Journal
EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY
Volume 57, Issue 3, Pages 535-544Publisher
OXFORD UNIV PRESS INC
DOI: 10.1093/ejcts/ezz258
Keywords
Mitral valve repair; Chordae tendineae forces; Biomechanics; Mitral valve surgery
Funding
- National Institutes of Health [R01HL089315-01]
- American Heart Association [17POST33410497, 18POST33990223]
- National Science Foundation [GRFP]
- Stanford Graduate Fellowship in Science and Engineering
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OBJECTIVES: Posterior ventricular anchoring neochordal (PVAN) repair is a non-resectional technique for correcting mitral regurgitation (MR) due to posterior leaflet prolapse, utilizing a single suture anchored in the myocardium behind the leaflet. This technique has demonstrated clinical efficacy, although a theoretical limitation is stability of the anchoring suture. We hypothesize that the PVAN suture positions the leaflet for coaptation, after which forces are distributed evenly with low repair suture forces. METHODS: Porcine mitral valves were mounted in a 3-dimensional-printed heart simulator and chordal forces, haemodynamics and echocardiography were collected at baseline, after inducing MR by severing chordae, and after PVAN repair. Repair suture forces were measured with a force-sensing post positioned to mimic in vivo suture placement. Forces required to pull the myocardial suture free were also determined. RESULTS: Relative primary and secondary chordae forces on both leaflets were elevated during prolapse (P<0.05). PVAN repair eliminated MR in all valves and normalized chordae forces to baseline levels on anterior primary (0.370.23 to 0.22 +/- 0.09 N, P<0.05), posterior primary (0.62 +/- 0.37 to 0.14 +/- 0.05 N, P=0.001), anterior secondary (1.48 +/- 0.52 to 0.85 +/- 0.43 N, P<0.001) and posterior secondary chordae (1.42 +/- 0.69 to 0.59 +/- 0.17 N, P=0.005). Repair suture forces were minimal, even compared to normal primary chordae forces (0.08 +/- 0.04 vs 0.19 +/- 0.08 N, P=0.002), and were 90 times smaller than maximum forces tolerated by the myocardium (0.08 +/- 0.04 vs 6.9 +/- 1.3 N, P<0.001). DISCUSSION: PVAN repair eliminates MR by positioning the posterior leaflet for coaptation, distributing forces throughout the valve. Given extremely low measured forces, the strength of the repair suture and the myocardium is not a limitation.
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