title: Artificial chordae in the setting of complex mitral valve repair: early outcomes using the folding leaflet technique.
abstract: OBJECTIVE
  Neochordal repair is particularly limited in case of large prolapse with absence of a reference point on a nearby segment. Our aim was to overcome these limitations by means of a simple technique: the 'Folding Leaflet'.
  
  
  METHODS
  Ninety-six patients underwent this technique between January 2009 and August 2012 from a global mitral valve (MV) repair group of 384 patients. A subgroup of 68 patients with complex lesions, bileaflet, commissural or multisegment prolapse, was selected. These more challenging patients were considered as the study group in order to assess the efficacy of our technique. The neochordae were fixed to the papillary muscle with a simple stitch and then were passed through the free margin of the prolapsing leaflet. Free-edge remodelling was achieved weaving this suture and surpassing the coaptation line. Then, the leaflet was folded and its free margin was temporarily approximated edge-to-edge to the adjacent annulus. This was used as the reference point while the neochordae were tied without the need for adjacent healthy chordae or use of callipers. Complete echocardiographic follow-up was obtained at 6-month intervals.
  
  
  RESULTS
  All patients had ≥ 2 prolapsed segments: posterior leaflet (40 patients), anterior leaflet (13 patients) or both leaflets (15 patients). Annuloplasty was routinely used and the mean number of neochordae per patient was 4.1 ± 2.2 (2-13). Mean follow-up was 28 ± 14 months (5-49 months). There was only one in-hospital death. Another patient died by pneumoniae (15th postoperative month). At the first-month follow-up, 51 patients had no mitral regurgitation (MR) and 16 patients had Grade 1 MR. Only 1 patient had more than mild regurgitation at the 6-month follow-up. There was no evidence of Grade 3 or 4 MR in any patient. At the 2-year follow-up, 34 patients remained with no MR or trace MR and 7 patients had Grade 1 MR.
  
  
  CONCLUSIONS
  MV repair for complex degenerative MR using this technique of neochordal repair results in excellent early and mid-term outcomes. This technique facilitates the extensive use of neochordae in case of large areas of prolapse.
authors: Department of Cardiac Surgery, University General Hospital of Valencia, Valencia, Spain.
authors: Rafael
authors: R
authors: García Fuster
authors: Elio
authors: E
authors: Martín
authors: Federico
authors: F
authors: Paredes
authors: Armando
authors: A
authors: Mena
authors: Sergio
authors: S
authors: Cánovas
authors: Oscar
authors: O
authors: Gil
authors: Fernando
authors: F
authors: Hornero
authors: Juan
authors: J
authors: Martínez
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002815:Chordae Tendineae / Q000601:surgery*; D005260:Female; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000601:surgery*; D058386:Mitral Valve Annuloplasty / Q000009:adverse effects / Q000401:mortality; D008944:Mitral Valve Insufficiency / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D008945:Mitral Valve Prolapse / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D011474:Prosthesis Design; D012189:Retrospective Studies; D013536:Suture Techniques; D013997:Time Factors; D016896:Treatment Outcome
keywords: Artificial chordae; Degenerative mitral regurgitation; Valve repair