Improving methods of chordal-sparing mitral valve replacement - Part II: Optimal tension for chordal resuspension

Background and aims of the study: Although chordal-sparing mitral valve replacement (MVR) is popular, the optimal tension for preserved or reattached chordae tendineae (CT) or for synthetic (ePTFE) CT is unknown. Methods: Changes in left ventricular (LV) systolic and diastolic function in nine dogs with anterior CT preservation with different levels of end-diastolic chordal tension (0, 10, 20, 30, and 40 gm, measured by spring scale) were compared using an isovolumic double-balloon technique. Results: LV function data at each level of tension were compared to control data using 0 gm of tension. Systolic function assessed as E(max) (mmHg/ml) at 10, 20, 30, and 40 gm versus control was: 5.7 ± 2.6/4.9 ± 2.7, 4.7 ± 2.2/4.7 ± 2.7, 4.8 ± 3.1/4.7 ± 2.8, and 5.0 ± 3.5/5.1 ± 2.9; Δ improvement from the control at 10 gm was larger than that at 20 gm (p < 0.05 by paired t-test). Diastolic function assessed as diastolic stiffness (S(d), mmHg/ml) at the same CT tensions versus control was: 0.56 ± 0.23/0.56 ± 0.34, 0.53 ± 0.30/0.57 ± 0.37, 0.56 ± 0.39/0.52 ± 0.38, and 0.60 ± 0.36/0.58 ± 0.39; ΔSd was smaller at 20 gm than at 30 gm (p = 0.05 by ANOVA). LV equilibrium volume (V(eg), ml) was: 10.7 ± 3.9/10.1 ± 3.9, 9.6 ± 3.4/9.9 ± 3.8, 10.8 ± 4.0/10.3 ± 3.4, and 10.6 ± 4.0/10.6 ± 3.5; ΔV(eq) was larger (i.e., more compliant chamber) at 10 gm than at 40 gm (p < 0.05 by rmANOVA). Arrhythmias precluding satisfactory measurements occurred in two dogs at 30 or 40 gm CT tension. Conclusions: With chordal tension exceeding 10 gm, which is barely palpable, there was no additional enhancement in LV systolic function compared to zero CT tension. V(eq) was largest at the lowest tension. LV diastolic function (assessed as S(d)) deteriorated with tensions of 30 gm or higher. The optimal end-diastolic tension of preserved CT should enhance systolic LV performance without adversely affecting diastolic function; in this isovolumic model, minimal CT tension (10 gm) best met these goals. Excessive tension may negate the potential hemodynamic benefits of chordal preservation during mitral valve replacement.