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(Circulation. 2004;110:II-91 – II-97.)
© 2004 American Heart Association, Inc.

Surgery for Valvular Heart Disease

Cutting Second-Order Chords Does Not Prevent Acute Ischemic Mitral Regurgitation

Filiberto Rodriguez, MD; Frank Langer, MD; Katherine B. Harrington, BA; Frederick A. Tibayan, MD; Mary K. Zasio, BA; David Liang, MD PhD; George T. Daughters, MS; Neil B. Ingels, PhD; D. Craig Miller, MD

From Department of Cardiothoracic Surgery (F.R., F.L., K.B.H., F.A.T., M.K.Z., G.T.D., N.B.I., D.C.M.) and Division of Cardiovascular Medicine (D.L.); Stanford University School of Medicine, Stanford, Calif; Laboratory of Cardiovascular Physiology and Biophysics (G.T.D., N.B.I.), Palo Alto Medical Foundation Research Institute, Palo Alto, Calif.

Correspondence to D. Craig Miller, MD, Department of Cardiothoracic Surgery, Falk Cardiovascular Research Center, Stanford University School of Medicine, Stanford, CA 94305-5247. E-mail dcm{at}stanford.edu

Background— Cutting anterior mitral leaflet second-order chordae has been proposed for repair in ischemic mitral regurgitation (IMR). We examined the efficacy of such chordal cutting in preventing acute IMR.

Methods and Results— Six sheep underwent radiopaque marker placement (left ventricle, mitral annulus, papillary muscles [PMs], and leaflets). The largest second-order chord from each PM was encircled with exteriorized wire snares. Three-dimensional marker coordinates were obtained with biplane videofluoroscopy before and during acute ischemia (80 seconds of mid-circumflex occlusion). Color Doppler transesophageal echocardiography was used to grade MR on a 0 to 4+ scale. Data were acquired immediately before and after dividing second-order chordae. Slope of the end-diastolic volume–stroke work relationship (PRSW) was calculated to assess systolic function. Chordal cutting increased anterior leaflet inflection angle (155±12 versus 162±9 degrees; P=0.03), resulting in a flatter leaflet, but did not increase effective leaflet length (1.97±0.24 versus 2.08±0.23 cm; P=0.15); PRSW decreased (63±15 versus 56±12 mm Hg; P=0.008). Both before and after chordal cutting, ischemia caused: Septal–lateral annular dilation (P=0.005), posterior PM displacement away from the mid-septal annulus (P=0.06), increased leaflet tenting area (P=0.001), and increased leaflet tenting volume (P=0.002). Before chordal cutting, MR increased significantly during ischemia (0.5±0.3 versus 1.7±0.4; P<0.001), and IMR increased similarly even after the second-order chords were cut (0.7±0.4 versus 1.9±0.9; P<0.001).

Conclusions— Cutting second-order chordae resulted in LV systolic dysfunction and neither prevented nor decreased the severity of acute IMR, septal–lateral annular dilation, leaflet tenting area, or leaflet tenting volume.

Key Words: mitral valve • ischemia • regurgitation • remodeling • contractility