Minimally Invasive Mitral Valve Repair Using Adjustable Chord-X and Locking Figure-of-Eight

The patient was a 65-year-old man with a newly identified systolic murmur in the mitral position on routine examination, who was asymptomatic without history of atrial fibrillation, pulmonary hypertension, or left atrial enlargement.

His echocardiogram showed severe mitral regurgitation with an anteriorly-directed jet and a posterior segment flail. Three-dimensional transesophageal echocardiography (TEE) showed a posterior segment with a ruptured chord.

The surgical approach consisted of a right minithoracotomy through the fourth intercostal space.

The left atrium was opened, the atrial lift retractor was inserted, and the valve was exposed. Ring stitches were placed. The valve was tested, and the ruptured chord in the posterior segment can be seen in the video. Methylene blue was used to mark the valve to find where the area of coaptation should have been. The sizing of the chordae in the case of the Leipzig loop technique was performed, just to illustrate. The valve was found to have only a posterior segment flail. The Superflex retractor was used to expose the papillary muscles. The neochords were sutured to the papillary muscle heads to the posteromedial muscle. Each one of these chords was anchored to the posterior segment flail with a figure-of-eight locking stitch, using each arm of the chordal system. With this, one stitch is applied and locked, and the sister arm is applied close to this—approximately 1 mm apart—and locked. This process was applied for each of the chordae. Notice that the leaflet was kept in a flail position above the annular plane because it is easier to push down the leaflet than to pull it up once the suture is locked.

The valve was tested, and one can see that the area of coaptation is improved and there was no longer a flail. Fine-tuning of the height of the posterior leaflet can be performed by grasping the posterior segment and with one hand grasping the suture. The authors did like the height of the posterior leaflet, so the sutures were tied. The valve was tested, and a 34 mm complete annular ring was used. Postoperative echocardiography showed a mean gradient of 3 mm Hg and no residual mitral regurgitation. The patient was discharged home on postoperative day number four.

Suggested Reading

1. El Gabry M, Jakob H, Lubarski J, Mourad F, Shehada S-E. Minimally invasive video-assisted mitral valve repair using PTFE-chordae: a simplified technique. August 2018. doi:10.25373/ctsnet.6990317.

Dr Castillo-Sang has been a compensated proctor for surgeons in the use of the Chordex System for mitral valve repair from ONX.