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Objective: Correction of severe mitral regurgitation (MR) is important for long term prognosis. Use of artificial chordae tendonae (AC) is an established technique to correct leaflet prolapse during mitral valve repair. Setting the correct length of AC’s in the flaccid heart during cardiopulmonary bypass is challenging. We have developed a custom instrument that allows placement of AC’s via the left ventricular (LV) apex off-pump, with real-time echo assessment of the AC length.
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Giovanni Speziali1, Charles Bruce2, Davide Ricci3, Richard Daly3.
1Cardiac Surgery, University of Pittsburgh, Pittsburgh, PA, USA, 2Cardiology, Mayo Clinic, Rochester, MN, USA, 3Cardiac Surgery, Mayo Clinic, Rochester, MN, USA.
Methods: A custom instrument was used to place AC (4-0 PTFE sutures) via the LV apex off-pump in two patients with posterior leaflet prolapse. Intraoperative transesophageal echocardiography (TEE) was used to precisely guide the intracardiac instrument and enable capture of the prolapsing leaflet segment. The appropriate length of the AC (a 4-0 PTFE suture) that restored normal leaflet coaptation and corrected MR was established using real-time TEE while the AC was fixed at the LV apex. Standard mitral repair using an open technique was then performed with a standard annuloplasty to assure a secure repair. This permitted direct inspection of the insertion site of the AC into the valve leaflet.
Results: A single AC was successfully inserted into the prolapsing mitral leaflet off-pump via the LV apex in both patients. Proper tension on the AC was set by TEE guidance and resulted in reduction of MR from severe to trivial in both patients, prior to any additional intervention on the valve. There were no complications. When the valve was inspected, the AC was placed in the center of the prolapsed leaflet segment in both patients. MR has not recurred at followup to 4 months.
Conclusions: MR was essentially eliminated in 2 patients by AC placed off-pump via the LV apex using TEE guidance. This technique can potentially be applied through a minimally invasive incision. 
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