DK2985_C000 1..28 - AlSharqia Echo Club

Mitral Valve Replacement and Repair 443Figure 18.38 Repair of anterior leaflet prolapse due tochordal rupture, by transposition of mural leaflet chordae.[With permission of Carpentier (17).]aspect of the LA. Repair of anterior lesions necessitates amastery of surgical techniques.A. Chordal TransferWhen ruptured chords are responsible for anterior leafletprolapse, chordal transfer constitutes the treatment ofchoice (21). The advantage of this approach is the constantlength of the transferred scallop. The scallop of theanterior leaflet is located and 2-0 Ticron traction suturesare placed on each side of the prolapsed area. A correspondingsegment of the posterior leaflet is selected andtraction sutures are also used to delimitate the surfacearea to be transferred. Then, two simple 4-0 Cardionylsutures are applied directly on the lateral borders of theleaflet segment to be transferred. The diseased posteriorleaflet will be excised (#15 blade scalpel) and transferredto the corresponding area of the anterior leaflet(Fig. 18.38). The 4-0 Cardionyl sutures are inserted onthe edge of the anterior leaflet and tied to appose the transferredportion. Several 4-0 Cardionyl simple sutures areadded to secure the repair. The posterior leaflet cleft isthen repaired as in posterior resections. In a similarapproach for limited prolapse, healthy anterior secondarychords can be transferred to the free margin of the anteriorleaflet (17).B. Artificial Goretex ChordsSynthetic chords can be used for diffuse anterior leafletprolapse. This technique is now widely utilized with excellentlong-term results. The anterior leaflet is assessedduring valve analysis. A double armed 4-0 Goretexsuture is passed through the papillary muscle and tied onDacron pledgets. The two ends are then passed throughthe leaflet edge, at the site of ruptured or elongatedchords from the ventricular side to the atrial side; thenpassed through the leaflet again and tied, using staysutures on the posterior and anterior leaflet edges toassess proper length of the neo chordae (Fig. 18.39).(A)(B)ANTERIORLEAFLETPROLAPSELALAARVLV(C)(D)PAPILLARY MUSCLEPLEDGETS ANDCHORDS IMPLANTATIONSYNTHETIC FREE EDGE CHORDSFigure 18.39 (A,B) Mid-esophageal 688 view of a patient with anterior leaflet prolapse. (C, D) Synthetic chords attached to the freeedge are then implanted on the papillary muscle, preventing prolapse of the leaflet (LA, left atrium; LAA, left atrial appendage; LV, leftventricle; RV, right ventricle).