Misconnected: Valve Failure from an Unexpected Chordal Insertion

A 64-year-old woman with no significant past medical history presented with heart failure symptoms secondary to severe mitral regurgitation. She was referred for mitral valve repair with the intention of valve preservation. Initial transthoracic echocardiography (TTE) suggested that the regurgitation was due to a ruptured chordae resulting in prolapse of the A2 segment. Intraoperative inspection following atriotomy revealed an aberrant chordae tendineae inserting anomalously into the left atrial wall, which was contributing to the A2 prolapse. The aberrant chordae was excised and replaced with polytetrafluoroethylene (Gore-Tex) neochords. A mitral annuloplasty ring was placed to complete the repair. Intraoperative transesophageal echocardiography confirmed excellent valve function with only minimal residual regurgitation. The patient had an uneventful recovery and was discharged on the fourth postoperative day. Aberrantly inserted chordae tendineae are an exceedingly rare finding and may lead to significant valvular dysfunction. Prompt surgical recognition and correction can result in successful valve preservation and excellent clinical outcomes.