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. 1985 Dec;202(6):673–680. doi: 10.1097/00000658-198512000-00002

A clinical evaluation of the hypothesis that rupture of the left ventricle following mitral valve replacement can be prevented by preservation of the chordae of the mural leaflet.

F C Spencer, A C Galloway, S B Colvin
PMCID: PMC1250997  PMID: 3907548

Abstract

Experiences with 14 patients undergoing rupture of the left ventricle following mitral valve replacement over a period of 9 years have been described. Three different types have been recognized. Before 1978, most injuries occurred in the atrioventricular groove, apparently resulting from traction that insidiously avulsed the mitral annulus from the underlying left ventricular muscle. Several changes in operative technique, described in the text, were made to prevent this traction avulsion. Following the adoption of these principles, rupture in the atrioventricular groove virtually disappeared. A second type of injury, strut perforation, has been recognized in only one patient, a small 81-year-old female in whom the prosthesis inserted was too large for the ventricular cavity. Translucent obturators were subsequently developed not only to size the left ventricle but also to note the location of the post of the porcine prosthesis before insertion. Further problems of this type have not been seen. The most puzzling, and currently the most significant, problem is a third type of rupture, the mid-ventricular rupture, suggested as Type III by Miller in 1978 and described in detail by Cobbs in 1977 and 1980. The phenomenon seems to be a true spontaneous rupture of a thin left ventricle, usually occurring in small elderly women with mitral valve disease. If the friability of the left ventricle is transiently increased with potassium cardioplegia, such ventricles may spontaneously rupture following division of the chordae to the annulus of the mural leaflet. If this concept is correct, a rupture in some patients can best be prevented by preserving these chordae. It is well realized, of course, that a fortunate narrative experience of 3 1/2 years does not have any statistical value concerning a complication that occurs in 1 to 2% of operations. The experiences are reported, however, because to our knowledge, the untethered loop hypothesis has not been previously evaluated in a large number of consecutive patients operated on. Future comparison of experiences reported by others should make it possible to determine whether or not this concept is correct.

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Selected References

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  1. Armour J. A., Randall W. C. Structural basis for cardiac function. Am J Physiol. 1970 Jun;218(6):1517–1523. doi: 10.1152/ajplegacy.1970.218.6.1517. [DOI] [PubMed] [Google Scholar]
  2. Björk V. O., Henze A., Rodriguez L. Left ventricular rupture as a complication of mitral valve replacement. J Thorac Cardiovasc Surg. 1977 Jan;73(1):14–22. [PubMed] [Google Scholar]
  3. Björk V. O. Left ventricular rupture after mitral valve replacement. Ann Thorac Surg. 1981 Feb;31(2):101–101. doi: 10.1016/s0003-4975(10)61524-x. [DOI] [PubMed] [Google Scholar]
  4. Bortolotti U., Livi U., Mazzucco A., Gallucci V., Cévese P. G. Successful treatment of intraoperative rupture of the left ventricle after mitral valve replacement: report of a case and review of the literature. Int Surg. 1981 Oct-Dec;66(4):345–347. [PubMed] [Google Scholar]
  5. Celemín D., Nuñez L., Gil-Aguado M., Larrea J. L. Intraventricular patch repair of left ventricular rupture following mitral valve replacement: new technique. Ann Thorac Surg. 1982 Jun;33(6):638–640. doi: 10.1016/s0003-4975(10)60829-6. [DOI] [PubMed] [Google Scholar]
  6. Chi S., Beshore R., Gonzalez-Lavin L. Left ventricular wall rupture after mitral valve replacement: report of successful repair in 2 patients. Ann Thorac Surg. 1976 Oct;22(4):380–382. doi: 10.1016/s0003-4975(10)64972-7. [DOI] [PubMed] [Google Scholar]
  7. Cobbs B. W., Jr, Hatcher C. R., Jr, Craver J. M., Jones E. L., Sewell C. W. Transverse midventricular disruption after mitral valve replacement. Am Heart J. 1980 Jan;99(1):33–50. doi: 10.1016/0002-8703(80)90312-9. [DOI] [PubMed] [Google Scholar]
  8. Dark J. H., Bain W. H. Rupture of posterior wall of left ventricle after mitral valve replacement. Thorax. 1984 Dec;39(12):905–911. doi: 10.1136/thx.39.12.905. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Devineni R., McKenzie F. N. Type I left ventricular rupture after mitral valve replacement. J Thorac Cardiovasc Surg. 1983 Nov;86(5):742–745. [PubMed] [Google Scholar]
  10. Engelman R. M., Rousou J. H., Wittenberg S. A. New technique for repair of posterior left ventricular rupture. J Thorac Cardiovasc Surg. 1979 May;77(5):757–759. [PubMed] [Google Scholar]
  11. Gosalbez F., de Linera F. A., Cofiño J. L., Naya J. L., Rodrìguez J., Ortuña A. Isolated mitral valve replacement and ventricular rupture: presentation of 6 patients. Ann Thorac Surg. 1981 Feb;31(2):105–110. doi: 10.1016/s0003-4975(10)61526-3. [DOI] [PubMed] [Google Scholar]
  12. Katske G., Golding L. R., Tubbs R. R., Loop F. D. Posterior midventricular rupture after mitral valve replacement. Ann Thorac Surg. 1979 Feb;27(2):130–132. doi: 10.1016/s0003-4975(10)63252-3. [DOI] [PubMed] [Google Scholar]
  13. LILLEHEI C. W., LEVY M. J., BONNABEAU R. C., Jr MITRAL VALVE REPLACEMENT WITH PRESERVATION OF PAPILLARY MUSCLES AND CHORDAE TENDINEAE. J Thorac Cardiovasc Surg. 1964 Apr;47:532–543. [PubMed] [Google Scholar]
  14. MacVaugh H., 3rd, Joyner C. R., Johnson J. Unusual complications during mitral valve replacement in the presence of calcification of the annulus. Ann Thorac Surg. 1971 Apr;11(4):336–342. doi: 10.1016/s0003-4975(10)65459-8. [DOI] [PubMed] [Google Scholar]
  15. Miller D. W., Jr, Johnson D. D., Ivey T. D. Does preservation of the posterior chordae tendineae enhance survival during mitral valve replacement? Ann Thorac Surg. 1979 Jul;28(1):22–27. doi: 10.1016/s0003-4975(10)63386-3. [DOI] [PubMed] [Google Scholar]
  16. Nuñez L., Gil-Aguado M., Cerron M., Celemin P. Delayed rupture of the left ventricle after mitral valve replacement with bioprosthesis. Ann Thorac Surg. 1979 May;27(5):465–467. doi: 10.1016/s0003-4975(10)63347-4. [DOI] [PubMed] [Google Scholar]
  17. Phillips S. J., Zeff R. H., Kongtahworn C. LV wall rupture. Ann Thorac Surg. 1979 Apr;27(4):390–390. doi: 10.1016/s0003-4975(10)63324-3. [DOI] [PubMed] [Google Scholar]
  18. RUSHMER R. F., FINLAYSON B. L., NASH A. A. Movements of the mitral valve. Circ Res. 1956 May;4(3):337–342. doi: 10.1161/01.res.4.3.337. [DOI] [PubMed] [Google Scholar]
  19. RUSHMER R. F. Initial phase of ventricular systole: asynchronous contraction. Am J Physiol. 1956 Jan;184(1):188–194. doi: 10.1152/ajplegacy.1955.184.1.188. [DOI] [PubMed] [Google Scholar]
  20. Roberts W. C., Morrow A. G. Causes of early postoperative death following cardiac valve replacement. Clinico-pathologic correlations in 64 patients studied at necropsy. J Thorac Cardiovasc Surg. 1967 Sep;54(3):422–437. [PubMed] [Google Scholar]
  21. Ross M. A. Rupture of myocardium and mitral valve replacement. Am Heart J. 1980 Dec;100(6 Pt 1):946–946. doi: 10.1016/0002-8703(80)90094-0. [DOI] [PubMed] [Google Scholar]
  22. Treasure R. L., Rainer W. G., Strevey T. E., Sadler T. R. Intraoperative left ventricular rupture associated with mitral valve replacement. Chest. 1974 Nov;66(5):511–514. doi: 10.1378/chest.66.5.511. [DOI] [PubMed] [Google Scholar]
  23. Wolpowitz A., Barnard M. S., Sánchez H. E., Barnard C. N. Intraoperative posterior left ventricular wall rupture associated with mitral valve replacement. Ann Thorac Surg. 1978 Jun;25(6):551–554. doi: 10.1016/s0003-4975(10)63607-7. [DOI] [PubMed] [Google Scholar]
  24. Zacharias A., Groves L. K., Cheanvechai C., Loop F. D., Effler D. B. Rupture of the posterior wall of the left ventricle after mitral valve replacement. J Thorac Cardiovasc Surg. 1975 Feb;69(2):259–263. [PubMed] [Google Scholar]

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