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(Circulation. 1999;100:II-90.)
© 1999 American Heart Association, Inc.

Surgery for Valvular Heart Disease

Randomized Trial of Partial Versus Complete Chordal Preservation Methods of Mitral Valve Replacement

A Preliminary Report

Kwok L. Yun, MD; Colleen F. Sintek, MD; D. Craig Miller, MD; Gregg T. Schuyler, MD; Alden D. Fletcher, MD; Thomas A. Pfeffer, MD; Gary S. Kochamba, MD; Siavosh Khonsari, MD; Michael R. Zile, MD

From the Department of Cardiac Surgery, Kaiser Permanente Medical Center, Los Angeles, Calif; Department of Cardiology, Medical University of South Carolina, Charleston, SC (G.T.S., M.R.Z.); and Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif (D.C.M.).

Correspondence to Kwok L. Yun, MD, Department of Cardiac Surgery, Southern California Permanente Medical Group, 1526 North Edgemont St, Third Floor, Los Angeles, CA 90027. E-mail Kwok.L.Yun{at}kp.org

Background—The merits of retaining the subvalvular apparatus during mitral valve replacement for chronic mitral regurgitation have been demonstrated in numerous clinical and laboratory investigations. In this preliminary report, we analyzed the early effects of complete versus partial chordal preservation on left ventricular mechanics.

Methods and Results—Fifty patients undergoing isolated surgical correction of mitral insufficiency were prospectively randomized to either total or partial chordal-sparing mitral valve replacement. Of the first 19 patients studied, 8 had preservation of the posterior leaflet only, and 11 had complete preservation of all chordal structures. A comparison group consisted of 6 patients who had primary mitral valve repair. Echocardiography was performed preoperatively and at discharge from the hospital to determine dimensions, wall stress, and ejection fraction. Preservation of the posterior leaflet only resulted in a reduction in end-diastolic volume, an increase in end-systolic volume (P=0.058), a rising trend in end-systolic stress, a decrease in long-axis fractional shortening, and a fall in ejection fraction from 0.68±0.16 to 0.46±0.19 (P=0.001). Although patients who had preservation of all chordal structures also had decreased end-diastolic volume, long-axis fractional shortening, and ejection fraction (0.60±0.13 to 0.52±0.07, P=0.01), end-systolic stress fell and end-systolic volume decreased instead of increased. Compared with the posterior leaflet preservation group, those in the group with completely preserved chordal structures had a larger decline in end-diastolic volume and smaller decreases in long-axis fractional shortening and ejection fraction. Changes in end-systolic volume and stress were also statistically different between the 2 cohorts. No differences were detected between the group with total preserved chordal structures and the mitral repair group in any of the measured parameters.

Conclusions—Compared with posterior chordal preservation only, complete retention of the subvalvular apparatus during mitral valve replacement resulted in improved ejection performance and smaller chamber volumes due to reduced systolic wall stress. These hemodynamic advantages are comparable to those observed with primary mitral reconstruction.

Key Words: mitral valve • hemodynamics • surgery • physiology