fibrotic. The valve was irreparable, so the anterior mitral leaflet was resected and the posterior leaflet preserved. The previous ring was removed, and valve replacement was performed with a 27-mm St Jude Medical bileaflet valve with an expanded PTFE cuff (St Jude Medical Inc, Minneapolis, Minn). The patient did well and was discharged home on postoperative day 5 with anticoagulation.

View larger version (60K): [in this window] [in a new window]   Figure 1. Real-time 3-dimensional transesophageal echocardiographic en face image of mitral valve from left atrial perspective showing original Cosgrove-Edwards annuloplasty ring (white arrows) and flail anterior leaflet (red arrow). PMC, Posteromedial commissure; ALC, anterolateral commissure.

View larger version (74K): [in this window] [in a new window]   Figure 2. Real-time 3-dimensional transesophageal echocardiographic image of mitral valve apparatus from left ventricular perspective showing fractured neochordae (red arrow). LVOT, Left ventricular outflow tract; PL, posterior mitral valve leaflet; AL, anterior mitral valve leaflet.

PTFE neochordae have been used for a variety of mitral reconstructive procedures. They were introduced and evaluated experimentally in sheep and shortly thereafter introduced by David¹ and Zussa and colleagues² for patients undergoing mitral valve surgery. PTFE neochordae have since been used in minimally invasive procedures and the pediatric population.

To date, there has been only a single published report, by Butany and associates in 2004,³ of a PTFE neochordal fracture in a patient with mitral neochordae constructed for anterior leaflet pathology in a rheumatic valve. This fracture was noted at reoperation, 14 years after the initial repair. Butany and associates³ postulated that calcification of the PTFE suture had led to fracture, and the patient's valve was replaced as in our case. Similarly, the PTFE suture was calcified and had been degraded.

Although it is known to be extremely durable, the natural history of PTFE suture has not been completely elucidated. PTFE has a greater than 50% porosity. As a linear, nonabsorbent, monofilament polymer, it has a breaking strength almost an order of magnitude greater than that of native chordae (1 kg vs 60–200 mg, respectively). There is some compliance in the suture. It has an electronegative charge, similar to native endothelium. Although thought to repel hematocytes and tissue incorporation initially, eventually it is covered by host fibrosa and endothelium. Finally, calcium has been noted to penetrate the interstices with possible stiffening.³ This gives neochordae the potential for calcification, with the potential for eventual fracture.

Several investigators have documented durability of PTFE neochordae in the midterm (<10 years). David and coworkers⁴ have shown no PTFE fractures in 134 patients at 8 years, and Kobayashi and associates⁵ have shown no PTFE failures in 74 patients at 10 years. Even in children, who have a tendency toward quite rapid calcification of bioprosthetic valves, no fractures have been reported. Stiffening of the PTFE chord has the potential to result in mitral valve insufficiency. Although midterm durability has been excellent, the long-term (>10 y) outcome remains unreported.

Our patient had hemolytic anemia and hemoglobinuria, well-recognized complications of mitral valve surgery that are rare after mitral valve repair. This is the first report of fractured chordae leading to hemolysis and hematuria as a result of whiplash motion of the chordae and trauma on the patient's red blood cells.

References

1. David TE. Replacement of chordae tendineae with expanded polytetrafluoroethylene sutures. J Card Surg 1989;4:286-290.[Medline]
   
2. Zussa C, Frater RW, Polesel E, Galloni M, Valfre C. Artificial mitral valve chordae: experimental and clinical experience. Ann Thorac Surg 1990;50:367-373.[Abstract/Free Full Text]
   
3. Butany J, Collins MJ, David TE. Ruptured synthetic expanded polytetrafluoroethylene chordae tendineae. Cardiovasc Pathol 2004;13:182-184.[Medline]
   
4. David TE, Armstrong S, Sun Z. Replacement of chordae tendineae with Gore-Tex sutures: a ten-year experience. J Heart Valve Dis 1996;5:352-355.[Medline]
   
5. Kobayashi J, Sasako Y, Bando K, Minatoya K, Niwaya K, Kitamura S. Ten-year experience of chordal replacement with expanded polytetrafluoroethylene in mitral valve repair. Circulation 2000;102(19 Suppl 3):III30-III34.[Medline]
   

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Stanton K. Shernan Lawrence H. Cohn Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Farivar, R. S. Articles by Cohn, L. H. Search for Related Content PubMed Articles by Farivar, R. S. Articles by Cohn, L. H. Related Collections Related Article