IJTCVS Talwar et al 45

Review
2005; 21: 45–52 Chordal preservation

Chordal preservation during mitral valve replacement:

basis, techniques and results
Sachin Talwar, M.Ch., Honnakere Venkataiya Jayanthkumar, MS, Arkalgud Sampath Kumar, M.Ch.,
Department of Cardiothoracic & Vascular Surgery, Cardiothoracic Centre, All India Institute of Medical
Sciences, New Delhi

Introduction chordae of the anterior leaflet insert on either side of a

central clear zone. There are two papillary muscles -
The aim of mitral valve (MV) surgery is to provide a
antero-lateral and postero-medial. Each of these gives
competent, non-obstructed valve without
chordae to both the anterior and posterior mitral leaflets.
compromising the left ventricular (LV) function. To a
In 1922, Wiggers and Katz5 and later Rushmer et al6,7
large extent, these aims are met with valve conservation
proposed the concept of annulo-ventricular continuity.
and repair rather than valve replacement1, 2 . However,
According to this concept, the left ventricular geometry
a large number of patients require mitral valve
and function are a result of a dynamic interaction
replacement (MVR) when repair is not feasible and in
between the mitral annulus and the LV wall. The
this subgroup of patients preservation of left ventricular
attachments between the mitral annulus and the LV wall
function is an important concern. As the awareness of
moderate the LV distension during diastole and wall
the deleterious effects of the loss of annulo-ventricular
tension during systole. When the papillary muscles
continuity has increased, chordal preservation has
contract during the isometric phase of the cardiac cycle,
gained popularity and is now a standard procedure
the closed MV is drawn into the LV cavity thus reducing
during MVR 3 . A wide variety of techniques are
the longitudinal axis of the LV and increasing its short
available. The aim of this article is to systematically
axis8. The bulbo-spiral muscles play an important role
review the basis, historical aspects, techniques, concerns
in this9. As a result of this interaction, the myocardial
and long-term results of MVR with chordal
fibres stretch additionally and generate more tension,
preservation.
leading to greater contraction and an increase in stroke
volume (SV). During systole, the ventricle undergoes
Anatomy and physiology counterclockwise torsional deformation of the apex with
respect to base; during isometric relaxation and in early
The bicuspid design of the mitral valve along with
diastole, this is reversed (diastolic recoil)10. Disruption
its subvalvular apparatus has evolved over millions of
of the papillary-annular continuity impairs this torsional
years and it is not by accident, rather it is by nature’s
deformation thereby causing abnormal diastolic
design. In normal hearts, the orifice which results from
function and disruption of normal LV stress-strain
a bicuspid configuration of the MV is round in diastole
patterns 11.
and ellipsoidal in systole. In systole, the mitral orifice
decreases by almost 25% and the circumference of the
mitral annulus reduces by 30%4. Historical aspects and animal experiments
The chordae of the mitral valve insert either into the
In 1964, Lillehei introduced the concept of chordal
free edge or into the rough zone on the ventricular
preservation during MVR to reduce the problem of post-
surface of the anterior and posterior mitral leaflets. The
operative low cardiac output syndrome12. However very
soon there emerged strong opposition to this idea13-16.
Address for correspondence:
The concept was re-introduced by David in 1981 after
Dr. A Sampath Kumar
Professor, Department of Cardiothoracic & Vascular Surgery an experimental study of MVR in dogs17. This study
Cardiothoracic Centre showed that LV function deteriorated if the chordae
All India Institute of Medical Sciences, Ansari Nagar were transected but remained unchanged when the
New Delhi – 110 029
chordae were intact. David also compared resting pre-
Telefax : 91-11-26588889
E-mail : [email protected] operative and post-operative LV function and exercise
@IJTCVS 097091342110305/118 induced changes after MVR with or without chordal
preservation in patients with chronic mitral
Received - 25/10/04; Review Completed - 19/11/04; Accepted - 19/11/04.
regurgitation. LV function showed a decline in those

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 46 Talwar et al IJTCVS
Chordal preservation 2005; 21: 45–52

who had chordal transection but not in those with by chordal transection could be completely reversed by
chordal preservation. Left ventricular end-diastolic reattaching the papillary muscles. This forms the basis
volume (LVED), end-systolic volume (LVESV) and for neo-chordal reconstruction at re-operation in those
stroke volume (SV) reduced significantly in both groups. patients in whom chordae have been transected
With exercise, cardiac output increased in both the previously.
groups primarily by an increase in the heart rate, but These effects were described in a simplified manner
only those patients in whom the chordae had been in a recent editorial on the issue23. The function of the
spared could increase the LV ejection fraction (EF) and chordae and papillary muscles was eloquently
stroke volume index. Also in the chordal preservation compared to a pair of gymnasts on parallel bars (Fig. 1
group, there was better long-term systolic function and & 2). As the gymnasts (chordae) move towards the
LV performance both at rest and during exercise. They parallel bars (mitral annulus), they bring the floor (LV
also demonstrated increased LV end-diastolic pressures wall) with them and in addition prevent overstretching
after chordal transection and conventional MVR of the LV cavity. When either of the chordae are
whereas these decreased after MVR with chordal transected, only one gymnast works, and the
preservation18. unsupported portion of the LV thins and dilates. When
both the anterior and posterior chordae are divided, the
gymnasts do not have the arms to pull themselves up
Effects of chordal transection
Canine experiments have been performed to assess
the effects of chordal transection on the LV mechanics.
Gams et al19demonstrated that chordal transection in a
working dog heart led to an increase in the long axis of
the LV followed by a reduction in contractility. The LV
stroke volume could then be maintained only by a
higher preload and up to 30% increase in fibre force.
Hansen20 demonstrated that transection of chordae to
the anterior mitral leaflet (AML) reduced the LV
function to a greater degree as compared to the
transection of chordae to the posterior mitral leaflet
(PML). He hypothesized that preservation of the
subvalvular apparatus improved LV systolic Fig. 1. The parallel bars are the mitral annulus. (b) The arms of the
performance by reduction of the LV afterload; He gymnasts are chordae and their bodies the papillary muscles. The
further proposed that the detrimental effect of floor is the left ventricular wall.
(Reproduced with permission from : Kumar AS. Heart strings. Ind
transection of the chordae to the AML was because of J Thorac Cardiovasc Surg 2004;20:115-16.)
regional afterload reduction. Because the AML is larger
than the PML, the development of tension in the chordae
to this leaflet should be greater at a given LV pressure.
Chordal transection also appeared to shorten the long
axis of the LV with an increase in the minor axis and
dilatation of the chamber. However when the chordae
were intact, the chamber shape remained same during
isometric contraction. In addition to this, transection of
the chordae produced dyskinetic areas at the insertion
of severed papillary muscles.
Rastelli14 after his canine experiments indicated that
preservation or excision of the chordae did not affect
the cardiac performance after replacement with Starr-
Edwards prosthesis. However, Doces and Kennedy21
have reported reduction in ejection fraction after Fig. 2. Effect of chordal resection- Note dilatation & ventricular wall
conventional MVR. thickness where chordae are resected partially or completely
(a)Partial chordal resection (b) Complete chordal resection.
Sarris and colleagues22 demonstrated that in an open- (Reproduced with permission from : Kumar AS. Heart strings. Ind
chest swine experimental model, the changes induced J Thorac Cardiovasc Surg 2004;20:115-16.)

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 IJTCVS Talwar et al 47
2005; 21: 45–52 Chordal preservation

and in an attempt to reach the bars, they have to jump is less common after mitral valve repair as compared to
higher and higher, but with each attempt they sink conventional MVR without chordal preservation which
lower, resulting in dilatation of the LV cavity and possibly explains the role of subvalvular apparatus in
thinning of its walls. When all the chordae are intact, preserving LV function2.
the gymnasts are free to do their work. In patients undergoing surgery for mitral stenosis
(MS), the LV is small and because of severe subvalvular
fusion and often fused, rigid and calcified leaflets, the
Physiologic alterations in mitral valve disease
annulus loses it sphincter-like function. Excision of this
In chronic mitral regurgitation (MR), the LV function valve with chordae does not produce the picture of
gradually declines. This can be easily demonstrated by reduced preload and increased after-load as observed
selective angiography where the LV contractility is poor after MVR for chronic MR. Nevertheless, the loss of
in successive films and also by an elevated LV filling annulo-ventricular continuity still leads to progressive
pressure. The regurgitation into the left atrium during LV dilatation with eventual decline of LV function in
systole (regurgitatnt stroke volume) is added to the the long-term9,23.
forward stroke volume and tends to increase the total
forward output and ejection fraction (EF) in the early
Techniques of chordal preservation
phase. However, progressive LV dilatation increases the
wall tension as per the Laplace law which leads to PML preservation
increased systolic wall stress and also increases the In the original technique as described by Lillehei12,
afterload. After MVR, there is a rapid increase in the the posterior leaflet was bound to the annulus with a
LV afterload and the adaptation of LV to this change running stitch. In 2 of the 23 patients, this stitch was
depends upon the annulo-ventricular continuity9,24. continued around the entire annular circumference and
Fixation of the mitral annulus with a rigid prosthesis chordae to both the AML and PML were preserved. In
interferes with the distension and contraction of the the remaining 21 patients, only the PML was preserved
basoconstrictors. Also, after MVR, the LV volume because it was thought that the AML would interfere
decreases because of elimination of the regurgitant with the ball of the caged ball valve prosthesis used for
volume. After MVR with chordal transection, the EF is MVR. Using this technique, Lillehei reported reduction
determined by contractility, preload and after-load. in operative mortality from 37% to 14% 12.
Because there is elimination of the low impedance
pathway into the left atrium, it increases the after-load Total chordal preservation
and at the same time reduces the preload. This may be With the development of low profile bi-leaflet
further worsened by some residual gradient across the mechanical valves, and refinements in surgical
prosthesis and may be responsible for the syndrome of technique, various methods of total chordal preservation
“low output” in many of these patients despite a have been described to preserve the LV systolic function
satisfactory prosthesis function. It has been and to avoid interference with the mechanical prosthesis
demonstrated that post-operative low output syndrome function by portions of the retained subvalvular
apparatus and also to prevent left ventricular outflow
tract obstruction (LVOTO).
In addition to these considerations, it is important to
adjust tension on the chordae during chordal
preservation as too much stress on the chordae can lead
to chordal rupture and entanglement with the
prosthesis. Also the method of AML preservation
should avoid the systolic anterior motion of the AML
which has the potential to produce LVOTO.

David’s technique25 (Figure 3)

The AML is incised at its base, 2-3 mm from its
attachment. The incision is carried to both the sides and
brought down centrally towards the free edge of the
Fig. 3. David’s technique: (a) Normal Mitral valve. AML = anterior
mitral leaflet, PML = posterior mitral leaflet (b)A triangular portion leaflet and a triangular segment of the AML is thus
of the AML and a crescent of PML are excised. excised leaving the chordae attached to the remaining

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 48 Talwar et al IJTCVS
Chordal preservation 2005; 21: 45–52

AML which is re-suspended to the mitral annulus by

sutures used to secure the prosthetic valve. The PML
with its chordae is left intact. In patients with
myxomatous MR undergoing MVR, the chordae are
shortened by imbricating the PML in the mitral annulus
using the sutures used for prosthetic valve fixation.
Alternatively, a part of the posterior leaflet is excised
and reattached to the mitral annulus during fixation of
the prosthetic valve.
Advantages of the David technique are the
maintenance of the chordae in their natural anatomic
orientation, reduced risk of LVOTO and reduction in
the bulk of leaflet tissue.
Fig. 4. Feikes technique: (a)The AML is incised in the midline and
26 the incision is extended sideways (b)The 2 segments of the AML
Feikes technique (Figure 4) are turned backwards and sutured to the posterior mitral annulus.
The AML is split from the centre of the free edge
towards the annulus. Incisions are made on either side
of this split towards the two commissures to detach the
AML from the annulus. The resulting two halves of the
leaflet along with the intact chordae are trimmed to
remove thickened and calcific areas and then rotated
posteriorly and sutured to the posterior mitral annulus.
This technique has been reported to be specially
useful while implanting tilting disc prosthesis where
disc entrapment by the subvalvular apparatus is a
concern. The chordal continuity to the AML is well
maintained. A theoretical disadvantage of this technique
is that it disturbs the normal geometric relationships of
the mitral subvalvular apparatus which could alter the
distribution of regional LV wall stresses and disturb
chordal tension during papillary muscle contraction
thereby reducing global LV systolic and diastolic Fig. 5. Khonsari technique: (a) The AML is separated from the mitral
annulus (b)The two chordal buttons are re-attached to the anterior
function11. mitral annulus (Khonsari I) in such a way that the point 1 is
approximated with 2 and the point 3 is sutured to point 4. (c)
Khonsari Technique 27 (Figure 5) Multiple buttons of AML with chordae are attached to the anterior
After the AML is detached from the annulus between mitral annulus (Khonsari II)
the two commissures, an ellipse of tissue is excised and
the rim of the leaflet tissue containing the chordae is valve function. It is believed that with the use of this
reattached to the anterior annulus (Khonsari I technique, myocardial rupture is prevented by
technique). If the leaflet is thick or calcified, it is divided maintaining the tethering effect of the intact subvalvular
into 2-5 chordal segments which are re-attached to the apparatus28.
annulus (Khonsari II technique). The PML is retained A concern with the Khonsari technique is that the
completely and the redundant leaflet tissue is folded chordae could become stretched around the struts of
up into the annulus by passing the valve sutures the bioprostheses thereby exerting more stress on the
through the annulus and bringing them through the retained chordae.
leading edge of the leaflet tissue. They also advocate
construction of artificial chordae using 4-0 Miki’s technique29 (Figure 6)
polytetrafluoroethylene (PTFE) sutures if there is This is the most commonly used technique as it is
considerable thickening and fusion of chordae and thought to maintain more normal chordal tension as the
papillary muscles. direction of the chordal force is more anterior than the
With this technique, there has been no reported Fiekes technique. The AML is separated from the
incidence of LVOTO or interference with prosthetic annulus and incised in centre. The anterior and posterior

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 IJTCVS Talwar et al 49
2005; 21: 45–52 Chordal preservation

The AML is stretched posteriorly and its central

portion is excised. The rim of the remaining leaflet tissue
contains the marginal chordae. The defect in the AML
is then closed with a running suture placed parallel to
the annulus. This tacks the marginal chordae to the
fibrous triagones and displaces the anterior leaflet
chordae to the periphery of the mitral orifice. Valve
sutures are placed to reinforce the previously running
suture line. The prosthetic valve is sutured to orient the
leaflets perpendicular to the native annulus. In this way,
restriction of the prosthetic leaflet motion is minimized.
Reported advantages of this technique are reduced bulk
of the AML which reduces the possibility of impairment
of valve function, low risk of LVOTO, and reduced risk
of thrombosis on the redundant leaflet tissue.
Fig. 6. Miki’s technique: The PML is incised in the midline (b) & (c)
The two papillary muscles are split and the two halves of the PML
are reattached to the commissures. Miscellaneous techniques
Vander-Salm32 and Yu33 have described procedures
commissures are incised and papillary muscles are split. for complete retention of valve leaflets and subvalvular
Excessive cuspal tissue and fibrous and calcific nodules apparatus without the risk of LVOTO or interference
are excised. The two chordal segments thus created are with prosthetic valve function. In these techniques the
sutured to the respective antero-lateral and postero- central part of the AML is incised from the edge to the
medial commissures. The PML is incised in the centre base and pledgeted horizontal mattress sutures are
and the prosthetic valve is sutured in position plicating passed from the left atrium through the mitral annulus
the PML and including the AML and chordae in valve avoiding the papillary muscles and chordae around the
sutures. free edge of the leaflet and up through the prosthetic
The technique is simple, and LVOTO is uncommon sewing ring. If the AML is large, it is reefed within the
with good preservation of LV function. This technique sutures and the prosthetic valve is seated and tied. This
is particularly suitable for patients with rheumatic mitral has the advantage that the native leaflet is reefed and
valve disease and thickened, deformed and calcific compressed between the prosthesis and the native
cusps 30. Also this technique allows placement of a larger annulus and also chordal tension is evenly maintained.
prosthesis. The use of a low profile prosthesis further
reduces the incidence of leaflet obstruction from
Safeguards
retained chordae.
In choosing the technique to be used for chordal
Rose and Oz technique 31 (Figure 7) preservation, the factors to be considered are the
simplicity and reproducibility of the technique,
prevention of post-operative LVOTO due to systolic
anterior motion of the remaining AML and risk of
interference with the prosthetic valve function. The
technique used should allow for implantation of an
adequate size prosthesis to prevent post-operative
patient-prosthesis mismatch.
In MVR with chordal preservation, the function of
the native valve leaflets is replaced by the prosthetic
mitral valve and the preserved chordae and the
papillary muscles assist the myocardium during systole
and diastole. Care should therefore be taken to ensure
that these attachments are of sufficient length to
moderate left ventricular distension during diastole and
Fig. 7. Rose and Oz technique : (a) An ellipse of AML is removed,
(b)The defect in AML is closed is closed with a running wall tension during systole. Care should be taken to
polypropylene suture and valve sutures are placed. prevent excessive shortening of the chordae as it may

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 50 Talwar et al IJTCVS
Chordal preservation 2005; 21: 45–52

cause rupture of a papillary muscle head34. chordae if these had been transected at previous
In patients with pure MS, the papillary muscles operation. 187 patients did not have any form of chordal
should be incised. This allows the anterior and posterior preservation. The incidence of low-output syndrome
chordae to fall away and ensures free movement of the and operative mortality were less in patients in whom
discs. Further, incision of the PML in the middle allows chordae were preserved as compared to the non-chordal
a larger prosthesis to be seated30. group. Based on these results, the authors recommended
re-preservation of chordae in patients undergoing MVR
if the chordae had been transected earlier 40 . The
Results of partial or complete chordal preservation
technique of chordal reconstruction using PTFE sutures
Experiments by Hansen and associates20 have clearly was described in detail recently 41.
demonstrated that LV function was superior with an Chowdhary et al42 reported on 451 patients who
intact subvalvular apparatus, intermediate with underwent mitral valve replacement for rheumatic
preservation of either the AML or PML and poorest with disease. The entire valve was excised in 70 patients while
loss of all chordae. Horskotte et al35 showed that partial 124 had preservation of the posterior mitral apparatus
chordal preservation preserving the PML alone and 257 had partial anterior leaflet resection with
improved the event-free survival, but they did not preservation of both anterior and posterior chordae.
attempt total chordal preservation. Clinical improvement was observed in all three groups
Hennein et al36 showed that after chordal excision, of patients but echochardiographically determined
exercise capacity, LV systolic dimensions and cardiac indices of left ventricular size, shape, and function were
index did not improve and the LV function declined. In superior in patients with complete preservation of the
contrast, after preservation of the entire subvalvular mitral apparatus42. Hetzer’s study43 clearly lists the
apparatus, the exercise capacity improved markedly, major advantages of chordal preservation – (a) reduction
LV function improved and resting ejection fraction was in operative mortality (b) improvement in early and late
preserved. However there was no significant difference ventricular function (c) improvement in long-term
between posterior chordal preservation alone or the total survival and (d) elimination of risk of ventricular
chordal preservation group. rupture.
In an experimental evaluation of different chordal Despite the clear advantages of complete chordal
preservation methods during MVR, there was no preservation as detailed above, many surgeons still
statistically significant difference between the results of retain only the posterior leaflet because of greater
anterior (Khonsari)27 and posterior (Feikes)26 technique technical complexity, longer operating time, and fear
in terms of global LV systolic and diastolic function11. of potential interference with mechanical leaflet motion,
The pioneering work in this field has been reported need to undersize the mitral prosthesis and the
from David’s centre. The late results of a randomized possibility of LVOTO. However, with application of the
trial comparing chordal preservation with no chordal correct surgical technique tailored to suit the individual
preservation indicated that even 7 years after operation, patient, preservation of the entire subvalvular structures
patients with chordal preservation had better LV is feasible in all patients with an adequate sized
function than those without it37. In a recent randomized prosthesis43.
trial from the same centre38, comparing partial versus Although these techniques can be easily learnt and
complete chordal sparing MVR, it was clearly reproduced, it is probably still not adopted by some as
demonstrated that complete retention of the subvalvular it involves a change in behaviour which has always been
apparatus confers a significant early advantage by met with by skepticsm and increased resistance from
reducing the chamber size and systolic after-load as critics44.
compared with partial chordal preservation. Also the
LV ejection fraction improved with time in the complete
Effects of chordal preservation on right ventricular
preservation group because of favourable LV
(RV) function
remodeling. David went on to study 241 patients
undergoing redo-MVR 1-22 years after initial MVR39. Improvement of LV function is automatically
54 of these had intact chordae after re-operation. The expected to lead to an improvement in the RV function.
chordae and papillary muscles which had been However, a study from Sweden 45 has shown a
preserved in some patients as early as 22 years prior to statistically significant improvement in right ventricular
re-operation were intact and non-atrophic suggesting function after LV chordal preservation. This
good function. 4-0 PTFE sutures were used to create new improvement in RV function has been clearly

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 IJTCVS Talwar et al 51
2005; 21: 45–52 Chordal preservation

documented by radionuclide studies and is an area of 13. Bjork VO, Bjork L, Malers L. Left ventricular function after
future investigation as this is very important in patients resection of the papillary muscles in patients with total mitrl
valve replacement. J Thorac Cardiovasc Surg 1964; 48; 635-39.
with severe pulmonary arterial hypertension who may 14. Rastelli GC, Tsakiris AG, Banchero N, Wood EH, Kirklin JW.
have significant RV dysfunction prior to surgery and Cardiac performance after replacement of the dog mitral valve
may benefit from LV chordal preservation. with Starr-Edwards prosthesis with and without preservation
of the chordae tendinae. Surg Forum 1966; 17: 178-79
15. Cohen LH, Reis RL, Morrow AG. Left ventricular function after
Conclusion mitral valve replacement. J Thorac Cardiovasc Surg 1968; 56: 11-
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