Heart Views

CASE REPORT
Year
: 2005  |  Volume : 6  |  Issue : 3  |  Page : 115--117

Repair of idiopathic rupture of mitral chordae tendinea by triangular resection and annuloplasty


Turkan Tansel, Murat Ugurlucan, Eylul Kafal, Omer Ali Sayfn, Murat Murat, Enver Dayfoglu, Ertan Onursal 
 Istanbul University Istanbul Medical Faculty, Department of Cardiovascular Surgery, Istanbul, Turkey

Correspondence Address:
Murat Ugurlucan
No: 110-112, Benli Apt., Daire: 6, 80250 Kurtulus / Istanbul
Turkey

Abstract

Major causes of rupture of chordae tendinea are myocardial infarction, trauma, hypertension, myxomatous degeneration, endocarditis and rheumatic heart disease. We describe an idiopathic rupture of the chordae tendinea of the posterior mitral leaflet in a 67 years old patient who had no evidence of coronary artery disease, rheumatic disease or other etiologies. The defect was repaired with triangular resection and annuloplasty. He had an uneventful postoperative course for 5 months.



How to cite this article:
Tansel T, Ugurlucan M, Kafal E, Sayfn OA, Murat M, Dayfoglu E, Onursal E. Repair of idiopathic rupture of mitral chordae tendinea by triangular resection and annuloplasty.Heart Views 2005;6:115-117


How to cite this URL:
Tansel T, Ugurlucan M, Kafal E, Sayfn OA, Murat M, Dayfoglu E, Onursal E. Repair of idiopathic rupture of mitral chordae tendinea by triangular resection and annuloplasty. Heart Views [serial online] 2005 [cited 2021 Jan 22 ];6:115-117
Available from: https://www.heartviews.org/text.asp?2005/6/3/115/64022


Full Text

 Introduction



Myocardial infarction, trauma, hypertension, myxomatous degeneration, endocarditis, rheumatic heart disease are the major causes of rupture of chordate tendinea. In the literature, there are only a few cases described with idiopathic rupture of chordae tendinea1. We present in this case report a 67 year old male patient referred to our institution for surgical treatment of mitral regurgitation.

 Case Presentation



A 67 year-old male patient was admitted to the hospital with, dyspnea, chest pain, and problems of urination. He was on no medical treatment and over the last two years, the dyspnea has progressed. He denied any history of chest trauma or rheumatic heart disease.

Cardiac auscultation revealed, a grade 3/6 apical pansystolic murmur. ECG demonstrated atrial fibrillation. Laboratory findings were within normal except for slight elevation of prostatic enzymes. Chest X-ray showed cardiomegaly.Transthoracic echocardiography (TTE) revelaed left atrial enlargement and severe mitral regurgitation due to ruptured chordae tendinea of the posterior mitral leaflet [Figure 1]. Coronary angiography and cardiac catheterization showed high grade mitral regurgitation and normal coronary arteries. The patient was referred to our institution for mitral valve surgery.

After induction of anesthesia, transesophageal echocardiography (TEE) was performed. Mitral regurgitation with flail chordate tendinea of posterior mitral leaflet was observed.

The operation was performed through a median sternotomy incision under cardiopulmonary bypass with standard aortic and bicaval cannulations at moderate hypothermia. Myocardial protection was achieved with antegrade cold crystalloid cardioplegia and topical ice saline. After the establishment of cardioplegic arrest, a left atriotomy was fashioned. The mitral valve was examined. There was a tear of the basal chordate tendinea of the posterior mitral leaflet close to the posteromedial commissure, and it was decided to repair the valve.

A segment of the prolapsed posterior leaflet due to the rupture was excised in a triangular manner. The margins of the posterior leaflet were approximated with 5.0 pledgeted polyprolene sutures. Annular plication was performed with 4.0 pledgeted polyprolene sutures [Figure 2]. Patency of the valve was checked by insufflation of saline into the left ventricle and showed effective repair.

W eaning from cardiopulmonary bypass was accomplished with no difficulty. The cardiopulmonary bypass and aortic cross-clamp times were 57 minutes and 38 minutes, respectively. Intraoperative TEE revealed insignificant mitral regurgitation [Figure 3].

The patient was extubated at 8 hours postoperatively and postoperative period in the intensive care unit was two days. Postoperative TTE showed effective valve repair and the patient was discharged on the 10 th postoperative day without any cardiac symptoms.

 Discussion



Rupture of chordae tendinea might be a result of myocardial infarction, trauma, hypertension, myxomatous degeneration, endocarditis, rheumatic heart disease [1] . In the absence of these etiologic factors, and with the pathologic confirmation of the biopsy material, the disease can be accepted as idiopathic. There are only a few cases defined in the literature with spontaneous rupture of chordae tendinea[1].

Clinical findings of the patients vary from asymptomatic to cardiogenic shock. Some may remain asymptomatic for years[2]. Thus, surgical intervention after the initial symptoms can be very different [2],[3] . Early surgery is related with promising postoperative quality of life.

The choice between repair and valve replacement depends on the etiology and integrity of the valvular and subvalvular structures [3],[4] . Quadrangular resection and annuloplasty is the mode of surgical repair for ruptured chordae tendinea of the posterior mitral leaflet. Large segments of posterior leaflet can be excised in cases with annular dilatation due to ventricular enlargement [4] . However, sometimes surgeons face problems while approximating the edges such as in cases when the cut edges have different heights [5] .

For mild to moderately damaged valve tissue, triangular resection can be performed easily and safely. Due to the anatomical properties of the anterior leaflet of the mitral valve, triangular resection is mostly used to remodel this leaflet [4],[5] . However, for posterior mitral leaflet pathologies, quadrangular resection is usually the preferred method. Triangular resection technique is rather a new method for this leaflet. We performed triangular resection and annuloplasty for the repair of spontaneously ruptured chordate tendinea of the posterior mitral leaflet with satisfactory early surgical result.

 Conclusion



In cases with a small defect resulting from posterior chordae tendinea rupture, triangular resection and annuloplasty may be considered an alternative technique.

References

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