| DISCUSSION
When compared to mitral valve replacement, mitral valve repair in
patients with degenerative disease is associated with superior outcomes
and, in addition, excellent durability13. However,
there is an inherent failure rate after mitral valve repair14-15. Failure within 1 year of repair is
traditionally attributed to technical error rather than to disease
progression or new pathology 16. Non-resectional
techniques including the use of artificial chordae have potential
advantages over leaflet resection stemming primarily from preservation
of mitral valve physiology 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 18. We routinely utilize artificial chords
using either the free-hand or pre-measured loop techniques with great
success19. 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.