Table 4:
Techniques for the creation of artificial chordae of adjustable length
| Study | Key features | Comment/figure |
|---|---|---|
| Fattouch et al. 2007 [29] | Secure 5-0 Gore-Tex suture to papillary head before annuloplasty | The placement of neochordae when the LV is filled ensures that the length is appropriate to normal dimensions and geometry |
| Attach to prolapsing segment | Can be used for complex lesions. In such cases, the orifice is almost completely closed and tested. Care must be taken to avoid damage to the neochordae when performing edge-to-edge repair | |
| Perform temporary edge-to-edge repair (Alfieri stitch) | ||
| Annuloplasty performed | ||
| LV injection with saline, adjustments made if MR noted and then Gore-Tex sutures tied securely | ||
| Pretre et al. 2006 [16] | Neochordae are constructed to be similar to adjacent normal chordae. Artificial chordae are temporarily locked and then inspected, while the LV is filled from an aortotomy. Aortotomy is performed after posterior leaflet repair. Neochordae are adjusted and then tied definitively from the aortotomy | Only 25 min extra CPB time required for aortotomy and repositioning. Initially used to salvage failed repair from the atriotomy |
| Chocron 2007 [27] | Neochordae are placed through the papillary muscle and the free edge of the MV. Annuloplasty is then performed. Measurement of correct length made from papillary muscle to annuloplasty ring. Clips are then used to prevent sliding of valve during the competency test. LV filled via aorta. Clips adjusted and MV re-tested until MR is eliminated. Knots tied over the clips, which can be removed or left in place | Clips avoid knot sliding |
| Kasegawa et al. 1994 [18] | A small tourniquet is used to maintain chordae length during LV filling. Fine adjustments are then made and the final length is knotted in place | Good results obtained and reduced the time necessary to eliminate MR |
| Calafiore et al. 2008 [3] | This technique is used to obtain correct chordae lengths for the AML and to inhibit excessive movement of the PML | Obtained good results |
| The AML is pulled with nerve hooks to its maximum extent and the chordae is attached 5 mm higher than the border of the AML. For the PML, the same method was used without the added 5 mm. In both cases, after an initial chordae is tied, nerve hooks are used to fine tune the required length | Calafiore et al. had previously proposed the TOE approach but now use this technique | |
| Moorjani et al. 2009 [30] | After securing the suture to the papillary muscle, both ends of the Gore-Tex suture are passed to the atrial side. One limb is then placed back through the leaflet to the ventricular aspect. Annuloplasty rings are inserted and then the repair is tested by LV filling. The height of the sutures is easily adjusted. When MR has been eliminated, the limb of the suture is passed back through the leaflet and tied | Passing the suture through the leaflet, a third time prior to knot tying prevents the knot from altering the height of the neochordae |
| Rankin et al. 2006 [38] | An anchor suture is placed on the papillary muscle. A Gore-Tex suture is tied to this anchor and left in the ventricular cavity. After annuloplasty, the sutures are retrieved and tied by use of a slip-knot on the atrial aspect of the area of maximal prolapse of the leaflet. A clip prevents unintentional slipping. The length is tested by filling the LV with saline, adjustments are made by replacing the clip and then eight knots are tied at the correct position | |
| Maselli et al. 2007 [32] | Knots are tied at fixed intervals in a neochordae loop attached to the papillary muscle. These can be temporarily fixed by connecting them to a loop fixed to the papillary component (see description in earlier section) | Easily adjustable and does not involve damage to the leaflets or loops |
| Isoda et al. 2012 [51] | Two anchor system. Anchoring loop is placed at the papillary muscle. An additional anchoring loop is placed at the leaflet and the main chordae loop is tied between them. If adjustment of chordae length is required, an additional anchoring loop can be placed towards the annulus of the valve leaflet | This involves an anchor loop fixed to the papillary muscle |
| A series of loops to the approximate length required is made and tied to the papillary anchor point | ||
| The loop is fixed to the leaflet using additional small anchoring loops | ||
| If the length need to be adjusted, additional anchor sutures are placed to shorten the loop |