Results of Represervation of the Chordae
Tendineae During Redo Mitral Valve Replacement
Vivek Rao, MD, Masashi Komeda, MD, PhD, Richard D. Weisel, MD,
Joan Ivanov, RN, MSc, John S. Ikonomidis, MD, PhD, Toshizumi Shirai, MD, PhD, and
Tirone E. David, MD
Division of Cardiovascular Surgery, The Toronto Hospital, University of Toronto, Toronto, Ontario, Canada
Background. Previous studies have shown that preser-
vation of the chordae tendineae improves early and late
postoperative left ventricular function after mitral valve
replacement. This report describes the results of represer-
vation of the chordae tendineae during redo mitral valve
replacement in patients who had their chordae tendineae
preserved during their initial operation.
Methods. Fifty-four patients undergoing reoperative
mitral valve replacement with preservation of their
chordal annular attachments (chordae group) were com-
pared with 187 patients who had redo mitral valve
replacement without preservation of the chordae (non-
chordae group). The interval between the initial opera-
tion and the reoperation was 8.7 - 4.4 years in the
chordae group and 8.6 - 4.9 years in the nonchordae
group (p = 0.315). Seventy,three patients underwent
aortic valve replacement during their redo mitral valve
replacement compared with 168 patients who had mitral
valve replacement alone. There were 15 patients who had
their chordal attachments represerved during redo dou-
ble-valve replacement.
Results. In the chordae group, intraoperative assess-
ment revealed excellent chordal connections between the
umerous laboratory [1-8] and clinical [9-17] studies
N have shown that preservation of the chordae ten-
dineae improves early postoperative ventricular function
after mitra! valve replacement. We recently reported that
ventricular function remains improved 56 months post-
operatively [18]. However, there is little information on
the long-term status of the preserved chordae tendineae
and the papillary muscles, or on the feasibility of pre-
serving the chordae tendineae during mitral reoperation.
This study reviews 54 patients who had preservation of
their chordae tendineae during their redo mitral valve
replacement and compares them with 187 patients who
underwent reoperation without having their subvalvular
apparatus preserved.
Accepted for publication March 9, 1996.
Presented in part at the Sixty-eighthScientific Sessionsof the American
Heart Association,Anaheim, CA, Nov 13--16,1995.
Address reprint requests to Dr Weisel' The Toronto Hospital'EN14-215,
200 Elizabeth St, Toronto,Ontario, MSG2C4, Canada.
© 1996 by The Society of Thoracic Surgeons
Published by Elsevier Science Inc
preserved papillary muscles and the mitral annulus in all
patients. One patient had adhesions between the pre-
served chordae and the stent of the tissue valve. The
chordal attachments were preserved during insertion of
the second valve in all patients. The incidence of low
output syndrome and operative mortality in the chordae
group was 16.7% and 7.4%, respectively. In the nonchor-
dae group, the incidence of low output syndrome was
27.3% (p -- 0.112 compared with the chordae group) and
the operative mortality was 13.4% (p = 0.236 compared
with the chordae group). In patients with double-valve
replacement, represervation of the chg~dae was associ-
ated with a reduction in low output syndrome (0% versus
24%; p = 0.034) and mortality (6.7% versus 15.5%; p =
0.374).
Conclusions. Preservation of the chordal attachments
between the papillary muscles and the mitral annulus
can be accomplished during reoperative mitral valve
replacement. Represervation of the chordae tendineae
may reduce postoperative low output syndrome, espe-
cially in high-risk patients undergoing redo double-
valve replacement.
(Ann Thorac Surg 1996;62:179-83)
Patients a n d M e t h o d s
The clinical records were reviewed of 241 consecutive
patients who underwent redo mitral valve replacement at
our institution between January 1988 and December 1994.
Fifty-four patients underwent mitral valve replacement
having their chordal attachments preserved during their
redo operation (chordae group), whereas 187 patients
underwent conventional operation without preservation
of any subvalvular apparatus (nonchordae group). All
patients who had preservation of their chordae at the
previous operation had their chordal attachments pre-
served during their second operation.
The preoperative characteristics are presented in Table
1. There were 88 men (37%) and 153 women (64%) with a
mean age of 58.6 + 12.6 years (range, 17 to 82 years). One
hundred eighty-one patients (75%) had one previous
mitral valve replacement and sixty (25%) had multiple
previous open heart procedures including at least one
previous mitral valve replacement. The interval between
the initial operation and the repeat procedure was 8.6 +
0003-4975/96/$15.00
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 180 RAO ET AL Ann Thorac Surg
REPRESERVATION OF CHORDAE TENDINEAE 1996;62:179-83

Table 1. Preoperative Characteristicsa mitral valve failure (n = 191). Twenty-seven p e r c e n t of

the patients in the n o n c h o r d a e group h a d m u l t i p l e pre-
Chordae Nonchordae
Group Group p vious cardiac p r o c e d u r e s c o m p a r e d with 19% in the
Variable (n = 54) (n = 187) Value c h o r d a e group (p < 0.01). All other p r e o p e r a t i v e charac-
teristics were similar b e t w e e n the two groups.
Age (y) 0.513
Mean 56 + 13 59 + 12 Operative Technique
Range 28-77 17-82
C a r d i o p u l m o n a r y b y p a s s was established a n d m a i n -
Sex 0.681
t a i n e d with m i l d to m o d e r a t e systemic h y p o t h e r m i a (28 °
Male 21 (39) 67 (36)
to 32°C), a n d b l o o d cardioplegia in a 4:1 mixture was
Female 33 (61) 120 (64)
e m p l o y e d for m y o c a r d i a l protection. Myocardial revas-
Previous 0.010
Operations cularization was p e r f o r m e d for a n y significant coronary
1 44 (81) 137 (73) artery lesion with a reasonable distal vessel. Between
2 7 (13) 37 (20) 1982 a n d 1987, there has b e e n a g r a d u a l evolution to
>2 3 (6) 13 (7) chordal preservation b y all surgeons. Patients w h o were
NYHA class 0.103 o p e r a t e d on before 1984 were likely to have h a d their
I 0 (0) 7 (4) chordal a p p a r a t u s r e m o v e d d u r i n g their initial operation.
II 2 (4) 14 (7) O t h e r possible reasons for prior excision of the chordal
III 25 (46) 55 (29) attachments include severe r h e u m a t i c mitral stenosis
IV 27 (50) 106 (57) w h e r e fibrosis of the c h o r d a e p r e c l u d e d preservation, or
Timing 0.231 excision of the p a p i l l a r y muscle tips before insertion of a
Elective 27 (50) 63 (34) mechanical valve to avoid leaflet i m p i n g e m e n t . At our
Urgent 27 (50) 120 (64) institution, the posterior leaflet of the mitral valve a n d all
LVEF 0.640 chordal attachments are n o w p r e s e r v e d even d u r i n g
>0.60 22 (41) 60 (32) insertion of a mechanical valve. W h e n fibrosis necessi-
0.40-0.59 25 (46) 95 (51) tates excision of the chordae tendineae, Gore-Tex (W. L.
0.20-0.39 6 (13) 23 (12) G o r e & Assoc, Flagstaff, AZ) sutures are e m p l o y e d to
<0.20 0 (0) 2 (1) r e s u s p e n d the p a p i l l a r y muscles.
Diseased coronary 0.126 D u r i n g r e d o mitral valve operations, the prosthetic
vessels a n n u l u s is carefully dissected free from the native sub-
0 47 (87) 165 (88) valvular apparatus. Before i m p l a n t a t i o n of the n e w pros-
1 4 (7) 14 (7) thesis, the chordal attachments to the mitral a n n u l u s are
2 0 (0) 5 (3) i n s p e c t e d to ensure p r o p e r tension a n d r e p a i r e d if nec-
3 3 (6) 3 (2) essary.
Interval between 0.315
operations (y) Statistical Analysis
Mean 8.7 _+4.4 8.6 -+ 4.9 Statistical analysis was p e r f o r m e d with t h e SAS p r o g r a m
Range 0.8-21.8 0-26.2 (SAS Institute, Cary, NC). Univariate data were analyzed
using a X2 or Fisher's exact test w h e r e a p p r o p r i a t e , a n d
a Numbers in parentheses are percentages. continuous data were e v a l u a t e d b y S t u d e n t ' s t tests.
LVEF = left ventricular ejection fraction; NYHA = New York Heart Continuous variables are r e p o r t e d as m e a n - s t a n d a r d
Association functional class.
deviation. Statistical significance was a s s u m e d at p less
than 0.05.

4.8 years (range, 0 to 26.2 years) a n d was similar b e t w e e n

groups.
O n e h u n d r e d thirty-three patients (55%) were in N e w
York Heart Association functional class IV p r e o p e r a -
tively. N i n e t y patients (37%) u n d e r w e n t an elective op-
eration, w h e r e a s 147 patients (61%) u n d e r w e n t urgent
(within 72 hours of referral) or e m e r g e n t (within 12 hours
of referral) operation. There were 31 patients (13%) with
a left ventricular ejection fraction of less t h a n 0.40.
Twenty-five patients (10%) h a d concurrent coronary ar-
tery disease.
The indications for the r e p e a t operation [19] were
prosthetic valve endocarditis (n = 22), nonstructural
failure (paravalvular leak or prosthetic dehiscence, n =
23), p r o p h y l a c t i c r e p l a c e m e n t of B j t r k - S h i l e y con-
vexoconcave valve (n = 5), a n d structural prosthetic
Results
Operative Findings and Procedures
All patients who p r e s e n t e d with p r e s e r v e d chordae were
f o u n d to have intact p a p i l l a r y muscles with chordal
attachments to the mitral annulus. N o n e of the p a p i l l a r y
muscles w e r e atrophic. In 1 patient, s o m e of the pre-
served posterior chordae were a d h e r e n t to the stent of
the bioprosthesis a n d r e q u i r e d careful dissection to sep-
arate the chordal attachments a n d i m p l a n t t h e m into the
n e w mitral sewing ring. The p r o c e d u r e was successful,
a n d most of the chordae were p r e s e r v e d a n d the conti-
nuity b e t w e e n the papillary muscles a n d the mitral
a n n u l u s was maintained. Eleven patients r e q u i r e d four
sets of 4-0 Gore-Tex sutures to replace the native chordae
b y techniques previously d e s c r i b e d [20]. Eight patients
Ann Thorac Surg RAO ET AL 181
1996;62:179-83 REPRESERVATION OF CHORDAE TENDINEAE

h a d b o t h anterior a n d posterior chordae p r e s e r v e d at Table 2. Perioperative Data a

their initial mitral valve replacement. Seven of these
Chordae Nonchordae
patients h a d b o t h c h o r d a e p r e s e r v e d d u r i n g the r e o p e r a - Group Group p
tion. Forty-six patients h a d preservation of the posterior Variable (n = 54) (n = 187) Value
c h o r d a e only. Thus, all patients who p r e s e n t e d with
Size of mitral 0.374
previously p r e s e r v e d chordae h a d some c h o r d a e pre- valve (ram)
served at r e p e a t operation. <27 0 (0) 9 (5)
The base of the p a p i l l a r y muscle was still p r e s e n t for as 27 20 (37) 70 (37)
long as 22 years after the initial operation in 7 patients 29 19 (35) 60 (32)
w h o h a d u n d e r g o n e mitral valve r e p l a c e m e n t before 31 14 (26) 36 (19)
1974, at which time the chordae t e n d i n e a e a n d p a p i l l a r y >31 1 (2) 6 (3)
muscle tips were excised. The r e m n a n t papillary muscle Mean (-+SD) 28.1 + 2.6 28.2 + 2.1
allowed for the p l a c e m e n t of Gore-Tex sutures. These 7 No. of bypass 0.506
patients were i n c l u d e d in the chordae group. The re- grafts
m a i n i n g 187 patients w h o h a d u n d e r g o n e conventional 0 46 (85) 174 (93)
mitral valve r e p l a c e m e n t at their initial operation u n d e r - 1 5 (9) 9 (5)
w e n t conventional r e p e a t operation. 2 1 (2) 3 (2)
Pathologic findings of the previous prosthetic valve 3 2 (4) 1 (0.1)
r e v e a l e d the following: cusp tear (n = 132), p a r a v a l v u l a r AVR 15 (28) 58 (31) 0.648
leakage or prosthetic dehiscence (n = 23), h e a v y calcifi- TV operation 0.197
cation (n = 29), t h r o m b o s i s (n = 19), abscess (n = 13), None 45 (83) 134 (72)
n o r m a l BjSrk-Shiley valve (n = 5), vegetation (n = 3), a n d Repair 8 (15) 46 (25)
not d e s c r i b e d (n = 28). Replacement 1 (2) 7 (4)
Aortic cross-clamp 0.671
Operative Results time (min)
The operative results are s u m m a r i z e d in Table 2. There Mean 94 +- 38 98 -+ 39
were no differences in the size of the i m p l a n t e d valve Range 45-184 30-223
b e t w e e n groups (chordae 28 -+ 3 m m versus 28 --- 2 mm; Pump time (min) 0.495
p = 0.374). Eight patients (15%) in the chordae group Mean 128 + 53 142 _+58
r e q u i r e d coronary artery b y p a s s grafts c o m p a r e d with 13 Range 58-289 44-392
patients (7%) in the n o n c h o r d a e group (p = 0.506). Forty IABP 0.361
patients (17%) received a bioprosthesis at their redo None 49 (91) 163 (87)
operation, w h e r e a s 201 patients (83%) received a m e - Preop 0 (0) 8 (4)
chanical valve. The incidence of aortic (n = 73, 30%) or Postop 5 (9) 16 (9)
tricuspid valve (n = 62, 26%) p r o c e d u r e s was similar Inotropes 29 (54) 111 (59) 0.458
b e t w e e n groups. The aortic cross-clamp time a n d the Renal failure 5 (9) 21 (11) 0.573
c a r d i o p u l m o n a r y b y p a s s time were similar in the two Low output 9 (17) 51 (27) 0.112
groups. Five patients (9%) in the chordae group r e q u i r e d syndrome
postoperative intraaortic balloon p u m p s u p p o r t com- Stroke 4 (7) 9 (5) 0.457
p a r e d with 24 patients (13%) in the n o n c h o r d a e group Mortality 4 (7) 25 (13) 0.236
(p = 0.361). The r e q u i r e m e n t for postoperative inotropes a Numbers in parentheses are percentages.
was similar b e t w e e n groups (chordae 54% versus non-
AVR = aortic valve replacement; IABP= intraaortic balloon pump;
c h o r d a e 59%; p = 0.488). The incidence of postoperative SD = standard deviation; TV = tricuspid valve.
low o u t p u t s y n d r o m e (the r e q u i r e m e n t of intraaortic
balloon p u m p or inotropic s u p p o r t for greater than 30
m i n u t e s to maintain a systolic b l o o d p r e s s u r e greater initial operation a n d all u n d e r w e n t a r e p r e s e r v a t i o n
t h a n 90 m m H g a n d a cardiac index greater t h a n 2.1 p r o c e d u r e d u r i n g the r e d o operation. C h o r d a l p r e s e r v a -
L • m i n -a • m -2) was lower in the chordae group (17% tion l e d to a reduction in the incidence of postoperative
versus 27%), b u t the difference was not statistically sig- low o u t p u t s y n d r o m e (0% versus 24%; p = 0.034). There
nificant (p = 0.112). The incidence of postoperative stroke was a reduction in operative mortality (7% versus 16%),
(chordae 7% versus n o n c h o r d a e 5%; p = 0.457) a n d renal b u t this difference was not statistically significant (p =
failure (chordae 9% versus n o n c h o r d a e 11%; p = 0.573) 0.374). Figure 1 s u m m a r i z e s the results of chordal re-
was similar b e t w e e n groups. There were four operative preservation d u r i n g r e d o operations.
deaths in the chordae group (7%) c o m p a r e d with 25
deaths (13%) in the n o n c h o r d a e group (p = 0.236). MULTIVARIABLEPREDICTORS OF OPERATIVEMORTALITYAND
LOW OUTPUT SYNDROME. Stepwise logistic regression re-
DOUBLE-VALVEREPLACEMENT. There were 73 patients who v e a l e d left ventricular ejection fraction less than 0.40
u n d e r w e n t both aortic a n d mitral valve r e p l a c e m e n t (odds ratio = 2.53; 95% confidence interval = 0.91 to 7.03)
d u r i n g their redo operation. Fifteen (21%) of these pa- a n d age greater than 70 years (odds ratio = 2.14; 95%
tients h a d their chordal attachments p r e s e r v e d at their confidence interval = 0.90 to 5.08) to be i n d e p e n d e n t risk
182 RAO ET AL
REPRESERVATIONOF CHORDAETENDINEAE
[ ] NO PRESERVATION [ ] CHORDAEPRESERVED
~p -- 0.03 1
25
i,° 5
0 thetic valve was carefully excised from the mitral annulus
OM LOS OM LOS
MVR M V R and AVR
Fig 1. Effects of chordal preservation on postoperative low ou~Jut
syndrome (LOS) and operative mortality (OM). (AVR = aortic
valve replacement; MVR = mitral valve replacement.)
factors for operative mortality. The Hosmer-Lemeshow
goodness of fit p value for this model was 0.1160, indicat-
ing that the regression model is valid for this patient
population (goodness of fit p value > 0.05); however, the
predictive power of the model was poor, with an area
under the receiver operating characteristic curve of 64%.
The independent predictors for postoperative low out-
put syndrome were preoperative angina (odds ratio =
2.23; 95% confidence interval = 0.869 to 5.710) and male
sex (odds ratio = 1.77; 95% confidence interval = 0.95 to
3.27). The Hosmer-Lemeshow goodness of fit p value for
this model was 0.101, with an area under the receiver
operating characteristic curve of 59%.
Preservation of the chordal apparatus failed to emerge
as an independent predictor of either postoperative low
output syndrome or operative mortality.
Comment
More than a decade has passed since the revival of the
chordae-sparing mitral valve replacement [1, 10]. Preser-
vation of the subvalvular apparatus during operation has
become the preferred technique when feasible. We re-
cently presented the late results of a randomized trial
comparing preservation of the chordae tendineae with no
preservation [18]. Our results indicate that even 7 years
postoperatively, those patients with preserved chordae
and papillary muscles had better left ventricular function
when compared with patients who underwent resection
of the subvalvular apparatus. This finding corresponds to
other reports of improved left ventricular function after
papillary muscle preservation [16, 17]. Olinger [21] pub-
lished a case report of preservation of the chordae
tendineae during repeat mitral valve replacement in
1992. The present article reports the morphologic appear-
ance of the preserved chordae and papillary muscles
found at reoperation in a series of patients up to 22 years
Ann Thorac Surg
1996;62:179-83
(range, 1 to 22 years) after the initial chordae-sparing
operation.
In our experience, the preserved chordae tendineae
and papillary muscles were in excellent condition after
the initial chordae-sparing procedure. The presence of
intact and nonatrophic papillary muscles suggested that
they were still functioning. In patients who had under-
gone operation before 1974 and had their chordae and
papillary muscles excised, we were able to resuspend the
remnant papillary muscle base to the mitral annulus with
the aid of artificial Gore-Tex sutures. We encountered
little difficulty in preserving the chordae during repeat
operation. In most patients, the sewing ring of the pros-
and a new valve inserted without dissection of the
chordae. When a mechanical valve was inserted, we were
careful to ensure that the mechanical poppet did not
entrap any portion of the native subvalvular structures.
In patients who received a monoleaflet valve, the major
orifice was oriented upward to avoid interference from
the posterior chordae. Implanting the St. Jude Medical
bileaflet valve was easier than the Sorin valve when the
chordae tendineae were being preserved.
The operative mortality was similar in the two groups.
We found no difference in preoperative predictors of
postoperative mortality. Patients in the nonchordae
group had a greater number of previous cardiac proce-
dures. However, multiple previous operations did not
predict either mortality or the development of low output
syndrome.
The incidence of postoperative low output syndrome
was less in patients undergoing chordae-sparing proce-
dures; however, this too failed to reach statistical signif-
icance. In a high-risk subset of patients undergoing
simultaneous aortic and mitral valve replacement during
their reoperation, the incidence of low output syndrome
was reduced by preservation of the chordae tendineae
(chordae 0% versus nonchordae 24%; p = 0.034).
The power of the present study in detecting a differ-
ence in operative mortality or low output syndrome was
24% and 68%, respectively. If we had more patients in our
study, we may have found a significant improvement
with chordal preservation. For the observed difference in
operative mortality (7% versus 13%) and low output
syndrome (17% versus 27%), we would have required 391
and 268 patients per group, respectively, to achieve
statistical significance at a = 0.05.
Preservation of the chordae tendineae and papillary
muscles is now a standard procedure during mitral valve
replacement [22]. We believe that preservation of the
chordae ~endineae is technically feasible and may im-
prove outcomes after reoperative mitral valve replace-
ment.
Supported by the Heart and Stroke Foundation of Canada.
Doctor Rao is a Pharmaceutical Roundtable Research Fellow of
the Heart and Stroke Foundation of Canada, Dr Weisel is a
career investigator of the Heart and Stroke Foundation of
Ontario, and Dr Ikonomidis is a Research Fellow of the Heart
and Stroke Foundation of Ontario.
Ann Thorac Surg
1996;62:179-83
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