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Canadian Journal of Cardiology

STANDARDIZATION OF ARTIFICIAL CHORDAL LENGTH FOR POSTERIOR LEAFLET PROLAPSE: A SIMPLIFIED APPROACH FOR MULTIPLE SCENARIOS

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      BACKGROUND

      While leaflet resection is the most common repair technique for primary mitral regurgitation (MR), there has been a growing interest towards the use of artificial chords for the repair of primary MR. Neo-chord sizing is paramount to the effectiveness of this technique; inappropriate lengths can result in restriction or residual prolapse of the diseased segments. In previous reports, sizing was typically performed on the arrested heart either by visual inspection or with a caliper. Herein, we report our initial experience with a standardized length for multi-loop neo-chord for posterior leaflet (PL) prolapse based on a pre-operative measurement.

      METHODS AND RESULTS

      Between October 2017 and October 2020, 18 patients who underwent mitral valve (MV) repair for MR due to PL prolapse were included in the study. Pre-operative transesophageal echocardiogram (TEE) was used to determine the optimal neo-chordae length, which was the distance between the papillary muscle tip and desired coaptation point: consistently, 16mm was the optimal neo-chordae length regardless of the affected PL segment. Multi-loop neo-chords were prepared prior to incision. The procedure was performed minimally invasively in 6 patients. Pre-measured 16 mm neo-chords were used to treat prolapsing segments either at the level of P1 (28%), P2 (39%) or P2-P3 (33%). An incomplete semi-rigid band was implanted in all cases. Post-procedural TEE was performed to confirm MV competency. The mean age was 65±13 years and majority were male (74%). Patients either exhibited moderate-severe (11%) or severe (89%) MR. The mean aortic cross-clamp time was 101±17 min. The mean ICU and hospital length of stay were 2±1 and 7±5 days, respectively. No patient required conversion to MV replacement. There was no in-hospital mortality. None exhibited systolic anterior leaflet motion, residual MR greater than grade 2, or mitral stenosis. The mean post-procedural coaptation length was 11±3 mm. At discharge, the mean transmitral gradient and left ventricular ejection fraction were 3±1 mmHg and 61±7%, respectively.

      CONCLUSION

      Our results show that a standard neo-chord length of 16mm can sufficiently correct MR arising from PL prolapse, while avoiding SAM of the anterior leaflet and mitral stenosis and irrespective of the affected segment. However, long-term outcomes are warranted to validate the durability of this approach.
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