EFFECTS OF MITRAL VALVE REPLACEMENT WITH AND WITHOUT CHORDAL PRESERVATION ON CARDIAC FUNCTION: EARLY AND MID-TERM RESULTS

Authors

  • Saad Bader Zakai
  • Salman -Ur-Rehman Khan
  • Fazle Rabbi
  • Habiba Tasneem

Abstract

Background: Convention mitral valve (MV) replacement is known to cause deterioration in theleft ventricle function, the major mechanism responsible being disruption of the annulo-papillarycontinuity, thus favoring preservation of the mitral subvalvular apparatus. The aim of this studywas to compare the early and midterm results, in terms of cardiac mechanics and clinicaloutcomes, of preserving the subvalvular apparatus (partial/complete) verses resection duringmitral valve replacement. Methods: This was a prospective non randomised trial. One hundredand twenty-two patients (mean age 40.36±14.27 years) admitted for MV replacement fromJanuary 2009 to September 2009 were included in the study. They were divided into 3 groups:complete excision of the subvalvular apparatus (group 1=32); preservation of the posterior leaflet(group 2=54) and total chordal preservation (group 3=36). Echocardiography was donepreoperatively, at discharge, and at 6 months follow-up. Results: The preservation groups 2, 3revealed marked improvements with respect to the End-diestolic Volume (EDV) and End-SystolicVolume (ESV) as compared to the non-preservation group 1 at discharge from hospital. At followup, the preservation groups showed improved EDV and ESV in contrast to the non-preservationgroup, where the ventricular volumes had a declining pattern. Ejection fraction remained belowthe baseline preoperative level in all three groups at discharge from hospital. In the follow-up,chordal preservation groups showed significant improvements in the ejection fraction as comparedto the resection group. An interesting finding was that of PA pressures and LA size between thegroups. It was significantly improved in the preservation groups as compared to the resectiongroup. At follow-up, 43.5% of patients in group 1 were in AF compared with 27.5% in group 2and 21.4% in group 3. More patients in group 1 were in NYHA functional class III or IV atfollow-up: 30.4% versus 7.5% and 7.1% respectively. Conclusion: Preservation of the mitralsubvalvular apparatus resulted in a greater decrease of ventricular dimensions at discharge whichwas maintained at follow-up; complete resection resulted in ventricular dilatation at follow-up.Furthermore, the ejection fraction improved in the preservation groups compared to the completeresection group which showed a decline at follow-up.Keywords: Mitral valve, MV preservation, MV replacement, chordal preservation, MV surgery,subvalvular apparatus

References

Lillehei CW. New ideas and their acceptance as it has related to

reservation of chordae tendinae and certain other discoveries. J

Heart Valve Dis 1995;4(suppl 2):S106–14.

Le Tourneau T, Grandmougin D, Foucher C, McFadden EP, de

Groote P, Prat A, et al. Anterior chordal transection impairs not

only regional left ventricular function but also regional right

ventricular function in mitral regurgitation. Circulation

;104(suppl 1):141–6.

Hannein HA, Swain JA, McIntosh CL, Bonow RO, Stone CD,

Clark RE. Comparative assessment of chordal preservation

versus chordal resection during mitral valve replacement. J

Thorac Cardiovasc Surg 1990;99:828–37.

Kayacioglu I, Ates M, Sensoz Y, Gorgulu S, Idiz M, Kanca A.

Comparative assessment of chordal preservation versus chordal

resection in mitral valve replacement for mitral stenosis (longterm follow-up: 8 years). Tohoku J Exp Med 2003;200:119–28.

Thomson LE, Chen X, Greaves SC. Entrapment of mitral chordal

apparatus causing early postoperative dysfunction of a St. Jude

mitral prosthesis. J Am Soc Echocardiogr 2002;15:843– 4.

Rozich JD, Carabello BA, Usher BW, Kratz JM, Bell AE, Zile

MR.. Mitral valve replacement with and without chordal

preservation in patients with chronic regurgitation: mechanism

for differences in postoperative ejection performance. Circulation

;86:1718–26.

Yun KL, Sintek CF, Miller DC, Pfeffer TA, Kochamba GS,

Khonsari S, et al. Randomized trial comparing partial versus

complete chordal-sparing mitral valve replacement: effects on

left ventricular volume and function. J Thorac Cardiovasc Surg

;123:707–14.

Talwar S, Jayanthkumar HV, Kumar AS. Chordal Preservation

during mitral valve replacement: basis, techniques and results.

IJTCVS 2005;21:45–52.

García-Fuster R, Estevez V, Gil O, Cánovas S, Martínez-Leon J.

Mitral valve replacement in rheumatic patients: effects of chordal

preservation. Ann Thorac Surg 2008;86:472–81.

Chowdhury UK, Kumar AS, Airan B, Mittal D, Subramaniam G,

Prakash R, et al. Mitral Valve Replacement with and without

Chordal Preservation in a Rheumatic Population: Serial

echocardiographic Assessment of Left Ventricular Size and

Function. Ann Thorac Surg 2005:79:1926–33.

Sintek CF, Pfeffer TA, Kochamba GS, Khonsari S. Mitral valve

replacement: technique to preserve the subvalvular apparatus.

Ann Thorac Surg 1995;59:1027–9.

Miki S, Kusuhara K, Ueda Y, Komeda M, Ohkita Y, Tahata T.

Mitral valve replacement with preservation of chordae tendinae

and papillary muscles. Ann Thorac Surg 1988;45:28–34.

Feikes HL, Daugharthy JB, Perry JE, Bell JH, Hieb RE,

Johnson GH. Preservation of all chordae tendinae and papillary

muscle during mitral valve replacement with a tilting disc valve. J

Cardiac Surg 1990;5:81–5.

Bonow RO, Carabello BA, Kanu C, de Leon AC Jr, Faxon DP,

Freed MD, et al. ACC/AHA 2006 guidelines for the

management of patients with valvular heart disease: a report of

the American College of Cardiology/American Heart Association

Task Force on Practice Guidelines. Circulation 2006;114:e84–

Douglas PS, Khandheria B, Stainback RF, Weissman NJ.,

Brindis RG, Patel MR,

ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007

appropriateness criteria for transthoracic and transesophageal

echocardiography: a report of the American College of

Cardiology Foundation Quality Strategic Directions

Committee Appropriateness Criteria Working Group,

American Society of Echocardiography, American

College of Emergency Physicians, American Society of

Nuclear Cardiology, Society for Cardiovascular

Angiography and Interventions, Society of

Cardiovascular Computed Tomography, and the Society

for Cardiovascular Magnetic Resonance endorsed by the

American College of Chest Physicians and the Society of

Critical Care Medicine. J Am Coll Cardiol 2007;50:187–204.

Starr A, Edwards ML. Mitral valve replacement: clinical

experience with a ball prosthesis. Ann Surg 1961;154:726.

Wiggers CS, Katz LM. Contour of the ventricular volume curves

under different conditions. Am J Physiol 1922;58:439–75.

Rushmer RF, Finlayson BL, Nash AA. Movements of the mitral

valve. Circ Res 1956;4:337–42.

Rastelli GC, Tsakiris AG, Banchero N, Wood EH, Kirklin

JW.Cardiac performance after replacement of the dog mitral valve

with Starr-Edwards prosthesis with and without preservation of the

chordae tendinae. Surg Forum 1966;17:178–79

Lillehei CW, Levy MJ, Bonnabeau RC. Mitral valve replacement

with preservation of papillary muscles and chordae tendinae. J

Thorac Cardiovasc Surg 1964;47:532–43.

Lillehei CW. Value of preserving chordal integrity. Both

experimental and clinical data. J Thorac Cardiovasc Surg

;46:494—5 .

Lillehei CW, Levy MJ, Bonnabeau RC. Complete mitral valve

replacement preserving papillary muscle-chordae tendineaeannulus continuity. Circulation 1963;28:757 .

Lillehei CW, Levy MJ, Bonnabeau RC. Mitral valve replacement

with preservation of papillary muscles and chordae tendineae. J

Thorac Cardiovasc Surg 1964;47:532–43.

Rastelli GC, Tsakiris AG, Frye RL, Kirklin JW. Exercise

tolerance and haemodynamic studies after replacement of canine

J Ayub Med Coll Abbottabad 2010;22(1)

http://www.ayubmed.edu.pk/JAMC/PAST/22-1/Saad.pdf

mitral valve with and without preservation of chordae tendineae.

Circulation 1967;35(Suppl.):I34–41.

Cohen LH, Reis RL, Morrow AG. Left ventricular function after

mitral valvereplacement. J Thorac Cardiovasc Surg 1968;56:11–5.

Rouleau CA, Frye RL, Ellis FH. Haemodynamic state after open

mitral valve replacement and reconstruction. J Thorac Cardiovasc

Surg 1969;58:870–8.

Hansen DE, Cahill PD, Derby GC, Miller DC. Relative

contributions of the anterior and posterior mitral chordae

tendineae to canine global left ventricular function. J Thorac

Cardiovasc Surg 1987;93:45–55.

Komeda M, David TE, Rao V, Sun Z, Weisel RD, Burns RJ.

Late hemodynamic effects of the preserved papillary muscles

during mitral valve replacement. Circulation 1994;90:II190–4.

Wasir H, Chaudhary SK, Airan B, Srivastava S, Kumar AS..

Mitral valve replacement with chordal preservation in a

rheumatic population. J Heart Valve Dis 2001;10:84–9.

Athanasiou T, Chow A, Rao C, Aziz O, Siannis F, Ali A,

Darzi A, Wells F. Preservation of the mitral valve apparatus:

evidence synthesis and critical reappraisal of surgical

techniques. Eur J Cardiothorac Surg 2008;33:391–401.

Published

2010-03-01