**3. Methodology**

*Cardiac Diseases - Novel Aspects of Cardiac Risk, Cardiorenal Pathology and Cardiac Interventions*

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

**300**

**Figure 1.**

*Mitral valve non resectional graded chordal neoconstruction method.*

**2. Statistics**

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 significant.
