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Stefanelli G. Different methods of neo-chordal fixation to the papillary muscle: Do they have any influence on the chordal biomechanical characteristics? J Card Surg 2022; 37:4416-4417. [PMID: 36229972 DOI: 10.1111/jocs.17025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 09/26/2022] [Indexed: 01/06/2023]
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Di Mauro M, Bonalumi G, Giambuzzi I, Messi P, Cargoni M, Paparella D, Lorusso R, Calafiore AM. Mitral valve repair with artificial chords: Tips and tricks. J Card Surg 2022; 37:4081-4087. [PMID: 36321669 PMCID: PMC10092434 DOI: 10.1111/jocs.17076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/22/2022] [Accepted: 09/29/2022] [Indexed: 11/07/2022]
Abstract
Mitral valve regurgitation (MR) is a common valvular disorder occurring in up to 10% of the general population. Mitral valve reconstructive strategies may address any of the components, annulus, leaflets, and chords, involved in the valvular competence. The classical repair technique involves the resection of the prolapsing tissue. Chordal replacement was introduced already in the '60, but in the mid '80, some surgeons started to use expanded polytetrafluoroethylene (ePTFE) Gore-Tex sutures. In the last years, artificial chords have been used also using transcatheter approach such as NeoChord DS 1000 (Neochord) and Harpoon TSD-5. The first step is to achieve a good exposure of the papillary muscles that before approaching the implant of the artificial chords. Then, the chords are attached to the papillary muscle, with or without the use of supportive pledgets. The techniques to correctly implant artificial chords are many and might vary considerably from one center to another, but they can be summarized into three big families of suturing techniques: single, running or loop. Regardless of how to anchor to the mitral leaflet, the real challenge that many surgeons have taken on, giving rise to some very creative solutions, has been to establish an adequate length of the chords. It can be established based on anatomically healthy chords, but it is important to bear in mind that surgeons work on the mitral valve when the heart is arrested in diastole, so this length could fail to replicate the required length in the full, beating heart. Hence, some surgeons suggested techniques to overcome this problem. Herein, we aimed to describe the current use of artificial chords in real-world surgery, summarizing all the tips and tricks.
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Affiliation(s)
- Michele Di Mauro
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Giorgia Bonalumi
- Department of Cardiac Surgery, IRCCS Monzino Cardiology Center, Milan, Italy.,DISCCO (Dipartimento di Scienze Cliniche e di Comunità), University of Milan, Milan, Italy
| | - Ilaria Giambuzzi
- Department of Cardiac Surgery, IRCCS Monzino Cardiology Center, Milan, Italy.,DISCCO (Dipartimento di Scienze Cliniche e di Comunità), University of Milan, Milan, Italy
| | - Pietro Messi
- DISCCO (Dipartimento di Scienze Cliniche e di Comunità), University of Milan, Milan, Italy.,Department of Cardiac Surgery, Istituto Clinico Sant'Ambrogio, Milan, Italy
| | - Marco Cargoni
- Department of Cardiac Anesthesia, Mazzini Hospital, Teramo, Italy
| | - Domenico Paparella
- Department of Medical and Surgical Sciences, Division of Cardiac Surgery, University of Foggia, Foggia, Italy.,Division of Cardiac Surgery, Santa Maria Hospital, GVM Care & Research, Bari, Italy
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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Fernández L, Monzonís AM, El-Diasty MM, Álvarez-Lorenzo C, Concheiro Á, Fernández ÁL. Biomechanical characteristics of different methods of neo-chordal fixation to the papillary muscles. J Card Surg 2022; 37:4408-4415. [PMID: 36229983 PMCID: PMC10092600 DOI: 10.1111/jocs.17027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/15/2022] [Accepted: 09/03/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND AIM OF THE STUDY Several techniques have been described for neo-chordal fixation to the papillary muscles without any reported clinical differences. The objective of this study is to compare in vitro the biomechanical properties of four of these common techniques. METHODS We studied the biomechanical properties of expanded polytetrafluoroethylene neo-chordal fixation using four techniques: nonknotted simple stitch, nonknotted figure-of-eight stitch, knotted pledgeted mattress stitch, and knotted pledgeted stitch using commercially available prefabricated loops. Neo-chordae were submitted to a total of 20 traction-relaxation cycles with incremental loads of 1, 2, and 4 N. We calculated the elongation, the force-strain curve, elasticity, and the maximum tolerated load before neo-chordal failure. RESULTS The elongation of the neo-chordae was lowest in the simple stitch followed by the figure-of-eight, the pledgeted mattress, and he commercially prefabricated loops (p < .001). Conversely, the elastic modulus was highest in the simple stitch followed by the figure-of-eight, the pledgeted mattress, and the prefabricated loops (p < .001). The maximum tolerated load was similar with the simple stitch (28.87 N) and with the figure-of-eight stitch (31.39 N) but was significantly lower with the pledgeted mattress stitch (20.51 N) and with the prefabricated loops (7.78 N). CONCLUSION In vitro, neo-chordal fixation by nonknotted simple or nonknotted figure-of-eight stitches resulted in less compliance as opposed to the use of knotted pledgeted stitches. Fixation technique seemed to influence neo-chordal biomechanical properties, however, it did not seem to affect the strength of the suture when subjected to loads within physiological ranges.
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Affiliation(s)
- Luis Fernández
- Department of Applied Physics, School of Physics, University of Santiago de Compostela, Santiago, Spain
| | | | | | - Carmen Álvarez-Lorenzo
- Department of Pharmacology, Pharmacy, and Pharmaceutical Technology, University of Santiago de Compostela, Santiago, Spain
| | - Ángel Concheiro
- Department of Pharmacology, Pharmacy, and Pharmaceutical Technology, University of Santiago de Compostela, Santiago, Spain
| | - Ángel L Fernández
- Divison of Cardiac Surgery, Department of Surgery, University Hospital, University of Santiago de Compostela, Santiago, Spain
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Castaño M, Maiorano P, Castillo L, Laguna G, Martín-Gutiérrez E, Gualis Cardona J, Guevara A. Reparación mitral en prolapso de velo anterior: técnicas, indicaciones y resultados. CIRUGIA CARDIOVASCULAR 2022. [DOI: 10.1016/j.circv.2022.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Tabata M, Kasegawa H, Fukui T, Shimizu A, Sato Y, Takanashi S. Long-term outcomes of artificial chordal replacement with tourniquet technique in mitral valve repair: a single-center experience of 700 cases. J Thorac Cardiovasc Surg 2014; 148:2033-2038.e1. [PMID: 24768103 DOI: 10.1016/j.jtcvs.2014.03.045] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Revised: 02/28/2014] [Accepted: 03/21/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Artificial chordal replacement has been shown to be effective and durable, with numerous techniques reported. However, the outcomes of each technique have remained poorly defined. We report the long-term outcomes of the tourniquet technique. METHODS We reviewed the data from 700 patients who had undergone mitral valve repair with the tourniquet technique from 1992 to 2010. We analyzed the operative outcomes, long-term survival rate, freedom from reoperation, and freedom from recurrent moderate or severe mitral regurgitation (MR). We also performed Cox regression analysis to explore the predictors of recurrent MR after mitral valve repair using the tourniquet technique. RESULTS The mean age was 54.7±14.9 years; 212 patients (30.3%) had anterior leaflet prolapse, 142 (20.3%) had posterior leaflet prolapse, and 346 (49.4%) had bileaflet prolapse. Operative mortality was 1.3%. In 26 cases (3.7%), mitral valve repair was unsuccessful and was converted to replacement. Of those successfully repaired, the 12-year survival rate, freedom from mitral reoperation, freedom from recurrent moderate or severe MR, and freedom from recurrent leaflet prolapse was 85.9%, 88.7%, 72.3%, and 89.0%, respectively. The significant predictors of recurrent MR were anterior leaflet prolapse, age, New York Heart Association class III or IV, left ventricular end-systolic dimension, no annuloplasty ring or band, and postoperative residual mild or greater MR. CONCLUSIONS The tourniquet technique is a simple and effective method to repair leaflet prolapse, with a low incidence of recurrent prolapse. The incidence of recurrent MR was high in the anterior leaflet prolapse group. Age, no annuloplasty ring or band, and residual MR were strong predictors of recurrent MR.
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Affiliation(s)
- Minoru Tabata
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan.
| | - Hitoshi Kasegawa
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan
| | - Toshihiro Fukui
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan
| | - Atsushi Shimizu
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan
| | - Yasunori Sato
- Clinical Research Center, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Shuichiro Takanashi
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan
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García Fuster R, Martín E, Paredes F, Mena A, Cánovas S, Gil O, Hornero F, Martínez J. Artificial chordae in the setting of complex mitral valve repair: early outcomes using the folding leaflet technique. Interact Cardiovasc Thorac Surg 2014; 18:586-95. [DOI: 10.1093/icvts/ivu013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Ibrahim M, Rao C, Athanasiou T. Artificial chordae for degenerative mitral valve disease: critical analysis of current techniques. Interact Cardiovasc Thorac Surg 2012; 15:1019-32. [PMID: 22962321 DOI: 10.1093/icvts/ivs387] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The surgical repair of degenerative mitral valve disease involves a number of technical points of importance. The use of artificial chordae for the repair of degenerative disease has increased as a part of the move from mitral valve replacement to repair of the mitral valve. The use of artificial chordae provides an alternative to the techniques pioneered by Carpentier (including the quadrangular resection, transfer of native chordae and papillary muscle shortening/plasty), which can be more technically difficult. Despite a growth in their uptake and the indications for their use, a number of challenges remain for the use of artificial chordae in mitral valve repair, particularly in the determination of the correct length to ensure optimal leaflet coaptation. Here, we analyse over 40 techniques described for artificial chordae mitral valve repair in the setting of degenerative disease.
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Affiliation(s)
- Michael Ibrahim
- Harefield Heart Science Centre, National Heart and Lung Institute, Imperial College London, Harefield Hospital, Middlesex, UK
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Mitral Valve Repair With Artificial Chordae: A Review of Its History, Technical Details, Long-Term Results, and Pathology. Ann Thorac Surg 2012; 93:684-91. [DOI: 10.1016/j.athoracsur.2011.09.015] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2011] [Revised: 09/02/2011] [Accepted: 09/09/2011] [Indexed: 11/22/2022]
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Chang JP, Kao CL. Slit stent technique for ensuring the correct length of artificial chordae in mitral repair. J Card Surg 2011; 26:259-60. [PMID: 21443738 DOI: 10.1111/j.1540-8191.2011.01237.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Excellent long-term results have been described for replacement of diseased mitral valve chordae with polytetrafluoroethylene sutures. Tying the knot at the intended length of the artificial chordae is technically demanding. Herein, a simple and reproducible method, using a slit plastic tube for stenting the artificial chordae at the intended length is described. With this technique, the knot of the premeasured artificial chordae can be tied surely without change in the length.
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Affiliation(s)
- Jen-Ping Chang
- Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Kaohsiung, Taiwan.
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Bizzarri F, Tudisco A, Ricci M, Rose D, Frati G. Different ways to repair the mitral valve with artificial chordae: a systematic review. J Cardiothorac Surg 2010; 5:22. [PMID: 20377866 PMCID: PMC2873358 DOI: 10.1186/1749-8090-5-22] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2009] [Accepted: 04/08/2010] [Indexed: 11/17/2022] Open
Abstract
Myxomatous mitral regurgitation (type II Carpentier's functional classification) affects about 1-2% of the population. This represents a very common indication for valve surgery resulting in a low percentage of repairs compared to replacement which is actually performed. In the last decades, several methods for mitral valve repair have been developed, to make the surgical feasibility easier, improve the long-term follow-up thus avoiding the need for reoperations. A very interesting method is represented by the combination of various valve repair techniques, depending on the involvement of the anterior, posterior, or both leaflets, and the use of PTFE artificial chordae tendineae when excessive chordal elongation or rupture due to myxomatous degeneration co-exists. The aim of this review is to summarize the evolution of these techniques from the beginning till now.
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Affiliation(s)
- Federico Bizzarri
- Cardiac Surgery Unit, Polo Pontino, Heart and Great Vessels Department, University of Rome Sapienza, Latina, Italy.
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