- Email: [email protected]
SURGICAL CORRECTION OF RUPTURED CHORDAE TENDINEAE
SURGICAL CORRECTION OF R U P T U R E D C H O R D A E T E N D I N E A E Joe D. Morris, M.D., David A. Penner, M.D. (by invitation), Ralph L. Brandt, M.D. (by invitation),
Ann Arbor,
and
Mich.
F
ROM the first published description of ruptured chordae tendineae to the first report of surgical correction of such defects, there was a period of nearly one hundred and fifty years. As operations for mitral valve insufficiency become more common, it appears that ruptured chordae tendineae underlie this condi tion in a surprising number of cases. Since the mitral valve itself is likely to be functionally intact except for ruptured chordae in these cases, what is needed is a dependable technique for restoration of function rather than total replace ment of the valve. The importance of the atrioventricular ring-mitral valvepapillary muscle complex to left ventricular efficiency has been suggested by Lillehei. 1 The virtue of preserving this complex is inherent in valvular recon struction. Recently, at the University of Michigan Medical Center and St. Joseph Mercy Hospital, rupture of chordae tendineae was found to be the mechanism for mitral valve insufficiency in 13 of 58 patients operated upon for mitral regurgitation, an incidence of 22 per cent. The mitral valves were functionally intact, except for the ruptured chordae, in all but one. It became apparent early in this experience that annuloplasty alone, which was successful in 1 case, was not a dependable method of correcting mitral regurgitation due to ruptured chordae tendineae. Direct suture of the everting leaflet to the papillary muscle provided satisfactory mitral correction but doubtful stability from the standpoint of permanence. In the last 7 cases, a prosthetic chorda of knitted Teflon, involv ing a pulley principle, was used with apparent success.2 Annuloplasty has been used as an adjunctive technique to control the annular dilation which occurs as a sequel to mitral regurgitation in some cases. PATHOGENESIS
After Corvisart's description 3 of ruptured chordae tendineae appeared in 1812, various causes for this condition became recognized,4 including bacterial endocarditis, rheumatic valvular disease, and trauma. Coronary heart disease From the Departments of Surgery and Medicine University of Michigan Medical Center, and St. Joseph Mercy Hospital, Ann Arbor, Mich. This work was supported in part by the Michigan Heart Association and U.S. Public Health Service Grant H-5844 (CL). Read at the Forty-fourth Annual Meeting of The American Association for Thoracic Surgery, Montreal, Canada, April 27, 28, and 29, 1964. 772
Vol. 48, No. 5
BUPTUKED CHOKDAE TENDINEAE
773
November, 1964
has been cited as a cause of rupture of papillary muscles but not chordae tendineae. 5 - 6 In the absence of an apparent cause, the term "spontaneous r u p t u r e " has been applied. 7 Osmundson, Callahan, and Edwards 4 reported the clinical and pathologic features in 20 cases of ruptured chordae confirmed by necropsy studies. Published methods of correcting this entity start with McGoon,8 in 1960, and include reports by Henley, 9 J. H. Kay, 10 and Ehrenhaft. 11 In our study, the 13 patients with ruptured chordae tendineae were divided into two groups: those whose lesions were a result of rheumatic heart disease and those whose lesions resulted from other factors. It is perhaps significant that in no case was there evidence of bacterial endocarditis. Rheumatic Disease.—The mean age of the 6 patients with a history of rheumatic fever was 42 years. With one exception, the valves were neither stenotic nor calcified. Thickening of the leaflets and the chordae was noted; the ruptured chordae appeared to be heavier and club-shaped. In 1 patient, however, there was severe attenuation of the chordae, characterized by elongation and thinning to a hair-like appearance, and resulting in flailing eversion of the posterior leaflet. Although the chordae were intact they were ineffectual for a segment of the valve edge; the remaining chordae were normal in appearance and function. Flailing leaflets had a characteristic hood4 appearance. Change in stress on the valve, created by ventricular contraction in the absence of chordal support along the leaflet edge, may have been responsible for this contour. The anterior and posterior leaflets were involved equally; no preferential involvement of papillary muscle groups was observed. There was no loss of valve leaflet sub stance. In all patients in this group there had been a known murmur for some time, with increasing disability which led to surgical treatment. The oldest patient had suffered an episode of crushing trauma when he was caught in an excavation cave-in; heart murmur appeared immediately afterward, and the patient was chronically disabled thereafter. At operation the anterior leaflet was found to be devoid of chordae along the middle third of the free edge. Nonrheumatic Disease.—The mean age of the 7 patients in this group was 58 years. Coronary insufficiency was thought to be present in 4, 3 of whom had experienced posterior myocardial infarctions. Hypertension was present in 3 other patients, 1 of whom had angina. The posterior leaflet was involved in all cases. The valves in this group appeared thin, compliant, and normal in all respects other than the ruptured chordae. Heart murmurs had been present for less than 2 years. Two patients could pinpoint within hours the onset of the mitral insufficiency murmur. In 3 patients, mitral regurgitation became apparent in the course of periodic examinations for coronary disease. As a result of the shorter duration of valvular incompetence these patients' hearts were usually smaller than in the rheumatic group, although disability was as profound. DIAGNOSIS
In our series the initial clinical picture of mitral insufficiency due to rup tured chordae tendineae was the same as that of mitral insufficiency due to
774
MOEEIS, PENNEE, BEANDT
J. Thoracic and Cardiovas. Surg.
other causes, such as dilated mitral annulus or loss of valve leaflet substance. The history differed in that the ruptured chordae tendineae presented a more dramatic onset, sometimes attended by severe dyspnea and chest pain. The murmur of ruptured chordae may have a distinct and musical quality variously described as resembling the sound of a seagull, a cooing dove, or a whistle. The murmur may be heard by the patient in various positions while reclining, and the sudden appearance of this audible murmur may establish the time of rupture of the chordae tendineae. It is possible that the high-pitched systolic murmur is produced by high-frequency vibration of the free edge of the everting valve leaflet. All patients showed systolic murmurs at the apex. When the murmur radiated to the axilla there was found to be a rupture of chordae attached to the anterior (septal) leaflet. Eadiation of the murmur to the base of the heart in the aortic area, occurring in patients with a flailing posterior leaflet, suggested the possibility of aortic stenosis.12 A murmur radiating to the top of the head was looked for in the last 6 patients but was not heard. Left-heart catheterization was necessary to establish the presence of mitral impairment as a solitary lesion. Selective cardiography by injection into the left ventricle demonstrated regurgitation into the left atrium. A clinical impression of ruptured chordae tendineae of the mitral valve was established in 6 patients on the basis of the patient's history, the unique quality of the murmur, and special diagnostic studies that included left-heart catheterization and left cardioventriculography. T E C H N I Q U E OP CORRECTION
At operation the heart is approached by a right lateral thoracotomy incision through the fifth intercostal space with the incision carried anterior to the mammary line, to gain easier access to the right atrium and ascending aorta. The mitral valve is exposed by a left atriotomy incision made posterior to the interatrial groove under conditions of total bypass (roller pump, disc oxygenator, and hypothermia of 32° C.) in which adequate ventricular contractility is preserved, permitting assessment of valve correction. Prosthetic chordae are prepared by cutting strips 1 cm. wide from the edge of a 6-inch sheet (Fig. 1) of thin tight-knitted Teflon cloth.* The longitudinal ridges must run parallel to the long dimension of the strip. 13 ' 14 Each end of this strip is grasped firmly in the jaws of a hemostat and heavy tension applied, elongating the strip by approximately 60 per cent and attenuat ing the width into a tapered cylinder with spatulated ends. One flared end can then be cut off and the narrow diameter sharpened to aid passage through the eye of a one-half round three-quarter inch needle. The free margin of the flailing leaflet at the site of the ruptured chordae is stabilized by traction sutures taken at the corners of the flailing segment of the valve. The spatulated end of the prosthesis is then sutured to the ventricu lar surface of the valve at the site of the ruptured chordae by three mattress sutures of 3-0 nonabsorbable suture material (Fig. 2). The knots are tied on the ♦Available from C. R. B a r d , Inc., M u r r a y Hill, N.J., C a t . No. 3067.
Vol. 48. No. 5 November, 1964
RUPTURED CHORDAE TENDINEAE
775
superior or atrial surface of the flailing leaflet and the suture ends are left long to control the free edge of the valve. The opposite end of the prosthesis, which now measures about 8 inches and which has been passed through the eye of the needle, may be secured in the eye by doubling it back and tying it to the proximal portion of the chorda.
Fig. 1.—A, 1 cm. strip of thin, tight-knit Teflon fabric with lines parallel to long dimen sion. B, Tension deforms strip to make prosthesis. Spatulated end will be sutured to nailing edge of valve leaflet.
The needle is carried into the ventricle, and the papillary muscle from which the ruptured chordae have separated is identified. The needle is swung deeply into the substance of the left ventricular wall at the base of the appro priate papillary muscle and the prosthesis is drawn through the tunnel created by the needle, establishing a pulley deep in the myocardium of the left ventricle. Care is taken to avoid going outside the ventricle during this maneuver. The needle is then brought back through the annulus of the flailing leaflet at a point on the annulus located radially from the point of the ruptured chordae. Tension
Fig. 2.—A, Regurgitant jet produced by rupture of chordae attached to posterior leaflet as seen from right thoracotomy. B, Prosthetic chorda attached to flailing leaflet. C, Pulley stitch completed in ventricular wall. Tension adjusted on chorda, restoring leaflet position. D, Pros thetic chorda anchored to atrial wall and excess length excised.
on the prosthetic chorda coming up through the annulus will then draw the nailing free edge of the mitral leaflet into normal relationship with its opposing leaflet. By alternating traction on the sutures still attached to the free edge of the valve with traction on the prosthetic chorda, to-and-fro adjustment can be employed to establish the proper relationship of the flailing leaflet with the opposing leaflet (Fig. 2, C). The prosthesis is then fixed to the atrial wall and the annulus by interrupted nonabsorbable sutures, and the excess length of the prosthesis distal to this fixation is excised. The usual maneuvers to avoid hazards of air embolism must be strictly observed during this procedure. The valve is kept incompetent at all times until it is tested, and testing is carried out only after care is taken to assure that all air has been displaced from the left ventricle. The use of a venting
Vol. 48, No. 5
RUPTURED CHORDAE TENDINEAE
777
November, 1964
needle in the root of the aorta, as described by Groves and Effler,15 minimizes this hazard. It is thought that this technique may give a more stable and permanent control of the nailing leaf than suturing the free edge directly to the chordae tendineae or the papillary muscles, as described by Kay 10 and Ehrenhaft. 11 While annuloplasty alone has not been successful in controlling this variety of regurgitation in our experience, we believe that it is a valuable adjunct in the maintenance of correction. For this reason, annuloplasty at the posterior commissure has been used in the more recent cases and would be recommended at the anterior commissure, as well, in cases of severe annular dilation. The technique of annuloplasty has been modified to utilize the principles described bv J. H. Kay, 16 and advocated by Callaghan,17 as "mural leaflet advancement" (Fig. 3). RESULTS
Among the 10 patients undergoing mitral valve reconstruction with pros thetic chordae tendineae, satisfactory control of mitral insufficiency was achieved. Two early deaths occurred in this group, one due to massive pulmonary embolism and the second due to an uncontrollable arrhythmia and tachycardia in a patient who had undergone simultaneous repair of a large congenital ventricular septal
Pig. 3.—Annuloplasty technique employs principle of posterior (mural) leaflet advance ment (16, 11) Annulus distance (A-B) retains same relationship to anterior leaflet. A-B is short ened to A'B' behind the posterior leaflet when annuloplasty sutures are tied. Only one suture may be required. Suture is buttressed with Teflon pledgets. Reinforcing suture provides addi tional protection against dehiscence.
778
MORRIS, P E N N E R , BRANDT
J. Thoracic and Cardiovas. Surg.
Fig. 4.—A, Preoperative chest roentgenogrram of 50-year-old truck driver with a history of hypertension over 200 mm. Hg. One month previously, chordal attachment to posterior leaf let had ruptured and precipitated congestive failure refractory to treatment, functional Class IV. Severe cardiomegaly has not had time to develop. B, Chest roentgenogrram of same patient made 21 months after surgical correction shows clearing of pulmonary edema.
PRE-OPERATIVE
OS. 1)11179
2 YEARS POST-OPERATIVE
IV
B y~\—|—y—\—-y Pig. 5.'—A, Left heart pressure tracing of patient shown in Pig. 4. Systemic hypertension (LV) is masked by massive mitral valve regurgitation. Ventriculization of the left atrial pres sure has occurred. B, Left heart pressure tracing in same patient made 2 years after surgical correction by pulley prosthesis shows return of atrial pressures to normal range.
Vol. 48, No. 5 November, 1964
R U P T U R E D CHORDAE T E N D I N E A E TABLE
PA TIENT
AGE
DATE (MO./ YR.)
ETIOLOGY
PATHOLOGY ( S I T E OF RUPTURE)
779
I
T E C H N I Q U E OF CORRECTION
RESULT
N.D.
17
11/60 Rheumatic
Ant. leaflet
Annuloplasty
J. L.
56
11/60 Coronary
Post, leaflet
Straight prosthesis
W. P. A.M.
60 41
1/62 4/62
Post, leaflet Ant. leaflet
Straight prosthesis Straight prosthesis
Died; failure of correction Died of possible coronary occlu sion 6 mo. postop. Good Died; arrhythmia
0. S. P . H. N.V.
50 57 57
5/62 7/62 8/62
Post, leaflet Post, leaflet Ant. leaflet
Pulley prosthesis Pulley prosthesis Annuloplasty
Good Good Good
T. B. E. C. R. D.
61 35 60
1/63 3/63 4/63
Post, leaflet Ant. leaflet Post, leaflet
Pulley prosthesis Pulley prosthesis Pulley prosthesis
Good Good Good
E.D. F . H.
58 50
4/63 11/63
Post, leaflet Post, leaflet
Pulley prosthesis Pulley prosthesis
E. H.
43
Ant. leaflet
Starr-Edwards repl.
Good Died; pulmonary embolus Good
Coronary Rheum., cong. V.S.D. Hypertension Coronary Rheum. + trauma Coronary Rheumatic Coronary hy pertension Hypertension Rheumatic
4/63 Rheumatic
defect. One late death occurred, unexpectedly, 6 months after correction in a 56-year-old man with a history of angina. In 3 cases, efforts to control regurgitation by annuloplasty were successful in 1 and unsuccessful in 2. In 1 of these, the only instance of valvular calcification and rigidity, a Starr-Edwards total replacement was necessary.18 One patient in this series was classified as functional class IV before the operation (Fig. 4), while all others were designated Class III. All patients who have survived have shown dramatic clinical improvement and have returned to normal activity (Fig. 5). In 1 patient no residual murmur can be heard, although in all others a Grade 1 to 2/6 systolic murmur can be heard at the apex. SUMMARY
Recent studies indicate that ruptured chordae tendineae may be a more frequent cause of mitral valve insufficiency than has been suspected. In a series of 58 patients treated at the University of Michigan Medical Center and St. Joseph Mercy Hospital, the mitral regurgitation was found to be associated with ruptured chordae tendineae in 13. In 7 of these 13 cases the rupture had occurred as a complication of nonrheumatic diseases, such as coronary heart disease, myocardial infarction, and hypertension. In 6 cases there was a history of rheumatic fever. The lesions in the nonrheumatic group were characterized by involvement of the posterior leaflet only; in the rheumatic group, either the anterior or posterior leaflet was involved. A technique of prosthetic chordae substitution has been developed which has been effective in all patients in whom it has been tried. The operative procedure is less extensive and time-consuming than total valve replacement, and, therefore, should be much safer for patients with marginal myocardial reserve, many of whom have coronary heart disease.
780
MORRIS, PENNER, BRANDT
J. Thoracic and Cardiovas. Surg.
REFERENCES
1. Lillehei, C. W., Levy, M. J., and Bonnabeau, R. C.: Mitral Valve Replacement With Preservation of Papillary Muscles and Chordae Tendineae, J . THORACIC & CARDIOVAS. SURG. 47: 532, 1964.
2. Morris, J . D., Sloan, H., and Brandt, R.: Newer Concepts in Mitral Valve Surgery, J . Michigan State M. Soe. 6 1 : 1353, 1962. 3. Corvisart, J . N . : An Essay on the Organic Diseases and Lesions of the Heart and Great Vessels (translated by Jacob Gates), Boston, 1812, A. Finley; New York, 1962, Hafner Publishing Co. 4. Osmundson, P . J . , Callahan, J . A., and Edwards, J . E . : Ruptured Mitral Chordae Tendineae, Circulation 2 3 : 42, 1961. 5. Askey, J . M.: Spontaneous Rupture of a Papillary Muscle of the H e a r t : Review With Eight Additional Cases, Am. J . Med. 9: 528, 1950. 6. Craddoek, W. L., and Mahe, G. A . : Rupture of Papillary Muscle of Heart Following Myocardial Infarction: Differential Criteria From Perforation of Interventricular Septum, J . A. M. A. 151: 884, 1953. 7. Frothingham, C , and Hass, G. M.: Rupture of Normal Chordae Tendineae of the Mitral Valve, Am. Heart J . 9: 492, 1934. 8. McGoon, D. C.: Repair of Mitral Insufficiency Due to Ruptured Chordae Tendineae, J . THORACIC & CARDIOVAS. SURG. 39: 357, 1960.
9. Henley, W. S., Discussion, Prosthetic Valves for Cardiac Surgery, Merendino, K. A., Springfield, 1961, Charles C Thomas, Publisher. 10. Kay, J . H., and Egerton, W. S.: The Repair of Mitral Insufficiency Associated With Ruptured Chordae Tendineae, Ann. Surg. 157: 351, 1963. 11. January, L. E., Fisher, J . M., and Ehrenhaft, J . L . : Mitral Insufficiency Resulting From Rupture of Normal Chordae Tendineae, Circulation 26: 1329, 1962. 12. Osmundson, P . J., Callahan, J . A., and Edwards, J . E . : Mitral Insufficiency From Ruptured Chordae Tendineae Simulating Aortic Stenosis, Proc. Staff. Meet., Mayo Clin. 33: 23, 1958. 13. K a y , E . B., Suzuki, A., and Mendelsohn, D., J r . : Operative Results in Aortic Valve Surgery, Circulation 26: 484, 1962. 14. Kay, E . B., and Suzuki, A . : Personal communication. 15. Groves, L . K., and Effler, D. B . : A Needle Vent Safeguard Against Systemic Air Embolus in Open-Heart Surgery, J . THORACIC & CARDIOVAS. SURG. 47: 349, 1964.
16. Kay, J . H., Magidson, O., and Meihaus, J . E . : Surgical Treatment of Mitral Insufficiency and Combined Mitral Stenosis and Insufficiency Using the Heart Lung Machine, Am. J . Cardiol. 9: 300, 1962. 17. Callaghan, J . C : Mural Leaflet Advancement, Dis. Chest 4 3 : 87, 1963. 18. Starr, A., and Edwards, L. M.: Mitral Replacement: Clinical Experience With a Ball-Valve Prosthesis, Ann. Surg. 154: 726, 1961. (For Discussion, see page 815)
Ann Arbor,
and
Mich.
F
ROM the first published description of ruptured chordae tendineae to the first report of surgical correction of such defects, there was a period of nearly one hundred and fifty years. As operations for mitral valve insufficiency become more common, it appears that ruptured chordae tendineae underlie this condi tion in a surprising number of cases. Since the mitral valve itself is likely to be functionally intact except for ruptured chordae in these cases, what is needed is a dependable technique for restoration of function rather than total replace ment of the valve. The importance of the atrioventricular ring-mitral valvepapillary muscle complex to left ventricular efficiency has been suggested by Lillehei. 1 The virtue of preserving this complex is inherent in valvular recon struction. Recently, at the University of Michigan Medical Center and St. Joseph Mercy Hospital, rupture of chordae tendineae was found to be the mechanism for mitral valve insufficiency in 13 of 58 patients operated upon for mitral regurgitation, an incidence of 22 per cent. The mitral valves were functionally intact, except for the ruptured chordae, in all but one. It became apparent early in this experience that annuloplasty alone, which was successful in 1 case, was not a dependable method of correcting mitral regurgitation due to ruptured chordae tendineae. Direct suture of the everting leaflet to the papillary muscle provided satisfactory mitral correction but doubtful stability from the standpoint of permanence. In the last 7 cases, a prosthetic chorda of knitted Teflon, involv ing a pulley principle, was used with apparent success.2 Annuloplasty has been used as an adjunctive technique to control the annular dilation which occurs as a sequel to mitral regurgitation in some cases. PATHOGENESIS
After Corvisart's description 3 of ruptured chordae tendineae appeared in 1812, various causes for this condition became recognized,4 including bacterial endocarditis, rheumatic valvular disease, and trauma. Coronary heart disease From the Departments of Surgery and Medicine University of Michigan Medical Center, and St. Joseph Mercy Hospital, Ann Arbor, Mich. This work was supported in part by the Michigan Heart Association and U.S. Public Health Service Grant H-5844 (CL). Read at the Forty-fourth Annual Meeting of The American Association for Thoracic Surgery, Montreal, Canada, April 27, 28, and 29, 1964. 772
Vol. 48, No. 5
BUPTUKED CHOKDAE TENDINEAE
773
November, 1964
has been cited as a cause of rupture of papillary muscles but not chordae tendineae. 5 - 6 In the absence of an apparent cause, the term "spontaneous r u p t u r e " has been applied. 7 Osmundson, Callahan, and Edwards 4 reported the clinical and pathologic features in 20 cases of ruptured chordae confirmed by necropsy studies. Published methods of correcting this entity start with McGoon,8 in 1960, and include reports by Henley, 9 J. H. Kay, 10 and Ehrenhaft. 11 In our study, the 13 patients with ruptured chordae tendineae were divided into two groups: those whose lesions were a result of rheumatic heart disease and those whose lesions resulted from other factors. It is perhaps significant that in no case was there evidence of bacterial endocarditis. Rheumatic Disease.—The mean age of the 6 patients with a history of rheumatic fever was 42 years. With one exception, the valves were neither stenotic nor calcified. Thickening of the leaflets and the chordae was noted; the ruptured chordae appeared to be heavier and club-shaped. In 1 patient, however, there was severe attenuation of the chordae, characterized by elongation and thinning to a hair-like appearance, and resulting in flailing eversion of the posterior leaflet. Although the chordae were intact they were ineffectual for a segment of the valve edge; the remaining chordae were normal in appearance and function. Flailing leaflets had a characteristic hood4 appearance. Change in stress on the valve, created by ventricular contraction in the absence of chordal support along the leaflet edge, may have been responsible for this contour. The anterior and posterior leaflets were involved equally; no preferential involvement of papillary muscle groups was observed. There was no loss of valve leaflet sub stance. In all patients in this group there had been a known murmur for some time, with increasing disability which led to surgical treatment. The oldest patient had suffered an episode of crushing trauma when he was caught in an excavation cave-in; heart murmur appeared immediately afterward, and the patient was chronically disabled thereafter. At operation the anterior leaflet was found to be devoid of chordae along the middle third of the free edge. Nonrheumatic Disease.—The mean age of the 7 patients in this group was 58 years. Coronary insufficiency was thought to be present in 4, 3 of whom had experienced posterior myocardial infarctions. Hypertension was present in 3 other patients, 1 of whom had angina. The posterior leaflet was involved in all cases. The valves in this group appeared thin, compliant, and normal in all respects other than the ruptured chordae. Heart murmurs had been present for less than 2 years. Two patients could pinpoint within hours the onset of the mitral insufficiency murmur. In 3 patients, mitral regurgitation became apparent in the course of periodic examinations for coronary disease. As a result of the shorter duration of valvular incompetence these patients' hearts were usually smaller than in the rheumatic group, although disability was as profound. DIAGNOSIS
In our series the initial clinical picture of mitral insufficiency due to rup tured chordae tendineae was the same as that of mitral insufficiency due to
774
MOEEIS, PENNEE, BEANDT
J. Thoracic and Cardiovas. Surg.
other causes, such as dilated mitral annulus or loss of valve leaflet substance. The history differed in that the ruptured chordae tendineae presented a more dramatic onset, sometimes attended by severe dyspnea and chest pain. The murmur of ruptured chordae may have a distinct and musical quality variously described as resembling the sound of a seagull, a cooing dove, or a whistle. The murmur may be heard by the patient in various positions while reclining, and the sudden appearance of this audible murmur may establish the time of rupture of the chordae tendineae. It is possible that the high-pitched systolic murmur is produced by high-frequency vibration of the free edge of the everting valve leaflet. All patients showed systolic murmurs at the apex. When the murmur radiated to the axilla there was found to be a rupture of chordae attached to the anterior (septal) leaflet. Eadiation of the murmur to the base of the heart in the aortic area, occurring in patients with a flailing posterior leaflet, suggested the possibility of aortic stenosis.12 A murmur radiating to the top of the head was looked for in the last 6 patients but was not heard. Left-heart catheterization was necessary to establish the presence of mitral impairment as a solitary lesion. Selective cardiography by injection into the left ventricle demonstrated regurgitation into the left atrium. A clinical impression of ruptured chordae tendineae of the mitral valve was established in 6 patients on the basis of the patient's history, the unique quality of the murmur, and special diagnostic studies that included left-heart catheterization and left cardioventriculography. T E C H N I Q U E OP CORRECTION
At operation the heart is approached by a right lateral thoracotomy incision through the fifth intercostal space with the incision carried anterior to the mammary line, to gain easier access to the right atrium and ascending aorta. The mitral valve is exposed by a left atriotomy incision made posterior to the interatrial groove under conditions of total bypass (roller pump, disc oxygenator, and hypothermia of 32° C.) in which adequate ventricular contractility is preserved, permitting assessment of valve correction. Prosthetic chordae are prepared by cutting strips 1 cm. wide from the edge of a 6-inch sheet (Fig. 1) of thin tight-knitted Teflon cloth.* The longitudinal ridges must run parallel to the long dimension of the strip. 13 ' 14 Each end of this strip is grasped firmly in the jaws of a hemostat and heavy tension applied, elongating the strip by approximately 60 per cent and attenuat ing the width into a tapered cylinder with spatulated ends. One flared end can then be cut off and the narrow diameter sharpened to aid passage through the eye of a one-half round three-quarter inch needle. The free margin of the flailing leaflet at the site of the ruptured chordae is stabilized by traction sutures taken at the corners of the flailing segment of the valve. The spatulated end of the prosthesis is then sutured to the ventricu lar surface of the valve at the site of the ruptured chordae by three mattress sutures of 3-0 nonabsorbable suture material (Fig. 2). The knots are tied on the ♦Available from C. R. B a r d , Inc., M u r r a y Hill, N.J., C a t . No. 3067.
Vol. 48. No. 5 November, 1964
RUPTURED CHORDAE TENDINEAE
775
superior or atrial surface of the flailing leaflet and the suture ends are left long to control the free edge of the valve. The opposite end of the prosthesis, which now measures about 8 inches and which has been passed through the eye of the needle, may be secured in the eye by doubling it back and tying it to the proximal portion of the chorda.
Fig. 1.—A, 1 cm. strip of thin, tight-knit Teflon fabric with lines parallel to long dimen sion. B, Tension deforms strip to make prosthesis. Spatulated end will be sutured to nailing edge of valve leaflet.
The needle is carried into the ventricle, and the papillary muscle from which the ruptured chordae have separated is identified. The needle is swung deeply into the substance of the left ventricular wall at the base of the appro priate papillary muscle and the prosthesis is drawn through the tunnel created by the needle, establishing a pulley deep in the myocardium of the left ventricle. Care is taken to avoid going outside the ventricle during this maneuver. The needle is then brought back through the annulus of the flailing leaflet at a point on the annulus located radially from the point of the ruptured chordae. Tension
Fig. 2.—A, Regurgitant jet produced by rupture of chordae attached to posterior leaflet as seen from right thoracotomy. B, Prosthetic chorda attached to flailing leaflet. C, Pulley stitch completed in ventricular wall. Tension adjusted on chorda, restoring leaflet position. D, Pros thetic chorda anchored to atrial wall and excess length excised.
on the prosthetic chorda coming up through the annulus will then draw the nailing free edge of the mitral leaflet into normal relationship with its opposing leaflet. By alternating traction on the sutures still attached to the free edge of the valve with traction on the prosthetic chorda, to-and-fro adjustment can be employed to establish the proper relationship of the flailing leaflet with the opposing leaflet (Fig. 2, C). The prosthesis is then fixed to the atrial wall and the annulus by interrupted nonabsorbable sutures, and the excess length of the prosthesis distal to this fixation is excised. The usual maneuvers to avoid hazards of air embolism must be strictly observed during this procedure. The valve is kept incompetent at all times until it is tested, and testing is carried out only after care is taken to assure that all air has been displaced from the left ventricle. The use of a venting
Vol. 48, No. 5
RUPTURED CHORDAE TENDINEAE
777
November, 1964
needle in the root of the aorta, as described by Groves and Effler,15 minimizes this hazard. It is thought that this technique may give a more stable and permanent control of the nailing leaf than suturing the free edge directly to the chordae tendineae or the papillary muscles, as described by Kay 10 and Ehrenhaft. 11 While annuloplasty alone has not been successful in controlling this variety of regurgitation in our experience, we believe that it is a valuable adjunct in the maintenance of correction. For this reason, annuloplasty at the posterior commissure has been used in the more recent cases and would be recommended at the anterior commissure, as well, in cases of severe annular dilation. The technique of annuloplasty has been modified to utilize the principles described bv J. H. Kay, 16 and advocated by Callaghan,17 as "mural leaflet advancement" (Fig. 3). RESULTS
Among the 10 patients undergoing mitral valve reconstruction with pros thetic chordae tendineae, satisfactory control of mitral insufficiency was achieved. Two early deaths occurred in this group, one due to massive pulmonary embolism and the second due to an uncontrollable arrhythmia and tachycardia in a patient who had undergone simultaneous repair of a large congenital ventricular septal
Pig. 3.—Annuloplasty technique employs principle of posterior (mural) leaflet advance ment (16, 11) Annulus distance (A-B) retains same relationship to anterior leaflet. A-B is short ened to A'B' behind the posterior leaflet when annuloplasty sutures are tied. Only one suture may be required. Suture is buttressed with Teflon pledgets. Reinforcing suture provides addi tional protection against dehiscence.
778
MORRIS, P E N N E R , BRANDT
J. Thoracic and Cardiovas. Surg.
Fig. 4.—A, Preoperative chest roentgenogrram of 50-year-old truck driver with a history of hypertension over 200 mm. Hg. One month previously, chordal attachment to posterior leaf let had ruptured and precipitated congestive failure refractory to treatment, functional Class IV. Severe cardiomegaly has not had time to develop. B, Chest roentgenogrram of same patient made 21 months after surgical correction shows clearing of pulmonary edema.
PRE-OPERATIVE
OS. 1)11179
2 YEARS POST-OPERATIVE
IV
B y~\—|—y—\—-y Pig. 5.'—A, Left heart pressure tracing of patient shown in Pig. 4. Systemic hypertension (LV) is masked by massive mitral valve regurgitation. Ventriculization of the left atrial pres sure has occurred. B, Left heart pressure tracing in same patient made 2 years after surgical correction by pulley prosthesis shows return of atrial pressures to normal range.
Vol. 48, No. 5 November, 1964
R U P T U R E D CHORDAE T E N D I N E A E TABLE
PA TIENT
AGE
DATE (MO./ YR.)
ETIOLOGY
PATHOLOGY ( S I T E OF RUPTURE)
779
I
T E C H N I Q U E OF CORRECTION
RESULT
N.D.
17
11/60 Rheumatic
Ant. leaflet
Annuloplasty
J. L.
56
11/60 Coronary
Post, leaflet
Straight prosthesis
W. P. A.M.
60 41
1/62 4/62
Post, leaflet Ant. leaflet
Straight prosthesis Straight prosthesis
Died; failure of correction Died of possible coronary occlu sion 6 mo. postop. Good Died; arrhythmia
0. S. P . H. N.V.
50 57 57
5/62 7/62 8/62
Post, leaflet Post, leaflet Ant. leaflet
Pulley prosthesis Pulley prosthesis Annuloplasty
Good Good Good
T. B. E. C. R. D.
61 35 60
1/63 3/63 4/63
Post, leaflet Ant. leaflet Post, leaflet
Pulley prosthesis Pulley prosthesis Pulley prosthesis
Good Good Good
E.D. F . H.
58 50
4/63 11/63
Post, leaflet Post, leaflet
Pulley prosthesis Pulley prosthesis
E. H.
43
Ant. leaflet
Starr-Edwards repl.
Good Died; pulmonary embolus Good
Coronary Rheum., cong. V.S.D. Hypertension Coronary Rheum. + trauma Coronary Rheumatic Coronary hy pertension Hypertension Rheumatic
4/63 Rheumatic
defect. One late death occurred, unexpectedly, 6 months after correction in a 56-year-old man with a history of angina. In 3 cases, efforts to control regurgitation by annuloplasty were successful in 1 and unsuccessful in 2. In 1 of these, the only instance of valvular calcification and rigidity, a Starr-Edwards total replacement was necessary.18 One patient in this series was classified as functional class IV before the operation (Fig. 4), while all others were designated Class III. All patients who have survived have shown dramatic clinical improvement and have returned to normal activity (Fig. 5). In 1 patient no residual murmur can be heard, although in all others a Grade 1 to 2/6 systolic murmur can be heard at the apex. SUMMARY
Recent studies indicate that ruptured chordae tendineae may be a more frequent cause of mitral valve insufficiency than has been suspected. In a series of 58 patients treated at the University of Michigan Medical Center and St. Joseph Mercy Hospital, the mitral regurgitation was found to be associated with ruptured chordae tendineae in 13. In 7 of these 13 cases the rupture had occurred as a complication of nonrheumatic diseases, such as coronary heart disease, myocardial infarction, and hypertension. In 6 cases there was a history of rheumatic fever. The lesions in the nonrheumatic group were characterized by involvement of the posterior leaflet only; in the rheumatic group, either the anterior or posterior leaflet was involved. A technique of prosthetic chordae substitution has been developed which has been effective in all patients in whom it has been tried. The operative procedure is less extensive and time-consuming than total valve replacement, and, therefore, should be much safer for patients with marginal myocardial reserve, many of whom have coronary heart disease.
780
MORRIS, PENNER, BRANDT
J. Thoracic and Cardiovas. Surg.
REFERENCES
1. Lillehei, C. W., Levy, M. J., and Bonnabeau, R. C.: Mitral Valve Replacement With Preservation of Papillary Muscles and Chordae Tendineae, J . THORACIC & CARDIOVAS. SURG. 47: 532, 1964.
2. Morris, J . D., Sloan, H., and Brandt, R.: Newer Concepts in Mitral Valve Surgery, J . Michigan State M. Soe. 6 1 : 1353, 1962. 3. Corvisart, J . N . : An Essay on the Organic Diseases and Lesions of the Heart and Great Vessels (translated by Jacob Gates), Boston, 1812, A. Finley; New York, 1962, Hafner Publishing Co. 4. Osmundson, P . J . , Callahan, J . A., and Edwards, J . E . : Ruptured Mitral Chordae Tendineae, Circulation 2 3 : 42, 1961. 5. Askey, J . M.: Spontaneous Rupture of a Papillary Muscle of the H e a r t : Review With Eight Additional Cases, Am. J . Med. 9: 528, 1950. 6. Craddoek, W. L., and Mahe, G. A . : Rupture of Papillary Muscle of Heart Following Myocardial Infarction: Differential Criteria From Perforation of Interventricular Septum, J . A. M. A. 151: 884, 1953. 7. Frothingham, C , and Hass, G. M.: Rupture of Normal Chordae Tendineae of the Mitral Valve, Am. Heart J . 9: 492, 1934. 8. McGoon, D. C.: Repair of Mitral Insufficiency Due to Ruptured Chordae Tendineae, J . THORACIC & CARDIOVAS. SURG. 39: 357, 1960.
9. Henley, W. S., Discussion, Prosthetic Valves for Cardiac Surgery, Merendino, K. A., Springfield, 1961, Charles C Thomas, Publisher. 10. Kay, J . H., and Egerton, W. S.: The Repair of Mitral Insufficiency Associated With Ruptured Chordae Tendineae, Ann. Surg. 157: 351, 1963. 11. January, L. E., Fisher, J . M., and Ehrenhaft, J . L . : Mitral Insufficiency Resulting From Rupture of Normal Chordae Tendineae, Circulation 26: 1329, 1962. 12. Osmundson, P . J., Callahan, J . A., and Edwards, J . E . : Mitral Insufficiency From Ruptured Chordae Tendineae Simulating Aortic Stenosis, Proc. Staff. Meet., Mayo Clin. 33: 23, 1958. 13. K a y , E . B., Suzuki, A., and Mendelsohn, D., J r . : Operative Results in Aortic Valve Surgery, Circulation 26: 484, 1962. 14. Kay, E . B., and Suzuki, A . : Personal communication. 15. Groves, L . K., and Effler, D. B . : A Needle Vent Safeguard Against Systemic Air Embolus in Open-Heart Surgery, J . THORACIC & CARDIOVAS. SURG. 47: 349, 1964.
16. Kay, J . H., Magidson, O., and Meihaus, J . E . : Surgical Treatment of Mitral Insufficiency and Combined Mitral Stenosis and Insufficiency Using the Heart Lung Machine, Am. J . Cardiol. 9: 300, 1962. 17. Callaghan, J . C : Mural Leaflet Advancement, Dis. Chest 4 3 : 87, 1963. 18. Starr, A., and Edwards, L. M.: Mitral Replacement: Clinical Experience With a Ball-Valve Prosthesis, Ann. Surg. 154: 726, 1961. (For Discussion, see page 815)