Adjustable Pericardial Lock Technique for Complex Mitral Valve Repair

Several techniques have been introduced for the selection of the right length of neochords, which is an essential part of complex mitral valve repair. In most traditional techniques, the judgement of the necessary length is done during the repair, and then the neochords are tied and their length is fixed, so it is difficult or impossible to change if any major or minor adjustments are needed after the final water test. In order to give the surgeon the possibility of reversibility and corrections, the authors developed a novel technique in which the lengths of the neochords are determined at the end of the repair by moving a small pericardial lock along the neochord while the shape and competence of the valve is tested.

In this adjustable pericardial lock technique, determining the number and location of the necessary neochords is made after the initial valve analysis, and the required neochords are passed through the papillary muscles as pledgeted U shape sutures. The chords are then left alone until the final step, after placing and fixing the suitable annuloplasty ring. At this stage, the authors pass the neochords through the proper sites in the prolapsing leaflet free edges. In order to have the adjustable locks, both limbs of each neochord are passed twice in the same direction through a small 2 x 4 mm piece of pericardium. This piece of pericardium is moved along the chord and is placed in any desired point. The lock offers very nice resistance against movement, so it is movable, while at the same time it will not slip easily on the neochord during the pressurized water test. Initially, the authors leave each neochord lock at the level of the annuloplasty ring before conducting the water test. The competence, shape, and geometry of the cusps is visualized. If any adjustment is needed to have the most perfect shape, the lock on each neochord can be easily moved up or down and retested. When the desired perfect configuration and function of the cusps is obtained, the neochord length is fixed by putting four knots just above the lock, followed by passing the needles through the cusps again, and then creating another four knots. This provides the advantage of secure fixation, avoiding a long bulky row of up to 10 knots, while also hide the small pericardial locks.

The authors have been using this technique for all minimally invasive mitral valve repairs since 2018 (62 cases) and it is now their routine practice with excellent results.

This technique is highly reliable and reproducible, and most importantly, it gives security, courage, and confidence to the surgeon for repairs of very complex valves without fear of making mistakes, since any adjustment or correction is possible until the very end of the repair.

References

1. Artificial mitral chordae: When length matters. Grinberg D, Nouhou KA, Pozzi M,  Obadia J-F. Artificial mitral chordae: When length matters. J Thorac Cardiovasc Surg. 2019 Feb; 157(2):e23–e25.
2. Neely RC, Borger MA. Myxomatous mitral valve repair: Loop neochord technique. Op Tech Thorac Cardiovasc Surg. 2015;20(2):106-123.