Simplifying Mitral Valve Repair: A Guide to Neochordae Reconstruction

Fig. 1.. Guide to neochordae reconstruction.

Fig. 2.. Transesophageal echocardiography measurement technique. (a) Optimal view including the flail/prolapsing segment, mitral annulus, coaptation zone, and the corresponding papillary muscle head. (b) Length for posterior leaflet prolapse = X – Y. (c) Length for anterior leaflet prolapse = Z. (d) Length for bileaflet prolapse combines posterior and anterior leaflet measurements. A, mitral annulus.

Fig. 3.. Materials used for creating neochordae loops.

Fig. 4.. Neochordae loops preparation. (a) The first loop is created in the longitudinal orientation of the pledget. (b) Subsequent loops are created, and the knots are flattened. (c) Final aspect of the loops. (d) A 4-0 polytetrafluoroethylene suture is passed through each loop and secured with a hemostat, ensuring the correct order for implantation.

Fig. 5.. On valve inspection, (a) divide the valve into 4 quadrants, and (b) localize the flail/prolapsing segment and the corresponding papillary muscle head. For neochordae reconstruction, keep the AH to the anterior leaflet and the PH to the posterior leaflet. The same applies to the anterolateral papillary muscle. (c) In this view, only the posteromedial aspect of the valve is visible. (d) The posteromedial papillary muscle divides into AH and PH. AH, anterior head; PH, posterior head.

Fig. 6.. Neochordae implantation. (a) Base fixation at the corresponding papillary muscle head. (b) Loops equally distributed across the flail segment are anchored on the leaflet edge with polytetrafluoroethylene sutures. (c) Ring annuloplasty. (d) Saline test showing good coaptation and no residual mitral regurgitation.

Fig. 7.. Minor adjustments of the neochordae. (a) After removing the affixing suture from the leaflet, pass a new 4-0 polytetrafluoroethylene suture through the loop (b) and then through the leaflet edge on the new desired location.