Exploring better methods to preserve the chordae tendineae during mitral valve replacement

Background. It is not known how best to resuspend the mitral chordae tendineae during mitral valve replacement to optimize postoperative left ventricular (LV) systolic and diastolic function. Methods. Six different techniques to preserve the chordae during mitral valve replacement were compared in 12 dogs using a nondistorting isovolumic technique: conventional, all chordae severed; anterior, all chordae preserved anteriorly; partial, anterior papillary muscle chordae preserved anteriorly; posterior, all chordae preserved posteriorly; oblique, anterior papillary muscle chordae directed anteriorly and posterior papillary muscle chordae posteriorly; and counter, opposite of oblique chordal direction. Control measurements (no chordal tension) were recorded between each experimental condition. Results. The oblique method tended to have the best LV systolic function versus the conventional method (E(max) = 4.0 +/- 1.8 versus 3.3 +/- 1.2 mm Hg/mL [mean +/- standard deviation]; p = 0.08 by repeated-measures analysis of variance; physiologic intercept E(es100) = 20.3 +/- 8.6 mL [p < 0.05 versus control]), with no major change in LV diastolic stiffness. The posterior method had a lower E(max) (3.3 +/- 1.2 mm Hg/mL) than the oblique method, but a similar E(es100) (20.8 +/- 8.1 mL; p < 0.05 versus control) and the best diastolic LV performance (LV diastolic stiffness = 0.46 +/- 0.23 mm Hg/mL). The counter method also had good systolic function (E(max) = 3.8 +/- 1.2 mm Hg/mL; E(es100) = 19.7 +/- 7.5 mL; p < 0.05 versus control), but had less favorable diastolic properties (0.65 +/- 0.37 mm Hg/mL; p < 0.05 by repeated-measures analysis of variance versus posterior). Conclusions. In this isovolumic preparation in normal canine hearts, the oblique method of chordal resuspension was associated with the best LV systolic function, whereas the counter technique impaired LV diastolic function. These preliminary results warrant further study in ejecting and failing hearts to determine conclusively which chordal orientation best preserves LV performance after mitral valve replacement.