Minimally Invasive Artificial Chordae Replacement: The Clip Technique

This the case of a 55-year-old male with no record of previous disease or cardiovascular risk factors. At the time of surgery the patient was asymptomatic. TEE showed severe mitral regurgitation (MR) secondary to prolapse of the posterior mitral leaflet. The prolapse of the P2 segment with broken chordae was visible without doppler. A severe MR Jet was visible with doppler.

Surgical Strategy:

1. Selective left main bronchus ventilation, right femoral arterial and venous cannulation, 5 cm thoracotomy in 4th intercostal space, and 5 accessory ports.
2. Cardiopulmonary bypass was started before opening of pericardium.
3. The pericardium was opened and exposed from the ascending aorta to inferior vena cava.
4. Silk suture was used for traction of pericardium through port N3.
5. Dissection of interatrial groove.
6. Anterograde cardioplegia cannula were placed in ascending aorta.
7. Aortic clamp through port N2.
8. The left atrium was opened.
9. Atrial retractor was placed in the third intercostal space, parasternal line, with direct view of mammary vessels.
10. The mitral valve was exposed.
11. Braided polyester suture was placed in the mitral annulus to improve valve examination.
12. The mitral valve was examined. Prolapse of P2 segment with rupture of primary order chordae was observed.
13. Hydraulic test showed incompetence of mitral valve at the level of P2 segment.
14. Two Goretex sutures were passed twice in a “figure 8” through the posterior papillary muscle.
15. Sizers were used to identify the right size of the mitral ring. The authors selected a N31 semirigid incomplete ring.
16. The Goretex suture that had already been passed through the papillary muscle was passed through the leaflet border.
17. The chordae was tied on the atrial surface of the leaflet with a double slip knot, just tight enough to bring the leaflet to the plane of the annulus.
18. A clip was placed lightly across the knot. Eight more knots were tied over the clip, and the clip was removed.
19. Water test showed no significant MR.
20. Ultrasound intraoperative TEE showed a competent mitral valve with no significant MR.