**2. Statistics**

Mitral valve repair done via non resectional methods from January 2017 to November 2017 is included. Preoperative analysis included cardiac MRI and 3 D echocardiography. 25 patients who underwent non resectional methods during this period and techniques are discussed. Patients who underwent leaflet resection, LVEF less than 45%, reoperative mitral valve repairs, beating heart repairs or who underwent minimally invasive procedures during this period were excluded from the study. Intraop TEE was used in all cases. Approach to the mitral valve was through the superior septal approach with initial assessment done on beating heart. Repair was fashioned on arrested heart. After analysis of the valve artificial chordae were created with CV5 and CV6 e PTFE sutures (Gore-Tex R, WL Gore and associates Flagstaff AZ). Graded reconstruction with suture thickness simulating natural chordal stress patterns were used. The suture was first placed in the fibrous part of the papillary muscle. Pledgets and suture tie was avoided in the papillary muscle to minimize chances of ischemia, by taking a simple U stitch. The apposition points are marked on the anterior or posterior leaflets so that 1/3rd of the anterior leaflet enters the coapting zone (**Figure 1**). Slight billowing of anterior leaflet should be permitted as it reduces the stress. Intial position of neochordae can be fixed with a clip placed lightly 1.5 mm below the annular plane. Suture goes back through the leaflet edge from the atrial to the ventricular side placing knots on the ventricular side. The leaflet was drawn down into the ventricle so that the prolapse was eliminated and area of good zone of coaptation is ensured- usually 1/3rd. Peak height of coaptation point should be only up to the plane of annulus. Use the annular plane as a guide for fixing the neo chordal length. As many neochordae as deemed necessary is created following the natural line of attachment to papillary muscle. Avoid crossing the midline. Strut chordae are never excised. Repair methods are individualized as deemed necessary to shorten leaflet height of anterior leaflet or straightening of posterior leaflet margin. Plication of annulus at P2 and P3 needs to be done in ischemic lesions involving posterior wall. Pulling together of papillary muscles with Gore Tex sutures are done if more than 2 cm apart. Chordal shortening is avoided. In such cases leaflet folding by transferring tissue from atrial to coaptation zone is done. Coaptation zone along neochordae creation allows maximum coaptation at centre and less towards commissures as in the normal valve. Excess leaflet tissue may require plication. Sub commissural fusion has to be released. Chordal splitting

**301**

*Nonresectional-Graded Neo Chordal Dynamic Repair of Mitral Valve: Stress Analysis Induced…*

is done in an individual fashion depending on the pathology. Leaflet thinning and open commissurotomy may be required in rheumatic lesions. Reduction annuloplasty ring is fashioned making allowance for a push up of the ring at the interventricular triangle region of the anterior leaflet to allow for the postero superior movement of the annulus. Keep the posterior leaflet height less than 2 cm. Diastolic and systolic assessment of repair is then done. Post bypass intraop TEE is done to confirm the results. Repair can be assessed in systole in beating heart before atrial septal closure or by simultaneous saline filling of aortic root and left ventricle. No residual mitral regurgitation is accepted. Repair success rate was 100%. No patients

underwent mitral valve replacement. All repairs were successful on the first

The data was analyzed using SPSS version 13.0 for windows XP. Descriptive statistics for continuous variables are expressed as median or mean as needed while qualitative variables expressed as percentage and P < 0.05 being considered

Demographic and clinical data was obtained from the hospital records. Mean

by 3D methods showing a reduction efficiency of 60%.

P = 0.001. At follow up of 90 days

) P = 0.001. LVEF was median of 63% (30–77)

and

age was 63 ± 7.7, 15 were male. All patients were in NYHA class III.2 patients required tricuspid valve repair and 4 patients needed coronary bypass surgery. Interpapillary distance in patients with inferior wall involvement was 31 ± 3 mm. One patient required LA myxoma removal. Median surgical risk based on Logistic Euroscore was 3.95% (2.38%). Median Total cross clamp time was 74 ± 7 min. Total extracorporeal time being a median of 120 (80 to 146) minutes. 4 neochordae were created in 10, 6 in 12, 2 in 3 patients. 28 sized annuloplasty ring was used in one patient, 30 in 12 patients, 32 in 11 patients and 34 in 1patient. Mean coaptation height achieved was 8 ± 3 mm. 25 patients had zero MR on post bypass TEE. No patients had SAM. Preoperative annular area was 19.2 ± 4 cm<sup>2</sup>

The median ICU stay was 2 days (1–10) days and median total hospital stay was 7 days (5–17) days. One patient had atrial fibrillation which reverted with pharmacological therapy, 1 case of acute renal failure in a patient with chronic renal failure and type 1 neurological dysfunction in one patient. Preop ROA was median

before surgery to 68% (55–80) post op P = 0.14. Clinical follow-up was 100%. 25 patients are alive, and all were free of MR signs and symptoms. No patient required reoperation for recurrent MR. Echocardiographic follow-up has been obtained at the discretion of the referring cardiologists. Echocardiograms have been obtained on all patients with a mean follow-up of 1 year. All cause mortality at 30 days, 60 days, 90 days; 1 year after surgery has been zero. No reoperations were needed due to recurrent mitral regurgitation, no new onset atrial fibrillation or embolism or endocarditis was noted. No death, reoperations, heart failure, endocarditis, thromboembolism or pacemaker implantations were needed in any of these patients on follow up until Dec 25th 2017 (median of 9 months). Follow-up was performed till Dec 25 2017 was 100% complete for survival. All

*DOI: http://dx.doi.org/10.5772/intechopen.94433*

attempt.

significant.

**4. Results**

post op being 7.7 ± 2 cm<sup>2</sup>

9.10 (6.1–26.4) to post op of 1.10 (0.3–2.1) cm<sup>2</sup>

the median ROA was –0.50 (0.9 cm<sup>2</sup>

patients are currently in NYHA class I.

**3. Methodology**

**Figure 1.** *Mitral valve non resectional graded chordal neoconstruction method.*

*Nonresectional-Graded Neo Chordal Dynamic Repair of Mitral Valve: Stress Analysis Induced… DOI: http://dx.doi.org/10.5772/intechopen.94433*

is done in an individual fashion depending on the pathology. Leaflet thinning and open commissurotomy may be required in rheumatic lesions. Reduction annuloplasty ring is fashioned making allowance for a push up of the ring at the interventricular triangle region of the anterior leaflet to allow for the postero superior movement of the annulus. Keep the posterior leaflet height less than 2 cm. Diastolic and systolic assessment of repair is then done. Post bypass intraop TEE is done to confirm the results. Repair can be assessed in systole in beating heart before atrial septal closure or by simultaneous saline filling of aortic root and left ventricle. No residual mitral regurgitation is accepted. Repair success rate was 100%. No patients underwent mitral valve replacement. All repairs were successful on the first attempt.
