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\begin{document}

\title{Early Failure after Non-resectional Mitral Valve repair with Artificial
Chordae}



\author[1]{Ryan Moore}%
\author[2]{Per Wierup}%
\author[1]{A. Marc Gillinov}%
\affil[1]{Cleveland Clinic}%
\affil[2]{Cleveland Clinic Department of Thoracic and Cardiovascular Surgery}%


\vspace{-1em}



  
  \date{May 24, 2024}


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\selectlanguage{english}
\begin{abstract}
Severe recurrent mitral regurgitation (MR) within 1 year of mitral valve
repair is usually attributed to a technical issue with the original
repair procedure. However, when artificial chordae are employed to
correct mitral valve prolapse, ventricular remodeling (i.e. decreased
ventricular size) can lead to recurrent prolapse and valve dysfunction.
To highlight this phenomena, we present 2 patients who experienced early
failure after undergoing mitral valve repair with artificial chordae.%
\end{abstract}%



\sloppy


\textbf{1 \textbar{} INTRODUCTION}

Degenerative mitral valve disease is the most common indication for
mitral valve surgery in North America\textsuperscript{1} In such
patients, mitral valve repair is preferred over mitral valve
replacement\textsuperscript{2-4}. Historically, resectional techniques
described by Carpentier\textsuperscript{5} were the predominant approach
to mitral valve repair.

David and Frater\textsuperscript{6-8} originally described the used of
artificial ePTFE chords to reconstruct the mitral valve apparatus when
ruptured or elongated native chordae are the cause of prolapse. Mitral
valve repair with artificial chordae has excellent mid- and long-term
outcomes\textsuperscript{9-10}. It has been shown to produce equivalent
clinical outcomes when compared with resectional techniques. Potential
advantages when compared to resectional techniques include preservation
of the mitral valve apparatus, greater surface of leaflet coaptation and
decreased risk of SAM\textsuperscript{11-12}. However, a small
percentage of patients experience early mitral valve repair failure
after repair with artificial chordae.

We report 2 cases of recurrent mitral regurgitation early after mitral
valve repair with artificial chordae; these were attributable to
recurrent prolapse resulting from left ventricular remodeling.



\textbf{2 \textbar{} CASE SERIES}

\textbf{\textbar{} Approach to Artificial Chordae Implantation}

An ePTFE suture (CV-4) is passed through the fibrous region of a
papillary muscle on the same side of the valve (ie, medial or lateral)
as the region of prolapse. Each end of the suture is brought up to the
leaflet edge and passed twice through the leaflet tissue in the region
of prolapse; the needles pass from the ventricular to the atrial aspect
and finish adjacent to each other on the atrial aspect. The chordal
length is adjusted to a level to prevent prolapse, using the region of
A1-P1 as a reference point and ensuring a generous zone of coaptation
(Figure 1). The suture is tied on the atrial side of the MV leaflet. All
repairs include a posterior annuloplasty band.

\textbf{\textbar{} Case 1}

A 42 year old male presented with 4+ MR, annular dilatation, mild left
ventricular dilatation and mild left ventricular dysfunction. At index
operation he had extensive posterior leaflet prolapse with ruptured
chordae to P2/P3. Two sets of artificial chords were fixed to the
posterior leaflet and a 35-mm annuloplasty band placed. No SAM or MR was
noted after the case, and leaflet coaptation was excellent. Three months
postoperative, he presented with 3-4+ MR and mild symptoms. At
reoperation, previously placed chords remained intact but he had P2
prolapse with a noticeably remodeled ventricle that was now normal in
size. His valve was repaired with sliding valvuloplasty.

\textbf{\textbar{} Case 2}

A 51 year old male presented with 4+ MR, LV dilatation and mild
biventricular dysfunction. At index operation he had multiple ruptured
chords to his posterior leaflet. Artificial chords were fixed to the
posterior leaflet and a 35-mm annuloplasty band was placed. He presented
6 months later with 4+ MR and NYHA Class II symptoms; his ventricular
function had improved and ventricular size was now normal. At
reoperation, artificial chords remained intact but were now too long,
causing posterior leaflet prolapse. His valve was repaired with sliding
valvuloplasty.

\textbf{\textbar{} DISCUSSION}

When compared to mitral valve replacement, mitral valve repair in
patients with degenerative disease is associated with superior outcomes
and, in addition, excellent durability\textsuperscript{13}. However,
there is an inherent failure rate after mitral valve
repair\textsuperscript{14-15}. Failure within 1 year of repair is
traditionally attributed to technical error rather than to disease
progression or new pathology \textsuperscript{16}. Non-resectional
techniques including the use of artificial chordae have potential
advantages over leaflet resection stemming primarily from preservation
of mitral valve physiology \textsuperscript{17}. Here we describe our
experience with 2 patients who required early reoperation for recurrent
mitral regurgitation after mitral valve repair using artificial chordae.

In patients with left ventricular dysfunction and enlargement, mitral
valve repair can be associated with reverse remodeling that includes a
reduction in left ventricular dimension. We suggest here that reverse
remodeling after mitral valve repair may occasionally result in
ventricular morphology that causes recurrent prolapse in patients whose
initial mitral valve repair was achieved with the application of
artificial chordae. Further study of a larger number of patients will be
necessary to understand the precise changes in ventricular dimension
that can cause recurrent prolapse when artificial chordae are employed.

Determination of proper chordal length during surgery remains crucial in
successfully performing artificial chord repair. Numerous techniques
have been described to expand the number of tools at the surgeon's
disposal \textsuperscript{18}. We routinely utilize artificial chords
using either the free-hand or pre-measured loop techniques with great
success\textsuperscript{19}. We suggest the mechanism of early failure
described here represents an inherent risk of correcting mitral
regurgitation in patients who have left ventricular dilatation and
dysfunction rather than a technical failure. Reverse ventricular
remodeling may result in recurrent prolapse in such patients. One option
is to create chords that are somewhat shorter in patients with
ventricular dilatation, anticipating the possibility of remodeling. A
second option is to employ resectional techniques in such patients.

\textbf{4. \textbar{} REFERENCES}

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\tightlist
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\end{enumerate}

\textbf{Hosted file}

\verb`Figure 1_ Case Series_FailureACRepair.docx`  available at \url{https://authorea.com/users/324072/articles/452406-early-failure-after-non-resectional-mitral-valve-repair-with-artificial-chordae}

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