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In our Mitral Foundation Video Teaching Library, we are going to feature a series
of cases that demonstrate specific teaching points
in the field of mitral valve reconstruction.
In this video, we're going to present
a patient with anterior leaflet mitral valve prolapse.
And show a repair technique consisting of
both chordal transposition as well as neochordoplasty.
These are our disclosures.
There are a variety of repair strategies that are useful for anterior leaflet prolapse.
The main stays of reconstruction strategies include PTFE neochordoplasty,
anterior leaflet secondary chordal transposition, posterior leaflet chordal
transposition or posterior leaflet flip technique as well as triangular resection.
In today's case, we are going to emphasize technical points around PTFE neochordoplasty,
as well as anterior leaflet secondary chordal transposition.
Secondary chordal transposition into the anterior leaflet is
a very useful technique as we'll demonstrate.
It is particularly relevant in defining the height of the margin of the leaflet.
PTFE neochordoplasty is a mainstay technique at this point for anterior leaflet prolapse.
In this particular video, we're going to show a technique of single suture PTFE,
placed in the tip of the papillary muscle and passed through the free edge,
with final height adjustment during saline testing.
That is, a functional height adjustment, as opposed to geometric adjustment.
The case we are going to show is a 35 year
old woman who developed progressive dyspnea while under surveillance for mitral
valve regurgitation Her latest transthoracic
echocardiogram demonstrated normal ventricular size and function
as well as anterior leaflet prolapse and severe mitral valve regurgitation,
as is evident on the parasternal long axis and four chamber views.
She has a severe degree of mitral valve regurgitation,
which is posteriorly directed, and excess motion and prolapse, of the anterior leaflet.
This is the operative view, of her mitral valve.
You can see the posterior leaflet is small and looks normal.
The anterior leaflet appears to prolapse on saline testing.
The first step in all valve reconstruction, particularly for anterior leaflet prolapse,
is to place your annuloplasty sutures and optimize exposure.
Here you can see we're using a back hand technique across the superior
portion of the valve and encouraging cross over when necessary.
We usually will perform a forehand technique on the vertical
aspects of the valve and backhand on the horizontal aspects.
You can also see that we do not discourage
crossing sutures and we will respect the location of sutures
in the annuloplasty ring that have crossed on the annulus.
Placing these sutures first also gives us a good point of reference, to
adjust the height of the chords, and thus correct the prolapse.
You can already see the difference in the saline testing after placing ring sutures.
And now we can start to mark the areas of prolapse.
There are no obvious chord ruptures here, and that's why it's important
I think to create this plane of the annulus with sutures.
You saw us cut a secondary chord as a
first step, and now we're placing these figure of eight
sutures in the tips of papillary muscles, and we're lining
these up along the margin that we want to correct.
Now in this cut secondary chord we're using a 5-0 Prolene, creating a figure
of eight suture in it as a tag at first, and now you can see we've
identified another papillary muscle and we're placing a second 5-0 PTFE
figure of eight suture in the fibrous portion of this chord.
Additionally, we found a good secondary chord and we're also marking this with 5-0 Prolene.
Our first step with this technique then is to attach
the secondary chords to the margin of the leaflet.
You can see it's very useful that we marked
the areas of prolapse and this helps direct us
where to attach these, or transpose these secondary chords.
This
is usually done with a simple mattress suture, and these are then tied securely.
The advantages of first step of this approach, is it begins to
correct the height of the margin of the anterior leaflet.
We typically would not use this as
our only repair strategy, for anterior leaflet prolapse.
But as you'll see, it's a very useful technique and will
help us also guide the height of the neochordoplasty.
So there you can see we've corrected the
majority of the prolapse just by chordal transposition.
There's still a prolapse in the A3 segment, and we have placed our
Gore-Tex chord exactly in the right location, so that we can now pass this through the free
margin of the leaflet without any crossover of other chords.
And here you
can see how we've lined that up,
there was actually a fan chord that was prolapsing with no rupture.
And now we'll just tie a couple of knots, and then we can start
to think about a geometric adjustment as opposed to functional adjustment of the height.
You can see that we can slide these knots up or down depending on
whether we think they're too loose or too tight, lowering the leaflet too low
into the ventricle, so again the same maneuver.
We now take another Gore-Tex chord that we previously placed.
We respect the position of the remaining chords as well
as the transposed chords so that we don't cross them.
Pass them through the free margin and tie a few knots that can still
be slid up or down depending on our functional testing with saline.
Now you can see we've actually added five different points, two chordal transpositions
and three neochordoplasty, to help support the margin of the leaflet.
The next step is to implant the annuloplasty ring.
And see this patient has a small valve, that's a true size 28 Phyiso ring.
And now after implantation of the ring, we perform
another saline test to confirm the height of each Gore-Tex chord.
Once you're satisfied, you can tie and secure each
one of these and then cut them, as we've done.
And now we'll fill the ventricle for one final saline test
and you can see excellent coaptation, and a very symmetric closure line.
Finally we'll mark the margin of the valve with the ventricle
full, and as we empty the ventricle, we can assess
an excellent depth of closure and a symmetric closure line.
Here's the final four chamber transesophagael
echo showing excellent coaptation and preserved
mobility of the anterior leaflet and no residual mitral valve regurgitation.
This teaching video made several important points.
The first was that anterior leaflet prolapse can
result from chordal elongation as opposed to chordal rupture.
In this setting, it is particularly important to mark the areas of prolapse.
Reestablishing support at all points where you identify
a prolapse is the mainstay for a reconstructive strategy.
In this case we began by performing chordal transfer.
Secondary chordal transfer has the main advantage of providing a great height
reference in a majority of cases, as well as providing living tissue at the margin
Single PTFE neochordoplasties as a primary and
sometimes a supplemental technique when chordal transfer corrects the prolapse
is extremely versatile and allows fine tuning at the margin of the leaflet.
As opposed to a geometric chordal adjustment where you're
trying to measure a distance between the annular plane or
the marginal leaflet in the tip of papillary muscle, as this case showed, an isolated
neochordoplasty technique allows you to functionally adjust the height of the chord
under saline testing. We found this to be a
very useful adjunct to ensure proper height of the chord.
As you can see it also allows us to ensure the
optimal closure depth and symmetry of the closure line.
We hope you found this case educational and
encourage you to email us with questions or comments,
as well as suggestions for future teaching videos that
we will then add to our Mitral Foundation Library.