In vitro assessment of prosthetic valve function in mitral valve replacement with chordal preservation techniques

The importance of chordal preservation techniques in maintaining improved left ventricular function after mitral valve replacement has been well documented clinically. Currently, the choice of prosthetic valve used in chordal preservation is dependent upon the surgeon's preference. However, the transvalvular flow characteristics of common, clinically used prosthetic valves may be influenced by the mitral subvalvular apparatus, and may result in degraded valve function. The goal of this study was to perform an in vitro evaluation of the influence of chordal preservation on the transvalvular and left ventricular flow patterns of common valve prostheses.

Tissue and mechanical valves have been evaluated under physiologic pulsatile flow with anterior and/or posterior chordal preservation. Flow patterns were assessed by 2-D planar flow visualization, pulsed wave Doppler velocity measurements, 2-D echocardiography, and selected color Doppler flow mapping. Based on changes in transvalvular and left ventricular flow patterns, favorable prosthetic valve/chordal preservation combinations were identified. Additionally, valve orientation was varied to determine optimal orientation.

Baseline results without chordal preservation indicate that the anti-anatomic orientation is preferred for the bileaflet valve design while the tilting disc valve should be oriented with the major axis toward the posterior (free) wall of the ventricle, corroborating published conclusions by other investigators. Some form of flow restriction is observed in all test cases with chordal preservation due to the presence of the subvalvular tissue. In general, bioprostheses showed less flow restriction then the mechanical valves, particularly with lateral flow expansion. This flow restriction may influence pressure recovery downstream of the mechanical valves tested. Increased flow constriction is observed with anterior and posterior chordal preservation.

This study favors the use of the St. Jude Medical bileaflet valve orientated in the anti-anatomic position, or the Carpentier-Edwards pericardial valve with chordal preservation.