Importance of Preserving the Mitral Subvalvular
Apparatus in Mitral Valve Replacement
Masafumi Natsuaki, MD, Tsuyoshi Itoh, MD, Shinji Tomita, MD,
Koujirou Furukawa, MD, Masaru Yoshikai, MD, Hisao Suda, MD,
and Hitoshi Ohteki, MD
Department of Thoracic Surgery, Saga Medical School, Saga, Japan
Background. This clinical study sought to determine
whether mitral valve replacement (MVR) with the pres-
ervation of both anterior and posterior chordae tendineae
(MVR group II) would be more effective on the improve-
ment of left ventricular regional wall motion than MVR
with the preservation of posterior chordae tendineae
alone (MVR group I).
Methods. Postoperative left ventricular wall motion
was analyzed by a centerline method in three groups of
M V R m g r o u p I (n = 13), group II (n = 15), and repair
group (n = 15)--for mitral regurgitation. Shortening
fraction of chordal length was determined in 100 chords,
and these chords were divided into five regions.
Results. The comparison of postoperative versus pre-
operative shortening fraction among the three groups
ardiac function after mitral valve r e p l a c e m e n t
C (MVR) for chronic mitral regurgitation has been
r e p o r t e d to be i m p a i r e d owing to postoperative elevation
of left ventricular (LV) afterload [1], and postoperative
m a n a g e m e n t of severe cases using conventional MVR is
s o m e t i m e s troublesome. Some investigators have de-
scribed a modified technique of MVR with preservation
of the posterior submitral complex for mitral stenosis or
regurgitation [2, 3]. However, it is questionable w h e t h e r
or not MVR with preservation of the posterior chordae
t e n d i n e a e alone can achieve satisfactory i m p r o v e m e n t of
LV wall motion for severe mitral regurgitation with
d e p r e s s e d cardiac function. A n MVR p r o c e d u r e with
preservation of all the chordae tendineae was later intro-
d u c e d by David and colleagues [4], who s h o w e d that the
postoperative ejection fraction (EF) increased with exer-
cise and that LV p e r f o r m a n c e i m p r o v e d after operation.
However, LV regional wall motion was not evaluated
accurately by left ventriculography. We have used the
technique of MVR sparing all the chordae t e n d i n e a e with
continuity of all the chordae and papillary muscles to
examine w h e t h e r this technique is more effective on LV
regional cardiac function than MVR sparing the posterior
chordae t e n d i n e a e alone. The p u r p o s e of this clinical
study was to examine the LV regional wall motion after
mitral valve operation, and to clarify the contribution of
Accepted for publication Sep 18, 1995.
Address reprint requests to Dr Natsuaki, Department of Thoracic Sur-
gery, Saga Medical School, Nabeshirna 5-1-1, Saga 849, Japan.
© 1996 by The Society of Thoracic Surgeons
Published by Elsevier Science lnc
revealed that postoperative wall motion improved more
strikingly at apical and diaphragmatic regions in the
MVR group II and repair group in comparison to the
MVR group I. The postoperative shortening fraction at
the apical region in the MVR group I! was significantly
increased in comparison to preoperative shortening frac-
tion (preoperative, 3.68% + 1.87%; postoperative, 5.38%
+ 2.33%; p < 0.05). However, postoperative shortening
fraction in cardiac base was decreased in the MVR group
II as w e l l as other two groups.
Conclusions. The MVR with the preservation of both
anterior and posterior chordae tendineae contributed to
the improvement of left ventricular regional wall motion
in the apical and diaphragmatic regions.
(Ann Thorac Surg 1996;61:585-90)
the p r e s e r v e d chordae t e n d i n e a e to the wall motion
using the centerline m e t h o d of contrast left ventriculog-
raphy.
Patients and Methods
Mitral valve r e p l a c e m e n t or mitral valve repair was
p e r f o r m e d in 43 patients with severe chronic mitral
regurgitation of Sellers degree III or IV evident by
contrast left ventriculography [5]. The causes of mitral
regurgitation were degenerative lesion in 26 and rheu-
matic lesion in 17. If the patients also had infective
endocarditis, they were excluded from this study. The 43
patients were retrospectively divided into three groups
according to the surgical m e t h o d used b e t w e e n January
1992 and January 1995, and the preoperative a n d postop-
erative LV wall motions were c o m p a r e d a m o n g the
groups. The type of surgical technique used to treat
mitral regurgitation was selected according to the ana-
tomic severity of prolapse or the thickness of the anterior
leaflet. A s u m m a r y of the patient data is shown in Table
1. The MVR was p e r f o r m e d when the anterior leaflet was
widely p r o l a p s e d from the m i d - p o r t i o n to the commis-
sural side. For MVR, we used preservation of both the
anterior a n d posterior chordae t e n d i n e a e (MVR group II)
w h e n the anterior leaflet was smooth or slightly thick-
ened, or preservation of posterior chordae t e n d i n e a e and
resection of the anterior chordae t e n d i n e a e (MVR group
I) w h e n the anterior leaflet was calcified and thickened.
The m e a n size of the prosthetic valve did not differ
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586 NATSUAKIET AL Ann Thorac Surg
PRESERVING MITRALSUBVALVULARAPPARATUS 1996;61:585-90

Table 1. S u m m a r y o f Patient Data shortening fraction (SF) in each group of 20 chords in the
anterobasal (chords 1 to 20), anterolateral (21 to 40),
MVR MVR Repair
Group I Group II Group III apical (41 to 60), diaphragmatic (61 to 80), and postero-
Characteristic (n = 13) (n - 15) (n - 15) basal (81 to 100) regions. Shortening fraction was calcu-
lated as SF = chord-length/end-diastolic perimeter × 100
Demographics (%).
Age (y) 55 + 10 59 +- 10 56 + 11
Motion at each chord was normalized for heart size by
Range {38-69) {38-72) (37-70)
dividing by the perimeter of the end-diastolic contour [7].
Men 6 7 6
Normal control m e a n SF was 4.1% in the anterobasal,
Women 7 8 9
2.5% in the anterolateral, 3.3% in the apical, 3.4% in the
NYHA
diaphragmatic, and 3.2% in the posterobasal region (n =
IV 0 1 0
10). Postoperative SF in these five regions were compared
]II 11 13 12
with the preoperative value in each group, a n d the ratio
2 1 3
(percentage) of postoperative versus preoperative SF was
II
compared a m o n g the three groups. In patients with atrial
Preoperative
hemodynamics fibrillation, LV volume a n d regional wall motion were
AF 8 9 6 m e a s u r e d as the m e a n values in three continuous heart
EF 0.64 + 0.05 0.60 -+ 0.18 0.65 ± 0.70 beats. Postoperative left ventriculography was performed
about 1 m o n t h after operation in MVR or mitral valve
AF atrialfibrillation; EF = ejectionfraction; NYHA New York repair. Postoperative global and regional cardiac func-
Heart Association. tions were compared statistically with preoperative func-
tion by Student's paired t test, and the ratio (percentage)
of the postoperative versus preoperative value was corn-
between MVR groups I a n d II. For preservation of the
anterior chordae tendineae in group II, the anterior
leaflet was divided into two parts at its center, a n d the
two parts were separately shifted to both commissures. (WALL MOTION). 20
This m e t h o d was originally reported by Miki and col-
leagues in 1988 [6]. In our method, all the anterior
chordae tendineae were preserved to m a i n t a i n an ade-
quate tension of the papillary muscle, a n d the pos- 100
terior chordae tendineae were completely preserved. A
St. Jude medical valve with a low profile was selected as 40
prosthetic valve whose bileaflet m o v e m e n t was not dis-
turbed by the preserved submitral complex. Mitral valve
repair was performed (repair group, group IIl) w h e n the
anterior leaflet was not so widely prolapsed or w h e n only SHORTENING (%) 60
the posterior leaflet was prolapsed. The procedure of +9
mitral repair involved q u a d r a n g u l a r resection a n d plica-
tion for posterior leaflet prolapse, or reconstruction using
+6
artificial polytetrafluoroethylene chordae for anterior
leaflet prolapse. Artificial mitral ring annuloplasty was
used in 6 patients. All 43 patients were operated on by
the same surgeon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Preoperative a n d postoperative LV volume and re-

gional wall motion were compared a m o n g the three
groups. Contrast left ventriculography was performed in -3 i |

the 30-degree right anterior oblique projection and 60-

degree left anterior oblique projection using 35-mm
cineangiography. The LV end-systolic a n d end-diastolic
volumes were m e a s u r e d by the area-length method. The
preoperative end-diastolic volume index ranged from 130
to 260 mL/m 2. The LV regional wall motion was analyzed
by the modified centerline method (CAA100; Nishimoto
Inc, Osaka, Japan) in 13 patients in group I, 15 in group II,
and 15 in the repair group. A centerline was constructed
by computer midway between the end-diastolic a n d
end-systolic contours, and 100 chords ( n u m b e r e d 1 to
100) were drawn perpendicular to the centerline (Fig 1).
The LV regional wall motion was expressed as the m e a n
0 2'0 40 60 8'0 160
Fig 1. A centerline constructed by computer in the center between
the end-diastolic and end-systolic contours. One hundred chords are
drawn perpendicular to &e centerline. Each chord length reflects the
regional wall motion of the corresponding point on the centerline
(upper). The shortening fraction at each chord is calculated with the
correction of the end-diastolic perimeter at 100 points. Dotted lines
show the value of the shortening in normal control. Standard devia-
tion is shown above and below the mean value. Solid line shows
the shortening in a patient. The shortening in this case is decreased
at apical (chords 50 to 70) and posterobasal (chords 90 to 100) re-
gions (lower). (Chords 1 to 20: anterobasal, 21 to 40: anterolateral,
41 to 60: apical, 61 to 80: diaphragmatiG and 81 to 100: postero-
basal.)
Ann Thorac Surg NATSUAKI ET AL 587
1996;61:585-90 PRESERVING MITRAL SUBVALVULARAPPARATUS

Table 2. Preoperative and Postoperative Left Ventricular

Volume and Ejection Fraction '~ I pre-op *: P<0.05
**: p<0.01
MVR MVR Repair SF 8 MVR-Group I 1.] post-op
Variable Group I Group II Group III
(%) r ***
LV EDVI (mL/m 2)
Preop 181 -+ 52 161 + 24 152 + 39 6
Postop 117 + 27 ~ 126 + 27 ~ 100 _+ 16
Paired t test p < 0.001 p < 0.01 p < 0.001
Ratio (%) 68 + 14 78 - 15 68 +_ 15
4
LV ESVI (mL/m 2)
Preop 63 ± 18 63 +_ 14 52 ± 20
Postop 55 + 13~ 43 + 11 ~ 35 _+ 12
2
Paired t test p NS p < 0.01 p < 0.01
Ratio (%) 99 ÷ 34 70 _+ 19b 71 _+ 27 b
kV EF (%)
Preop 64 + 5 60 _+ 18 65 _- 7
Postop 52 + 6 63 -+ 10 b 65 + 8 b
AB AL AP DP PB
Paired t test p < 0.01 p NS p = NS
Ratio (%) 82 ± 13 106 + 18b 100 _+ 10 b Fig 2. Comparison between preoperative and postoperative left ven-
tricular regional wall motion with the centerline method. Postopera-
Data are mean -- standard deviation. Statistical examination was per- tive left ventricular shortening fraction (SF) deteriorated in the an-
formed by analysis of variance and group comparisons were performed
using Fisher's method, l, p < 0.05 versus group I; ~p < 0.05 versus terobasal, apical' diaphragmatic, and posterobasal ref~ions in MVR
group III. group I (n - 13) compared with preoperative value (paired t test).
Ratio postop value/preop value × 100(%). EDVI - end-diastolic (AB = anterobasal; AL = anterolateral; AP apicah DP = dia-
volume index; EF ejection fraction; ESVI end-systolic volume phragmatit, PB posterobasal.)
index; LV - left ventricular; Postop - postoperative; Preop
preoperative.

M V R g r o u p I w a s d e c r e a s e d in all five r e g i o n s (Fig 2),

w h e r e a s t h e SF in M V R g r o u p II w a s i n c r e a s e d in t h e
p a r e d a m o n g t h e t h r e e g r o u p s . R e s u l t s w e r e e x p r e s s e d as a n t e r o l a t e r a l , apical, a n d d i a p h r a g m a t i c r e g i o n s c o m -
t h e m e a n _+ s t a n d a r d d e v i a t i o n . C o m p a r i s o n b e t w e e n p a r e d w i t h t h e p r e o p e r a t i v e v a l u e (Fig 3). T h e p o s t o p e r -
t h r e e g r o u p s w a s c a r r i e d o u t b y o n e - w a y a n a l y s i s of ative SF in t h e r e p a i r g r o u p w a s s l i g h t l y i n c r e a s e d at t h e
v a r i a n c e . W h e n statistical s i g n i f i c a n c e w a s o b t a i n e d ,
group comparisons were performed using Fisher's
m e t h o d . A p v a l u e of less t h a n 0.05 w a s j u d g e d to i n d i c a t e
a statistically s i g n i f i c a n t d i f f e r e n c e . SF pre-op
(%)
D post-op
MVR-Group lI
Results *: p<0.05
**: p<0.0!
P r e o p e r a t i v e LV c i n e a n g i o g r a p h y s h o w e d n o s i g n i f i c a n t
d i f f e r e n c e s a m o n g t h e t h r e e g r o u p s in LV e n d - s y s t o l i c
v o l u m e index, e n d - d i a s t o l i c v o l u m e i n d e x , a n d EF. P o s t -
operative end-diastolic volume index was significantly
d e c r e a s e d in all t h r e e g r o u p s , a n d p o s t o p e r a t i v e e n d -
systolic v o l u m e i n d e x w a s s i g n i f i c a n t l y d e c r e a s e d in
M V R g r o u p II or t h e r e p a i r g r o u p c o m p a r e d w i t h t h e
p r e o p e r a t i v e value. P o s t o p e r a t i v e e n d - s y s t o l i c v o l u m e
i n d e x w a s n o t s i g n i f i c a n t l y d e c r e a s e d in M V R g r o u p I.
T h e d e g r e e of p o s t o p e r a t i v e d e c r e a s e in e n d - s y s t o l i c
v o l u m e i n d e x w a s j u d g e d to b e g r e a t e r in M V R g r o u p II
or r e p a i r g r o u p f r o m t h e ratio of p o s t o p e r a t i v e v e r s u s
preoperative end-systolic volume index compared with
t h a t of M V R g r o u p I (Table 2}. P o s t o p e r a t i v e EF w a s n o t AB AL AP DP PB
c h a n g e d in M V R g r o u p II or t h e r e p a i r g r o u p , w h e r e a s
Fig 3. Comparison between preoperative and postoperative left ven-
t h e EF of M V R g r o u p I w a s s i g n i f i c a n t l y i m p a i r e d c o m -
tricular regional wall motion with the centerline method. Postopera-
p a r e d w i t h p r e o p e r a t i v e value. T h e ratio of p o s t o p e r a t i v e tive left ventricular shortening fraction (SF) improved significantly
v e r s u s p r e o p e r a t i v e EF i n d i c a t e d t h a t t h e p o s t o p e r a t i v e in the anterolateral and apical regions in MVR group 1I (n = 15)
EF in M V R g r o u p II or r e p a i r g r o u p m o r e s i g n i f i c a n t l y compared with the preoperative value (paired t test). (AB antero-
i m p r o v e d t h a n t h a t in M V R g r o u p I (Table 2). basal; AL anterolateral; AP - apical; DP diaphragmatic; PB
In t h e a n a l y s i s of LV wall m o t i o n , p o s t o p e r a t i v e SF in posterobasal.)
588 NATSUAKIET AL Ann Thorac Surg
PRESERVING MITRAL SUBVALVULARAPPARATUS 1996;61:585-90

Table 3. Shortening Fraction of Left Ventricular Five C o m m e n t

Regions by Centerline Method~
M o s t i n v e s t i g a t o r s h a v e n o t e d a significant r e d u c t i o n of
MVR MVR Repair the EF in p a t i e n t s w i t h mitral r e g u r g i t a t i o n after M V R
Variable Group I Group II Group III
w i t h o u t p r e s e r v a t i o n of t h e c h o r d a e t e n d i n e a e [8-10].
AB (%) The d e c r e a s e in t h e LV EF after c o n v e n t i o n a l M V R was
Preop 4.10 _+ 0.82 3.90 _+ 1.31 4.88 _+ 1.58 c a u s e d by several factors such as d e c r e a s e d p r e l o a d ,
Postop 3.46 _+ 0.67 3.66 _+ 0.94 4.11 _+ 1.24 i n c r e a s e d afterload, or i m p a i r e d contractile function.
Paired t test p < 0.05 NS NS A f t e r M V R for mitral r e g u r g i t a t i o n , p r e l o a d is d e c r e a s e d
AL (%) b y r e m o v a l of t h e r e g u r g i t a n t v o l u m e a n d afterload is
Preop 3.88 _+ 0.76 3.48 + 1.38 3.66 _+ 1.96 i n c r e a s e d by d i s a p p e a r a n c e of the low i m p e d a n c e ejec-
Postop 3.06 _+ 1.45 4.57 _+ 1.46 4.60 + 2.07 tion root into the left atrium. T h e m a i n factor r e s p o n s i b l e
Paired t test NS p < 0.01 NS for d e c r e a s e d ejection p e r f o r m a n c e is t h o u g h t to he
AP (%)
i n t e r r u p t i o n of v e n t r i c u l a r v a l v u l a r i n t e r a c t i o n w i t h the
Preop 4.84 _+ 0.88 3.68 + 1.87 4.48 _+ 2.07
c h a n g e in l o a d i n g condition. S e v e r a l studies [4, 11] h a v e
Postop 2,88 +_ 0.72 5.38 _+ 2.33 b 5.42 _+ 2.19b
d e m o n s t r a t e d that ejection p e r f o r m a n c e did not w o r s e n
Paired t test p < 0.001 p < 0.05 NS
after c o r r e c t i o n or r e p l a c e m e n t of the mitral v a l v e u s i n g
DP (%)
p r o c e d u r e s that p r e s e r v e the mitral v a l v e a p p a r a t u s . O u r
Preop 4.31 _+ 0.40 4.44 _+ 1.56 4.81 _+ 1.73
p r e s e n t findings s u g g e s t that p r e s e r v a t i o n of all t h e
Postop 2.84 _+ 1.02 4.83 _+ 1.87b 4.72 _+ 1.09b
c h o r d a e t e n d i n e a e p r e v e n t s the d e p r e s s i o n of LV func-
Paired t test p < 0.01 NS NS
tion a n d allows LV e n d - s y s t o l i c v o l u m e a n d s h o r t e n i n g
PB (%)
of t h e r e g i o n a l a n t e r i o r wall to r e t u r n to n e a r n o r m a l . In
Preop 3.39 _+ 0.39 3.43 + 1.15 4.09 _+ 1.04
M V R g r o u p II w h e r e all the c h o r d a e t e n d i n e a e w e r e
Postop 2.31 _+ 0.47 2.79 + 1.17 2.69 +_ 0.94
p r e s e r v e d , t h e s h o r t e n i n g fraction of p o s t o p e r a t i v e a n t e -
Paired t test p < 0.01 NS p < 0.01
rior r e g i o n a l wall m o t i o n i m p r o v e d to t h e s a m e level of
a Data are mean -+ standard deviation. Statistical examination was per- the p o s t o p e r a t i v e SF after mitral repair. In contrast, M V R
formed by analysis of variance, b p < 0.05 versus group I, Fisher's g r o u p I in w h i c h the p o s t e r i o r c h o r d a e t e n d i n e a e a l o n e
method.
w e r e p r e s e r v e d did not a t t e n u a t e the e n d - s y s t o l i c vol-
AB = anterobasal; AL = anterolateral; AP = apical; DP =
diaphragmatic; PB posterobasal; Postop - postoperative; u m e as m u c h as M V R g r o u p II b e c a u s e of the i n c r e a s e d
Preop - preoperative. a f t e r l o a d r e s u l t i n g f r o m e l e v a t i o n of end-systolic wall
stress. This e l e v a t i o n w a s p r o b a b l y c a u s e d b y i n t e r r u p -
tion of t h e c o n t i n u i t y of p a p i l l a r y m u s c l e a n d the a n t e r i o r
c h o r d a e t e n d i n e a e a n d the i m p a i r e d f u n c t i o n of t h e
anterolateral, apical, a n d d i a p h r a g m a t i c r e g i o n s c o m -
p a p i l l a r y muscle. B e c a u s e of the i n a d e q u a t e f u n c t i o n of
p a r e d w i t h the p r e o p e r a t i v e v a l u e (Table 3). Also the
t h e p a p i l l a r y muscle, n o r m a l LV g e o m e t r y a n d axis
ratio of p o s t o p e r a t i v e v e r s u s p r e o p e r a t i v e SF i n d i c a t e d
s h o r t e n i n g c o u l d not be m a i n t a i n e d in t h e M V R g r o u p I
that p o s t o p e r a t i v e LV wall m o t i o n was relatively i m -
p r o v e d in the apical a n d d i a p h r a g m a t i c r e g i o n s in M V R [12]. The c o n t i n u i t y of all c h o r d a e t e n d i n e a e a n d papil-
g r o u p II a n d the r e p a i r g r o u p c o m p a r e d w i t h M V R g r o u p lary m u s c l e m a i n t a i n e d f u n c t i o n a l LV g e o m e t r y a n d
I (Table 4). P o s t o p e r a t i v e SF in the a n t e r o b a s a l a n d i m p r o v e d LV s h o r t e n i n g in the M V R g r o u p II. The
p o s t e r o b a s a l r e g i o n s was d e c r e a s e d in all t h r e e g r o u p s i m p o r t a n t effects of c o n n e c t i o n of t h e p a p i l l a r y m u s c l e to
c o m p a r e d w i t h t h e p r e o p e r a t i v e value. the a n t e r i o r mitral leaflet t h r o u g h the c h o r d a e t e n d i n e a e
on LV p e r f o r m a n c e h a v e b e e n d e m o n s t r a t e d e x p e r i m e n -
tally by several i n v e s t i g a t o r s [13-15]. If the c o n c e p t that
c o n t i n u i t y b e t w e e n t h e c h o r d a e t e n d i n e a e a n d the p a p -
Table 4. Comparison of the Ratio (Percentage) of illary m u s c l e e n h a n c e s contractile f u n c t i o n t h r o u g h re-
Postoperative Versus Preoperative Shortening Fraction in Left gional afterload r e d u c t i o n is correct, t h e n it follows that
Ventricular Regions ~ t h e a n t e r i o r mitral leaflet a n d its c h o r d a l c o n n e c t i o n m u s t
MVR MVR Repair h a v e a g r e a t e r i m p a c t on r e g i o n a l l o a d i n g c o n d i t i o n s
Region Group I Group II Group IIl t h a n the p o s t e r i o r mitral leaflet. G r e a t e r t e n s i o n is g e n -
AB 82 + 21 100 _+ 32 90 -+ 33 e r a t e d b y the a n t e r i o r leaflet with a large n u m b e r of
AL 97 +_ 53 142 +_ 46 154 +_ 94 c h o r d a e t e n d i n e a e at a g i v e n LV p r e s s u r e [13]. P o s t o p e r -
AP 62 + 17 161 --+ 78 b 139 _+ 75 b ative c i n e a n g i o g r a p h y , p e r f o r m e d in the early period,
DP 68 - 22 118 + 47 b 107 _+ 41b r e v e a l e d that the r e g i o n a l SF i m p r o v e d in the anterolat-
PB 69 ÷ 16 95 _+ 62 68 -+ 24 eral, apical, a n d d i a p h r a g m a t i c r e g i o n s a n d that the LV
SF of b o t h axes i m p r o v e d in M V R g r o u p II. In contrast,
a Statistical examination was performed by analysis of variance, bp < the p o s t o p e r a t i v e r e g i o n a l SF d e t e r i o r a t e d at the s a m e
0.05 versus group I Fisher's method. Ratio: Postop SF/preop SF x 100 (%).
regions, a n d LV p o s t o p e r a t i v e SF in b o t h axes was
AB = anterobasal; AL = anterolateral; AP = apical; DP =
diaphragmatic; BP - posterobasal; Postop = postoperative; d e c r e a s e d in M V R g r o u p I. Thus, p r e s e r v a t i o n of b o t h the
Preop = preoperative; SF - shortening fraction. a n t e r i o r leaflet w i t h its c o n n e c t i o n a n d the p o s t e r i o r
A n n Thorac S u r g
1996;61:585-90
leaflet contributed to the improvement of regional ante-
rior, apical, and diaphragmatic wall motion.
We expected that diaphragmatic and posterobasal re-
gional wall motions would improve in MVR group I.
However, we found that diaphragmatic regional wall
motion deteriorated although the posterior submitral
complex was preserved. These findings suggested that
the adequate cooperative tension of the anterior chordae
tendineae together with the posterior chordae played an
important role in tethering to the papillary muscles.
Previous studies have shown that LV cardiac functions
improved by MVR with the preservation of the posterior
chordae alone [16-18]. In contrast, our clinical data for
MVR group I revealed no improvement in global or
regional cardiac function. Thus, it was suggested that the
posterior chordae alone did not have a tethering effect on
the papillary muscle in MVR for chronic mitral regurgi-
tation. The improved ventricular performance after MVR
preserving all the chordae tendineae or rnitral valve
repair is thought to be caused by the buttressing effect of
the papillary muscle on the region as it contracts. This
buttressing effect may reduce the afterload stress on the
papillary muscle region [19, 20]. A recent study has
demonstrated improvement of postoperative LV regional
wall motion by analysis using the radial method in MVR
with all the chordae tendineae preserved [20]. However,
the radial method cannot show LV regional wall motion
precisely in enlarged elliptical LV geometry. The method
depends on the change of one ventricular perimeter
point toward one reference point on the long axis. It is the
assumption on radial method that the point on the
perimeter located in diastole is approximately the same
point measured in systole. This may be an invalid as-
sumption and sometimes it is clearly not the case. And
the radial line in the high cardiac base in diastole may be
seen in systole to intersect the aortic valve plane. In
contrast, the centerline method includes a long perimeter
of the ventricular contour for each segment. The method
has anatomically coinciding systolic and diastolic re-
gions. The method can be applied to various types of LV
contour because its method measures the wall motion
along locally determined vectors, and requires no geo-
metric reference figure [21]. Therefore, we used the
centerline method in our analysis of wall motion, and
detected a significant postoperative improvement in the
anterolateral, apical, and diaphragmatic regions and
slight impairment in the anterobasal and posterobasal
regions after MVR preserving all the chordae tendineae
or mitral valve repair. This finding suggests that a satis-
factory buttressing effect of both papillary muscles was
occurring in the anterolateral, apical, and diaphragmatic
regions, and the buttressing effect was incomplete in the
anterobasal and posterobasal regions, even when all the
chordae tendineae were preserved. An experimental
study demonstrated that impaired LV global function
and regional anterior wall motion in experimentally
created mitral regurgitation were almost reversed to
control values by surgical correction preserving all the
chordae tendineae [22, 23]. Another study has shown that
systolic shortening of the LV major axis was decreased by
NATSUAKI ET AL 589
PRESERVING MITRAL SUBVALVULAR APPARATUS
cutting both the chordae tendineae in MVR [24]. This
experimental finding reflects our clinical observation that
postoperative apical wall motion was improved by MVR
with preservation of both the chordae tendineae. In
contrast, the reduction of contractility after replacement
with a prosthetic valve or rigid ring in the mitral position
was reported to occur through mechanical restriction of
the basal portion of the heart [25]. The cause of postop-
erative impairment of the anterobasal or posterobasal
wall motion with our MVR technique or mitral repair
may have been mechanical restriction of contraction in
the basal portion of the heart because of limited move-
ment of mitral valve ring by prosthetic valve (or pros-
thetic ring) or narrowing of the mitral orifice by quadran-
gular resection in mitral repair.
Technically, we have been using a method involving
shifting of the anterior leaflet to both commissures for
preservation of the anterior chordae tendineae in MVR
[6]. This procedure is feasible for reattachment of sepa-
rated segments of the thick anterior leaflet to the mitral
ring of both commissures. In contrast, the preservation
technique using the in situ position of the anterior leaflet
and chordae is thought to be technically problematic for
a thick anterior leaflet and chordae [26, 27]. Feikes and
colleagues [28] described the another preservation tech-
nique involving rotation of the anterior leaflet and chor-
dae to the posterior leaflet. In an experimental study,
Moon and co-workers [15] demonstrated that the LV
pressure-volume relationship did not differ between the
two MVR methods with the preservation of all chordae
tendineae--an anterior chordal-sparing technique
(Khonsali technique [29]) and a posterior chordal-sparing
technique (Feikes technique [28]). The posterior chordal-
sparing method was different from our MVR technique
with the preservation of posterior chordae tendineae
alone. The function of papillary muscle may be preserved
in the Feikes technique or the Khonsali technique. How-
ever, anterior regional wall motion may not always im-
prove in the Feikes technique, because the m o v e m e n t of
posterior wall may be strengthened excessively by the
preserved chordae tendineae. The anterior chordal-
sparing technique of Khonsali may maintain an adequate
global and regional cardiac function after MVR. We
believe it is a problem that LV outflow obstruction may
occur when excessive retained leaflet tissue is folded up
into the annulus in the Khonsali technique.
In contrast, the Miki technique [6] can maintain nearly
normal chordal tension on the anterior and posterior
mitral ring owing to the more normal anatomic position
of the anterior chordae tendineae. We tried to insure that
the tension of anterior chordae tendineae was main-
tained from the commissural side in an anterior portion,
and that LV outflow was not obstructed by the excessive
leaflet tissue.
In conclusion, MVR preserving all the chordae tendi-
neae for mitral regurgitation is an excellent procedure for
improving postoperative LV regional wall motion in the
anterolateral, apical, and diaphragmatic regions and for
decreasing postoperative LV end-systolic volume index.
We found that preservation of both the anterior and
590 NATSUAKIET AL
PRESERVING MITRAL SUBVALVULARAPPARATUS
p o s t e r i o r mitral s u b v a l v u l a r a p p a r a t u s in M V R p l a y e d an
i m p o r t a n t role in p r e s e r v i n g LV r e g i o n a l wall motion. In
contrast, M V R p r e s e r v i n g the p o s t e r i o r c h o r d a e t e n d i -
n e a e a l o n e was not e n o u g h to i m p r o v e g l o b a l LV func-
tion or r e g i o n a l w a l l m o t i o n .
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