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Background and aim Second-order chord tethering of the anterior leaflet is a risk factor for failure of posterior leaflet prolapse repair. Materials and methods We describe two cases of second-order chord tethering of the anterior leaflet associated with severe mitral regurgitation due to prolapse or chordal rupture of the anterior leaflet, causing early and late failure of repair. Results We described two cases where this phenomenon happened. Conclusions Our cases demonstrate that the second-order chords of the prolapsing AL can be tethered and that this aspect should be carefully evaluated before surgery, as it can progress over time, affecting the results of surgical repair.

Suture-related injuries of the left circumflex branch are a serious and well-known complication of mitral valve surgery. Avoiding this complication is challenging, especially in an unexpected course of coronary arteries. We present a case of minimally invasive mitral valve repair in a patient with a rare anatomical variant of the main stem in direct proximity to the whole anterior leaflet.

Symptomatic cardiac rheumatoid nodules are a rare but recognized manifestation of rheumatoid arthritis. We describe the surgical management of a rheumatic nodule involving the anterior leaflet of the mitral valve.

Background Mitral annuloplasty is a reliable mitral valve repair technique. There are two types of annuloplasy rings: the rigid ring and the flexible ring. This study sought to examine the long-term results of mitral valve repair using a Duran flexible ring. Methods We retrospectively reviewed 226 patients who underwent primary mitral valve repair using the Duran flexible ring for mitral regurgitation between September 1994 and March 2003. Patients' mean age was 56.7 years, and 39% were female. The mean follow-up was 10.6 years (0.04 ∼ 18.3), and echocardiographic follow-up was 83.3% complete. Results There were three early and 25 late deaths. Survival was 89.3 ± 2.2 for 10 years, and 83.5 ± 3.2% for 15 years. The 10- and 15-year freedom from reoperation on the mitral valve were 96.4 ± 1.4 and 95.3 ± 1.7%, respectively. The 10- and 15-year freedom from moderate or severe mitral regurgitation were 92.5 ± 2.2 and 73.7 ± 7.1%, respectively. Cox regression analysis revealed that age, male gender, and isolated anterior leaflet prolapse were predictive of recurrent moderate or severe mitral regurgitation. Conclusions Mitral valve repair for mitral regurgitation using a flexible Duran ring is safe and durable for more than 10 years. doi: 10.1111/jocs.12522 (J Card Surg 2015;30:333–337)

Objectives This retrospective study assesses the outcomes of a modified Carpentier's technique for Ebstein's anomaly repair in respect to functional and anatomical recovery of the right ventricle and tricuspid valve. Patients and Methods From August 2005 to December 2010, 52 patients with Ebstein's anomaly were operated in Hanoi Heart Hospital, Vietnam using the modified Carpentier's technique: (1) extensive mobilization of the tricuspid leaflet by detachment of the posterior, septal, and the adjacent part of the anterior leaflet; (2) longitudinal plication of the atrialized chamber and the right atrium to reconstruct the right ventricle and reduce the size of the dilated right atrium; (3) relocation of the anterior, posterior, and septal leaflets to the normal tricuspid annulus; and (4) tricuspid annuloplasty. Results Mean age was 20 years (3–49 years). Tricuspid regurgitation (in four-grade scale) was reduced from 3.72 ± 0.48 to 1.56 ± 0.48 (p

Background Satisfactory results of bileaflet preserving mitral valve replacement (MVR) had forced several institutes to preserve both leaflets during MVR. Modifications were required to prevent the preserved tissue from interfering with prosthetic valve function, to implant an adequate size of valve and to prevent left ventricle outflow tract (LVOT) obstruction. Materials and methods Conventional MVR was performed to 51 patients (group 1) and bileaflet preserving MVR was performed to 43 patients (group 2). Mitral anterior leaflet incised from the middle of the leaflet to mitral annulus without chordal injury in group 2 patients. Sutures were placed through the mitral annulus first and then passed from the bottom to the tip of anterior leaflet. Posterior leaflet was also preserved. Prosthetic valve was put down into the mitral annulus and sutures were ligated. Excessive anterior leaflet tissue was attached to left atrial wall. Results Cross-clamping time was 45 +/- 5.33 minutes versus 61.32 +/- 4.43 minutes (p = 0.0001) and total cardiopulmonary bypass time was 60.80 +/- 4.44 minutes versus 80.55 +/- 3.65 minutes (p = 0.0001) in groups 1 and 2, respectively. Inotropy requirement was higher in group 1 (p = 0.0058). When compared with preoperative values postoperative left ventricle ejection fraction (LVEF) increased both at rest (from 52.74% +/- 3.88% to 62.86% +/- 3.18%, p = 0.0001) and during exercise (from 53.16% +/- 3.16% to 64.11% +/- 2.46%, p = 0.0001) in bileaflet preserving MVR group. But in conventional MVR group LVEF decreased postoperatively both at rest (from 51.45% +/- 4.27% to 48.27% +/- 3.35%, p = 0.0001) and during exercise (from 54.47% +/- 7.36% to 42.96% +/- 3.58%, p = 0.0001). Conclusion Leaflet preserving MVR operation not only improves the left ventricular performance but also reduces the mortality and morbidity after MVR. LVEF increases both at rest and during exercise. Risk of LVOT obstruction can be completely eliminated with our simple technique.

Isolated congenital tricuspid regurgitation without downward displacement of the leaflet is uncommon in adults, and repair of such valves often requires a procedure that is more complex than simple tricuspid annuloplasty. We describe a technique of tricuspid valvoplasty using the neo-papillary loop technique to reconstruct multiple artificial chords for isolated congenital tricuspid regurgitation associated with a dysplastic anterior leaflet with agenesis of the chordae tendineae and a hypoplastic anterior papillary muscle. This technique provides a simple and valuable option for the repair of dysplastic valves lacking chordae, even those with a hypoplastic papillary muscle.

During mitral valve replacement, total chordae preservation is very important for left ventricular functions. But leaving anterior leaflet and chordae may cause serious complications, such as left ventricular outflow tract obstruction and impairment in prosthetic valve functions. In this article, we present the anterior leaflet preservation technique by excising the central portion of the anterior leaflet. The rim of the leaflet tissue containing the marginal chordae was divided in two parts without destroying the chordae, and then the rim of leaflet tissue was sutured to the left atrium. This technique provided optimal chordae tension and improved avoidance of complications due to total chordae preservation, in mitral valve replacement operations.

Background: This study examined the septal cleft and septal commissure of the left atrioventricular (AV) valve, which are two different anatomical structures. Methods: We presented 36 cases of adult partial atrioventricular septal defect. A distinction was made between patients based on the anatomy of the anterior leaflet of the left AV valve. The left AV valve appeared to be normal or to have minimal radial openings from the free edge of the anterior leaflet of the left AV valve in 10 patients (28%). There was a septal commissure structure in 8 (22%), and a septal cleft structure in 18 (50%) patients. In the commissure type anatomy, leaflet coaptation was usually adequate and no or mild degree of left AV regurgitation existed preoperatively. Cleft type structure usually was associated with some degree of left AV regurgitation. Attempts were made to close the septal clefts and leave the septal commissures unsutured during the repair of the partial AV septal defects. Results: We have not found any increase of left AV regurgitation in patients with commissures during the follow-up period. Closure of the cleft successfully eliminated regurgitation. Long-term results for septal cleft and septal commissure after repair of partial AV septal defect were excellent with survival of 100% and freedom from reoperation of 100% at mean 6.5 years. Conclusions: Septal cleft and septal commissure should be considered two different structures. Repairing procedures for left AV valve abnormalities associated with partial AV septal defect should only be done in patients who have cleft type of leaflet structure.

Chordal transfer from the intact posterior mitral leaflet (PML) to the anterior mitral leaflet (AML) is an effective way to correct anterior leaflet prolapse and provides good long-term results. However, it is difficult to determine the accurate segment of the PML which needs to be transferred and the suture point of the leaflets. We describe a modified technique to determine the correct segment that needs to be transferred to effectively correct AMLs with elongated or ruptured chordae. This technique renders performing chordal transfer easier and more accurate.

We describe a case of mitral valve aneurysm associated with concomitant aortic valve endocarditis. Aneurysms appear as a localized saccular bulge of the anterior leaflet into the left atrium and thus are often misdiagnosed as mitral valve prolapse, myxomatous mitral valve, or atrial myxoma. The presentation and management of mitral valve aneurysms are the subject of this case report. (J Card Surg 2011;26:284-286)

Techniques of repair of defects in the anterior leaflet of the mitral valve and replacement of the aortic valve using allograft are presented. The case history and operative procedure of a reconstructive operation that did not require anticoagulant therapy after surgery are described for three adult patients. Mitral valve defects were repaired using the anterior leaflet of the mitral valve of the allograft. The aortic valve or entire root was replaced with the aortic allograft. The aortic/mitral allograft should be considered as an alternative to replacement of the aortic and mitral valves with prostheses in selected patients.

We report a 62-year-old female who required surgery for severe mitral regurgitation. Under robotic assistance, the valve was repaired by transection of the fibrous bridge, implantation of four neo-chordaes to the anterior leaflet, commissuroplasty of the posterolateral commissure, and annuloplasty.

Anomalous chordae tendinae (CT) originating from mitral valve leaflet is a rare congenital mitral valve anomaly. Our case report is unique as this anomaly is extremely rare in this pediatric age group. The anomalous CT extended from anterior mitral leaflet to the atrial septum (AS). Surgical repair in the form of anomalous CT excision, anterior leaflet chordoplasty, and posterior mitral annuloplasty was successfully performed. Congenital mitral valve (MV) leaflet or chordae anomalies are rare. In anomalous CT from MV leaflet to the AS, the surgical experience is extremely limited and only reported in adults and adolescents. We describe an unusual presentation of severe mitral insufficiency (MR) associated with anomalous CT from the anterior mitral valve leaflet (AMVL) to the AS that prompted successful repair during childhood.

Surgical treatment of tricuspid valve endocarditis is challenging especially in intravenous drug users. We present a case of a 30-year-old male active drug user with anterior leaflet endocarditis treated successfully with valve repair. This was achieved through excision of the vegetation with part of the leaflet. Bovine pericardium was used to close the defect. The edges were reinforced with Teflon pledgeted polytetrafluoroethylene Gore-Tex neochordae (W.L. Gore & Associates, Flagstaff, AZ, USA). An annuloplasty ring was used to reinforce the whole annulus. Repair was competent and the patient recovered well. This technique is simple and effective and should be considered for similar cases. (J Card Surg 2010;25:153-155)

Background: Different techniques have been proposed to measure the correct length of artificial chordae. We herein describe a new simple method to measure the chordal length in complex chordal replacement. Method: Chordal replacement was used by us for two different purposes: (1) to maintain the correct chordal length for the anterior leaflet (AL) and (2) to eliminate any movement of the posterior leaflet (PL) to fix it. To reach this goal, the AL is pulled up to the maximum extent and the new chordae are tied 5 mm higher than the related border. On the contrary, in the PL the new chordae are tied at the level of the related border. Results: From March 2006 to March 2007, at the University of Catania, this technique was used in 32 patients (16 for correction of PL prolapse, 6 patients for correction of AL prolapse, and in 10 patients for correction of both leaflets prolapse). The number of chordae per patients was 8.6 for the PL and 6.8 for the AL. No patient died or had major complications. After a mean follow-up of 5 ± 2 months, two-dimensional echocardiography showed that all the patients had no or trivial mitral regurgitation (MR). The echocardiogram showed a correct movement of the new chordae. Conclusions: This technique allows to easily establish the length of the new chordae of the AL and, if necessary, of the PL in complex mitral valve repair.

The use of conservative surgical techniques to treat mitral valve regurgitation secondary to acute endocarditis is controversial. Reconstruction of the anterior leaflet may represent an additional challenge in such a setting. We report a case of mitral valve repair where extensive excision of the anterior leaflet and related chordae tendinea was necessary because of large vegetation secondary to acute endocarditis. The “double-orifice” technique was performed and allowed the salvage of the native valve. There was no recurrent infection at 6 months from surgery, with optimal hemodynamic results. (J Card Surg 7998; 73:24–26)

A repair technique is reported for Ebstein's anomaly associated with partial atrioventricular canal. When there is inadequate size of the anterior leaflet of the tricuspid valve, pericardial patch augmentation of the anterior leaflet may result in a well functioning monocusp tricuspid valve.

Up to one-third of the patients with degenerative mitral valve disease and severe mitral regurgitation have anterior mitral valve prolapse due to chordal rupture or elongation. Surgical treatment of such a condition is often technically demanding and not infrequently associated with suboptimal results. Techniques used to treat anterior leaflet prolapse include chordal transfer, chordal shortening, artificial chordae, and anterior leaflet resection or plication. Each of these strategies has potential shortcomings, and there is considerable controversy concerning the durability of anterior leaflet prolapse repairs using these techniques. The "edge-to-edge" technique, a simple and effective method of correcting anterior mitral leaflet prolapse is described.

A rare case of congenital mitral insufficiency characterized by the hypoplasia of the posterior leaflet is reported. At operation, the mitral valve was successfully repaired by a ring annuloplasty, which created a satisfactory surface of coaptation between the anterior leaflet and the bulky posterior muscular structure. The presence of this posterior muscular structure represents a developmental arrest at the stage of conversion from muscular chordae and leaflets to thin connective structures.

A 22-year-old man developed exertional dyspnea 2 years after blunt chest trauma due to a horse kick. Preoperative echocardiography showed severe tricuspid insufficiency (TI) caused by chordal rupture and prolapse of the anterior leaflet. A novel repair technique, the "clover technique," was applied, but was unsuccessful in this case. The valve was then repaired successfully using conventional techniques, that is, insertion of an artificial chordae, plication of the prolapsing leaflet, and DeVega's annuloplasty. We present here a brief review of posttraumatic TI, and discuss effective and less expensive techniques for repair.

A 62-year-old woman presented with exertional dyspnea and fever. On physical examination, a holosystolic murmur was found. A cystic lesion was detected by echocardiography. At surgery, a membrane was seen on the anterior leaflet, which extended from the primary chordae to papillary muscle of the anterior leaflet, making a cavity. There was also fenestration in the mid portion of the anterior leaflet. Leaflet augmentation with a pericardial patch was performed.