European Journal of Echocardiography 2008 9(1):54-55; doi:10.1016/j.euje.2006.08.009
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2006. For permissions please email: journals.permissions@oxfordjournals.org.
Echocardiographic evaluation of mitral tethering for ‘chordal cutting’ procedure
U. Da Col,
I. Di Bella*,
G. Bardelli,
A. Affronti,
G. Koukoulis,
S. Pasquino and
T. Ragni
Department of Cardiac Surgery, Silvestrini Hospital, S. Andrea delle Fratte, 06100 Perugia, Italy
Received 20 March 2006; accepted after revision 22 August 2006; online publish-ahead-of-print 10 October 2006.
* Corresponding author. Tel: +39 75 5782213; fax: +39 75 5782214. E-mail address: isidorodibella{at}yahoo.it
 |
Abstract
|
|---|
‘Chordal cutting’ is a recently proposed surgical
option for the treatment of functional mitral regurgitation
due to leaflet tethering. With this technique the surgeon sections
second order chordae, restores leaflet's convexity towards the
left atrium and eliminates mitral incompetence. Preoperative
assessment of tethering mechanism, degree of leaflet distortion,
surface of coaptation, annular dilation, origin and quantification
of valve incompetence by echocardiographic means is essential
in indicating this surgical option. Intraoperative transesophageal
evaluation is crucial to assess the morphology and the absence
or degree of residual incompetence after procedure.
Keywords: Mitral incompetence; Tethering; Mitral valve repair
|
Introduction
|
|---|
The leading mechanism of functional mitral regurgitation (FMR)
is an outward and apical displacement of the papillary muscles
due to left ventricular remodelling which causes leaflet tethering.
1–4 Surface of coaptation is reduced with failure of closure at
annulus level.
3,5 Left ventricular dysfunction
2 and annular
dilatation increase valve incompetence. These findings can explain
why annular size reduction alone may be an incomplete treatment.
1,3,6,7 Recently, a group of new surgical options were introduced and
the most recent is ‘chordal cutting’.
1,3 It seems
to be simpler,
3 effective in experimental models,
8 although
poor in clinical data available. ‘Main’ or ‘strut’
anterior leaflet chordae are a couple of thicker second order
chordae, crucial in maintaining leaflet shape; responsible for
leaflet tethering when papillary muscle displacement occurs.
3,4,5,9 This results in leaflet concavity towards the left atrium, as
opposed to normal concavity towards the left ventricle. This
echocardiographic finding has been named the ‘seagull
sign’.
5 We present a case of FMR treated by ‘chordal
cutting’ .
|
Case report
|
|---|
A 68-year-old man was admitted at our institution with a history
of inferior myocardial infarction and episodes of congestive
heart failure. Preoperative transthoracic echocardiography (
Figure 1A and
1B) showed dilated left ventricle (LVEDD 65 mm, LVESD 45
mm), ejection fraction 30%, with impaired inferior, posterior
and apical wall motion. Mitral incompetence was 3+/4+ and functional
with specific echocardiographic patterns. The valve anatomy
was normal, but the leaflets showed restricted motion and did
not reach the annular plane. The coaptation point was lateralized
and displaced towards the apex with tenting area >2 cm
2.
The anterior leaflet appeared angulated for second order chordae
tethering with concavity towards the left atrium. The degree
of regurgitation was reduced in midsystole. A moderate annular
dilatation was observed. Coronary angiography showed two-vessels
disease. He underwent myocardial revascularization with two
saphenous vein grafts. The mitral valve repair was performed
by resection of the medial ‘main chorda’ of the
anterior leaflet (
Figure 2) and annuloplasty using a complete
flexible ring (Sovering no. 30; Sorin Biomedica, Saluggia, Italy)
chosen using a specific sizer and according to body surface
area. The intraoperative transesophageal echocardiography (
Figure 3) performed with arterial systolic pressure >100 mmHg showed
no residual incompetence, restored coaptation point and normal
anterior leaflet with convexity towards the left atrium. No
posterior leaflet tethering was observed. The residual functional
mitral area was >2.5 cm
2. Predischarge transthoracic echocardiography
showed dilated left ventricle (LVEDD 63 mm, LVESD 40 mm), ejection
fraction 35% with unchanged regional wall motion and trivial
mitral incompetence.
|
Discussion
|
|---|
‘Chordal cutting’ seems to be an effective and simple
technique for the surgical treatment of FMR due to leaflet tethering.
Nevertheless, since this option is specifically applied to a
single anatomical structure, a correct preoperative diagnosis
by means of echocardiography is crucial. The presence of a concavity
of the anterior leaflet towards the left atrium due to angulation
deriving by leaflet tethering is the main pattern that seems
directly related to the degree of incompetence.
5 In these specific
cases the annuloplasty alone could be ineffective leading to
recurrence of mitral incompetence
1–4,7 and ‘chordal
cutting’ seems to optimize the procedure. The decision
of which chorda to cut is based essentially on preoperative
surface echocardiography and intraoperative transesophageal
exam. Flexible ring is our first choice because it maintains
mitral annular three-dimensional shape. Since we treat each
anatomical lesion leading to mitral incompetence (anterior leaflet
tethering and annular dilatation) we do not undersize the ring.
An intraoperative transesophageal exam allows the surgeon to
evaluate the result obtained. We consider the repair acceptable
if the residual mitral incompetence is absent/mild, the normal
morphology of the leaflet is restored, and residual functional
area is >2.5 cm
2. Echocardiography is the right tool to identify
each single modification of the mitral apparatus for preoperative
evaluation, intraoperative assessment and follow-up.
|
References
|
|---|
- Tanemoto K. Surgical treatment of ischemic mitral valve regurgitation. Ann Thorac Cardiovasc Surg (2005) 11:228–31.[Medline]
- Levine RA, Hung J, Otsuji Y, Messas E, Liel-Cohen N, Nathan N, et al. Mechanistic insights into functional mitral regurgitation. Curr Cardiol Rep (2002) 4:125–9.[Medline]
- Messas E, Luis Guerrero J, Handshumacher M, Conrad C, Chow CM, Sullivan S, et al. Chordal cutting. A new therapeutic approach for ischemic mitral regurgitation. Circulation (2001) 104:1958–63.[Abstract/Free Full Text]
- Matsunaga A, Tahta SA, Duran CM. Failure of reduction annuloplasty for functional ischemic mitral regurgitation. J Heart Valve Dis (2004) 13:390–7. [discussion 397–8].[Web of Science][Medline]
- Nesta F, Otsuji Y, Handschumacher MD, Messas E, Leavitt M, Carpentier A. Leaflet concavity: a rapid visual clue to the presence and mechanism of functional mitral regurgitation. J Am Soc Echocardiogr (2003) 16:1301–8.[CrossRef][Web of Science][Medline]
- Wakijama H, Okada Y, Kitamura A, Tsuda S, Shomura Y, Shinkai M, et al. Chordal cutting for the treatment of ischemic mitral regurgitation: two case reports. J Cardiol (2004) 44:113–7.[CrossRef][Medline]
- Terai H, Tao K, Sakata R. Surgical treatment for ischemic mitral regurgitation: strategy for a tethered valve. Ann Thorac Cardiovasc Surg (2005) 11:288–92.[Medline]
- Messas E, Pouzet B, Touchot B, Guerrero JL, Vlahakes GJ, Desnos M, et al. Efficacy of chordal cutting to relieve chronic persistent ischemic mitral regurgitation. Circulation (2003) 108((Suppl 1):II):111–5.[CrossRef]
- Rodriguez F, Langer F, Harrington KB, Tibayan FA, Zasio MK, Liang D, et al, J Heart Valve Dis. Effect of cutting second-order chordae on in-vivo anterior mitral leaflet compound curvature. (2005) 14:592–601. [discussion 601–2].
CiteULike 
Connotea 
Del.icio.us What's this?
Top
Abstract
Introduction
