Totally Endoscopic Mitral Valve Repair With Predetermined Length of Synthetic Chordae

The artificial chordae technique is a well-established technique used to treat primary mitral regurgitation, especially when the anterior mitral leaflet is involved (1). The main difficulty of this technique is deciding the optimal length of the polytetrafluoroethylene (PTFE) chordae, and for this purpose, lots of techniques, mainly intraoperative, have been described (1). The authors have recently presented a preoperative method to predetermine the ideal length of the artificial chordae based on transesophageal echocardiography (TEE) (1). The authors hereby present the video of a 48-year-old patient with bileaflet prolapse, where the authors used this technique to totally endoscopically repair his mitral valve.

TEE revealed prolapsing A2 and A3 segments of the anterior leaflet and P2 and P3 scallops of the posterior. The optimal length of the artificial chordae was calculated in the four chamber view, in systole as 18 mm.

The authors’ totally endoscopic technique has been previously described on CTSNet videos and in the literature (2, 3, 4, 5). In summary, the authors used a 2-3 cm right periareolar working incision to enter the right chest through the fourth intercostal space. An extra small Alexis soft tissue protector was also used. The 3D, 30 degrees, Karl Storz endoscope was inserted through a 10 mm port in the same intercostal right anterior axillary line. Carbon dioxide was also administered through a side arm of the same port. Another 5 mm port was used for the left atrial vent. On full femorofemoral, vacuum-assisted cardiopulmonary bypass, with cannulae inserted in the groin under TEE guidance, the authors cross-clamped the aorta and arrested the heart with Custodiol cold crystalloid cardioplegia. A left atriotomy was opened and a patent foramen ovale was closed with a figure of eight 4-0 Prolene® suture.

The left atrial retractor was inserted, as well as a metallic net to prevent the left atrium wall from folding. Under stereoscopic vision, the authors examined the valve and found prolapsing A2, A3, P2, and P3 segments, as the TEE had previously suggested. The prolapsing parts of the leaflets were marked with methylene blue. A second metallic net was inserted through the valve to retract the leaflets and assist with work in the subvalvar apparatus. Three sets of 18 mm PTFE loops (Sheramon) were inserted, two at the tip of the head of the posteromedial papillary muscle (PMPM) and one at the anterolateral papillary muscle (ALPM). The anterior set of loops from the PMPM was used as four chords to repair the A3 and the medial part of the A2 segment. The posterior set of PTFE loops was used to repair the P3 and the medial part of the P2 scallops. The ALPM set of loops was used as two double loops to repair the lateral part of the P2 scallop. A water test revealed that there was still a prolapse of the lateral part of the A2 segment, which was repaired using another set of 18 mm loops inserted in the ALPM and used as two double loops. In summary, the authors used 12 loops, six for the anterior and six for the posterior. The repair was completed with a size 35 annuloplasty Tailor (Abbott) band secured using 2-0 Ethibond® sutures and the Cor-Knot® automated fastening device.

Postoperative TEE confirmed a competent mitral valve with no leaks or systolic anterior motion. Mitral valve area was calculated as 3.8 cm². The patient had an uneventful recovery.

References

1. Pitsis A, Tsotsolis N, Theofilogiannakos E, Boudoulas H, Boudoulas K. Preoperative determination of artificial chordae length by transesophageal echocardiography. Presented at ESC Congress 2019.
2. Pitsis A, Tsotsolis N, Nikoloudakis N, Kelpis T, Economopoulos V, Keremidis I. Totally endoscopic aortic valve replacement with a trifecta GT bovine pericardial valve. CTSNet. August 2019. doi:10.25373/ctsnet.9587900.
3. Pitsis A, Kelpis T, Theofilogiannakos E, Tsotsolis N, Boudoulas H, Boudoulas KD. Mitral valve repair: moving towards a personalized ring. J Cardiothorac Surg. 2019 Jun 13;14(1):108.
4. Pitsis A, Tsotsolis N, Nikoloudakis N, et al. Totally endoscopic redo tricuspid valve repair. CTSNet. June 2019. doi:10.25373/ctsnet.8199260.
5. Pitsis A, Nikoloudakis N, Tsotsolis N, et al. Totally endoscopic bileaflet mitral valve repair with preformed chordae loops. CTSNet. March 2019. doi:10.25373/ctsnet.7837853.

Dr Pitsis serves as a proctor for Abbott.