A Simple Nonresectional Technique for Degenerative Mitral Regurgitation With a Very Large Posterior Leaflet: Chordal Foldoplasty

Abstract

Leaflet resection with sliding valvuloplasty or additional chordal replacement is a standard technique for very large posterior leaflet prolapse. Regular chordal replacement without resection is simpler than those techniques. However, it may not reduce the leaflet height enough to avoid systolic anterior motion. In our technique, two pairs of neochordae are placed on the middle portion of the prolapsing scallop, which fixes the prolapse, reduces the functional height of the posterior leaflet, and blocks the leaflet tip from moving forward. This simple nonresectional technique can be easily performed with minimally invasive approaches. Postoperative echocardiography shows excellent leaflet motion and deep coaptation.

Nonresectional folding repair techniques for posterior leaflet lesions in degenerative mitral regurgitation

“…7 Early outcomes of 8 initial cases of chordal foldoplasty were previously reported. 8 We reviewed 60 patients who underwent chordal foldoplasty from August 2013 and May 2020. The median age of patients was 55 years (range, 30-85 years).…”

“…This technique should not be used in combination with commissural plication or annuloplasty with a small ring. 7 Folding techniques using the neochordae provide deep leaflet coaptation and preserves excellent leaflet motion, 8,10 which are advantages of neochordal techniques over resectional techniques. 15,16 They are still simple, although they require determining the length of the neochordae.…”

“…The neochordae naturally fold the leaflet toward the posterior ventricular wall, creating a new coaptation surface and blocking the leaflet tip from moving forward. 8 It is difficult to determine the neochordal length with premeasurement techniques in chordal foldoplasty because the appropriate length varies by the location at which sutures are fixed on the leaflet. The length of neochordae is determined with the tourniquet technique in which we temporarily hold the neochodae at a specific length using small tourniquets, assessed the leaflet competency by injecting saline into the left ventricle, and adjust the length by sliding the tourniquets.…”

“…We previously introduced modified neochordal replacement (chordal foldoplasty) to repair both prolapse and excess leaflet height without leaflet resection. 8 In this technique, applicable to any posterior leaflet scallop, neochordae are sutured on the middle portion of the P2 scallop instead of the leaflet edge ( Figure 3 ). The neochordae naturally fold the leaflet toward the posterior ventricular wall, creating a new coaptation surface and blocking the leaflet tip from moving forward.…”

“…The neochordae naturally fold the leaflet toward the posterior ventricular wall, creating a new coaptation surface and blocking the leaflet tip from moving forward. 8

Figure 3 Chordal foldoplasty. Left : The neochordal sutures are passed onto the atrial surface of the midportion of the tall posterior leaflet in a mattress fashion.

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