Mitral valve replacement

chordal sparing technique

Respect and not resect!!!

Basics
The left ventricular geometry and function
are a result of a dynamic interaction
between the mitral annulus and the LV wall.
During systole, the ventricle undergoes
counter clockwise torsional deformation of
the apex with respect to base;
During isometric relaxation and in early
diastole, this is reversed (diastolic recoil)

Disruption of the papillary-annular

continuity impairs this torsional deformation
thereby causing abnormal diastolic function
and disruption of normal LV stress-strain
patterns.

Mechanism
The function of the chordae and papillary
muscles was eloquently compared to a pair
of gymnasts on parallel bars.
As the gymnasts (chordae) move towards
the parallel bars (mitral annulus), they bring
the floor (LV wall) with them and in addition
prevent overstretching of the LV cavity

When both the anterior and posterior

chordae are divided, the gymnasts do not
have the arms to pull themselves up.
and in an attempt to reach the bars, they
have to jump higher and higher, but with
each attempt they sink lower, resulting in
dilatation of the LV cavity and thinning of its
walls.

PML preservation

Lillehei, introduced- the posterior leaflet was

bound to the annulus with a running stitch.
In 2 of the 23 patients, this stitch was
continued around the entire annular
circumference and chordae to both the AML
and PML were preserved.
In the remaining 21 patients, only the PML
was preserved because it was thought that
the AML would interfere with the ball of the
caged ball valve prosthesis used for MVR.

Using this technique, Lillehei reported

reduction in operative mortality from 37%
to 14%.
Method of AML preservation- should avoid
the systolic anterior motion of the AML
which has the potential to produce LVOTO.

David technique
The AML is incised at its base, 2-3 mm from
its attachment.
The incision is carried to both the sides and
brought down centrally towards the free
edge of the leaflet and a triangular segment
of the AML is thus excised leaving the
chordae attached to the remaining AML
which is re-suspended to the mitral annulus
by sutures used to secure the prosthetic
valve.
Added, the PML is also excised in MVPS.

Advantages
The maintenance of the chordae in their
natural anatomic orientation,
Reduced risk of LVOTO
Reduction in the bulk of leaflet tissue.

Feikes technique
The AML is split from the centre of the free
edge towards the annulus.
Incisions are made on either side of this
split towards the two commissures to
detach the AML from the annulus.
The resulting two halves of the leaflet along
with the intact chordae are trimmed to
remove thickened and calcific areas and
then rotated posteriorly and sutured to the
posterior mitral annulus.

Comments
Implanting tilting disc prosthesis where disc
entrapment by the subvalvular apparatusadvantageous
Disadvantage of this technique is that it
disturbs the normal geometric relationships
of the mitral subvalvular apparatus which
could alter the distribution of regional LV
wall stresses

Khonsari technique
After the AML is detached from the annulus
between the two commissures, an ellipse of
tissue is excised and the rim of the leaflet
tissue containing the chordae is reattached
to the anterior annulus (Khonsari I
technique).
If the leaflet is thick or calcified, it is divided
into 2-5 chordal segments which are reattached to the annulus (Khonsari II
technique).

The PML is retained completely and the

redundant leaflet tissue is folded up into the
annulus by passing the valve sutures
through the annulus and bringing them
through the leading edge of the leaflet
tissue.
NO LVOTO or interference with prosthetic
valve function.
No myocardial rupture

Mikis technique

The AML is separated from the annulus and

incised in centre.
The anterior and posterior commissures are
incised and papillary muscles are split.
The two chordal segments thus created are
sutured to the respective antero-lateral and
posteromedial commissures.
The PML is incised in the centre and the
prosthetic valve is sutured in position plicating
the PML and including the AML and chordae in
valve sutures.

Rose and oz technique

The AML is stretched posteriorly and its
central portion is excised.
The rim of the remaining leaflet tissue
contains the marginal chordae.
The defect in the AML is then closed with a
running suture placed parallel to the
annulus.
Valve sutures are placed to reinforce the
previously running suture line.

Beware
Attachments are of sufficient length to
moderate left ventricular distension during
diastole and wall tension during systole.
Care should be taken to prevent excessive
shortening of the chordae as it may cause
rupture of a papillary muscle head.

Results
LV function was superior with an intact
subvalvular apparatus, intermediate with
preservation of either the AML or PML and
poorest with loss of all chordae.
Chordal preservation preserving the PML
alone improved the event-free survival.
The exercise capacity improved markedly,
LV function improved and resting ejection
fraction was preserved.

significant improvement in right ventricular

function after LV chordal preservation.

Which technique???
No statistically significant difference
between the results of anterior (Khonsari)
and posterior (Feikes) technique in terms of
global LV systolic and diastolic function.
no significant difference between posterior
chordal preservation alone or the total
chordal preservation group.