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The effect of chordal preservation on late outcome after mitral valve replacement: a randomized study
D Horskotte1, H D Schulte, W Bircks
1Department of Medicine, Heinrich-Heine-University Düsseldorf, Germany.
Insights
Preserving posterior chordae during mitral valve replacement significantly improves long-term hemodynamic status and exercise tolerance. This approach enhances survival and reduces complications, particularly for patients with severe mitral regurgitation.
Area of Science:
- Cardiovascular Surgery
- Cardiac Valve Repair
- Biomedical Engineering
Background:
- Mitral valve replacement (MVR) is a common cardiac surgery.
- The impact of preserving posterior chordae during MVR on long-term outcomes is debated.
- Standard MVR procedures often involve the sacrifice of the posterior mitral leaflet apparatus.
Purpose of the Study:
- To compare postoperative survival, hemodynamic status, and exercise tolerance in patients undergoing isolated MVR with or without posterior chordal preservation.
- To evaluate the long-term benefits of maintaining the posterior mitral leaflet's chordal and papillary structure.
Main Methods:
- A prospective, randomized study of 100 patients undergoing isolated MVR with St. Jude Medical prostheses (sizes 29mm or 31mm).
- Patients were divided into two groups: those with posterior chordal preservation and those without.
- Follow-up included right heart cardiac catheterization and exercise testing at a mean of 263-293 months post-surgery.
Main Results:
- Patients with posterior chordal preservation demonstrated significantly better hemodynamics: higher cardiac index (2.81 vs. 2.63 L/min/m², p<0.05) and improved exercise tolerance (1.8 vs. 1.2 Watt/kg, p<0.01).
- Lower pulmonary arterial pressure (30 vs. 37 mmHg at 30W exercise, p<0.01) and better end-diastolic volume index (75 vs. 86 ml/m², p<0.02) were observed in the chordal preservation group.
- Actuarial freedom from complications was higher with chordal preservation (78.1% vs. 70.7%, p<0.02).
- Severe mitral regurgitation patients showed significant benefit from preserving the posterior leaflet apparatus (p<0.001).
Conclusions:
- Preservation of posterior chordae during isolated mitral valve replacement leads to superior long-term hemodynamic function and exercise capacity.
- This technique is associated with improved survival and reduced complication rates.
- Maintaining the posterior mitral leaflet structure is particularly beneficial for patients with severe mitral regurgitation.
Abstract:
Postoperative survival, hemodynamic status and exercise tolerance with or without posterior chordal preservation were compared in a case-limited prospective randomized manner in 100 patients who underwent isolated mitral valve replacement with size 29mm or 31mm St. Jude Medical prostheses. The preoperative clinical and hemodynamic parameters were comparable in the two groups. The mean follow up was 293.3 months for those with and 263.1 months for patients without chordal preservation. Right heart cardiac catheterization was performed in every patients at the end of the follow up period and it demonstrated significantly better results with than without chordal preservation (cardiac index 2.81 +/- 0.47 vs. 2.63 +/- 0.52, p < 0.05; pulmonary arterial pressure 30 +/- 11 mmHg vs. 37 +/- 13 mmHg at 30 Watts bicycle exercise, p < 0.01; end-diastolic volume index 75 +/- 22 vs. 86 +/- 38 ml/m2, p < 0.02; and maximum exercise tolerance 1.8 +/- 0.3 vs. 1.2 +/- 0.5 Watt/kg, p < 0.01). Actuarial freedom from complications was 78.1 +/- 4.2% with and 70.7 +/- 6.2% without chordal preservation (p < 0.02). In particular, patients with severe mitral regurgitation benefited from the preservation of the posterior mitral leaflet with its chordal and papillary structure (p < 0.001).