ORIGINAL ARTICLE

European Journal of Cardio-Thoracic Surgery 45 (2014) e227–e232
doi:10.1093/ejcts/ezu140 Advance Access publication 31 March 2014

Seamless reconstruction of mitral leaﬂet and chordae
with one piece of pericardium
Toshiaki Itoa,*, Atsuo Maekawaa, Masakazu Aokib, Satoshi Hoshinoa, Yasunari Hayashia, Sadanari Sawakia,
Junji Yanagisawaa and Masayoshi Tokoroa
abDepartment of Cardiovascular Surgery, Japanese Red Cross Nagoya First Hospital, Nakamura-ku, Nagoya , Japan
Department of Cardiovascular Surgery, Matsumoto Kyoritsu Hospital, Matsumoto, Nagano, Japan* Corresponding author. Department of Cardiovascular Surgery, Japanese Red Cross Nagoya First Hospital, 3-35 Michishita-cho, Nakamura, Nagoya 453-8511, Japan.
Tel: +81-52-4815111; fax: +81-52-4827733; e-mail: cvs1@nagoya-1st.jrc.or.jp (T. Ito).

Abstract
OBJECTIVES: Mitral valve repair is challenging when enough pliable mitral leaﬂets and chordae are not left intact because of extensive infective endocarditis or chronic sclerotic degeneration. For those cases, we developed a simple method to reconstruct defective leaﬂets
and chordae en bloc with a piece of pericardium, and the mid-term results were evaluated.

RESULTS: There was no hospital death, and mitral regurgitation at discharge was none or trivial in all patients. During 1–59 months (mean
12.7) of complete follow-up, death, infection or hemolysis was not observed. In one patient, mitral regurgitation recurred 8 months postoperatively because the ﬁxation suture of the pericardium to the papillary muscle broke. The valve was re-repaired with re-attaching theleg of the pericardium. Regurgitation was less than moderate in all other patients. One patient with rheumatic lesion who underwent anterior leaﬂet repair and Maze operation suffered minor stroke 1 month postoperatively but fully recovered.
CONCLUSIONS: Seamless reconstruction of leaﬂets and chordae with pericardium seemed promising to repair extensively destructed
mitral valve.
Keywords: Endocarditis • Mitral valve repair • Pericardium

INTRODUCTION
Mitral valve plasty for Carpentier’s type II lesion with sufﬁcientpliable leaﬂet tissue has been almost established using the resection and suture technique, and/or Gore-Tex (W.L Gore &Associates, Newark, DE, USA) artiﬁcial chordae [1]. However, insurgery for active infective endocarditis, for example, extensive
defect of leaﬂet and that of corresponding chordae sometimes
occur after debridement of infected tissue. Because direct approximation of remnant healthy tissues could lead to undue deformityof mitral valve, supplementation of leaﬂet tissue and reconstructionof chordae for successful repair are necessary. Glutaraldehydetreated autologous pericardium (GTAP) has commonly been used
for supplementation of leaﬂets, and its durability is reportedly
promising with a very low rate of calciﬁcation, shrinkage or

disruption [2–4]. Contrary to its well-established position as a substitute for mitral leaﬂet, GTAP is now rarely used as a substitute forchordae tendineae. However, if GTAP is used as artiﬁcial chordae
in a sheet shape as it is used as artiﬁcial leaﬂet, it could potentiallyshow durability similar to that in the case of supplementation of
leaﬂet. Therefore, we hypothesized that when reconstruction of
mitral leaﬂet and corresponding chordae is necessary in complex
mitral plasty, they could be seamlessly substituted with a piece ofGTAP in a very simple way, instead of being reconstructed using
two different materials: GTAP for leaﬂets and Gore-Tex for chordae.

PATIENTS AND METHODSThe Institutional Review Board at our institutions approved thisretrospective study. Consent for this study from each patient was© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

ADULT CARDIAC

METHODS: From January 2009 to November 2013, 25 patients with the mean age of 63 (range 20–88) years underwent this operation.
The causes of mitral regurgitation were infective endocarditis in 8, sclerotic degeneration in 8, leaﬂet dehiscence of previous repair in 2,
mitral annular calciﬁcation in 3, rheumatic in 2 and congenital in 2. After complete debridement of infected or consolidated tissue, wereconstructed defective mitral leaﬂets and chordae en bloc with a piece of glutaraldehyde-treated autologous pericardium. To substituteposterior leaﬂet and chordae, the pericardium was trimmed into a narrow pentagonal shape. The pointed end was attached directly to thecorresponding papillary muscle, basal side edges to remnant leaﬂets on both sides, and the base to the annulus. For anterior leaﬂet, thepericardium was trimmed into a triangular shape if the lesion was conﬁned in the left or right half or into a double-triangle shape if
the lesion involved whole anterior leaﬂet. The summit of triangle was ﬁxed to corresponding papillary muscle, and the base to remnant
anterior leaﬂet, thus reconstructing coaptation zone and chordae seamlessly.

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Received 12 January 2014; received in revised form 26 February 2014; accepted 27 February 2014

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Table 1:data

T. Ito et al. / European Journal of Cardio-Thoracic Surgery

Preoperative patient demographics and operativen = 25

Age; mean ± SD (range)
Male gender
History of cardiac surgery
NHHA ≥ III
Hemodialysis
MR/MSR/MS
Atrial fibrillation
Aetiology of mitral lesion
Endocarditis; active/healed
Consolidating degeneration
Rheumatic
Mitral annular calcification
Congenital
Dehiscence of previous repair
Operative data
Sternotomy/mini thoracotomy
Aortic cross clamp time (min; mean ± SD)
Cardiopulmonary bypass time (min; mean ± SD)
Concomitant Maze/TAP/AVR
Prosthetic ring size; mean(range), n = 17

63 ± 16.3 (20–88)
92
161
23/1/1
9
6/2
8
2
3
2
2
15/10
144 ± 39187 ± 55
8/13/230 (28–32)

MR: mitral regurgitation; MSR: mitral stenosis and regurgitation; MS:mitral stenosis; TAP: tricuspid annuloplasty; AVR: aortic valve
replacement.

waived because of the retrospective nature of this study. General
informed consent was obtained from each patient prior to surgery.
Patients’ demographic and operative data are shown in Table 1. The
ﬁrst patient [5], a 20-year-old woman, underwent this procedure asa bail-out technique in urgent surgery for extensive active endocarditis to avoid valve replacement in January 2009. Encouraged byfavourable mid-term results in 3 young patients with active endocarditis operated on during 2009, we eventually extended the indication for this procedure to elderly patients and to other mitrallesions. Between January 2009 and November 2013, 305 patients
underwent mitral valve plasty at our institutions. Of them, 25
patients underwent this type of surgery. Conventional repair techniques, for example, resection and suture, Gore-Tex artiﬁcial chordae
and ring annuloplasty, were preferred ﬁrst, and these techniques
were indicated only when valve repair was impossible or seemedvery difﬁcult because of loss of enough pliable leaﬂet tissue andcorresponding chordae. Most prevalent indication for this procedure was extensive loss of leaﬂet and chordae due to endocarditis.
Other indications were re-do plasty and Carpentier’s type IIIa lesion
because of consolidating degeneration, mitral annular calciﬁcation
extending to the leaﬂets and congenital mitral disease.

Technique
The mitral valve was approached via a median sternotomy andstandard cardio-pulmonary bypass in 15 patients and via a small
right thoracotomy and femoro-femoral bypass in 10. Autologous
pericardium was harvested and treated with 0.6% glutaraldehyde
for 10 min. In one re-do case, bovine pericardium (Edwards Life
Science, Irvine, CA, USA) was used instead because adequately
sized autologous pericardium could not be obtained. In patientswith active endocarditis, infected mitral tissues were completely
resected ﬁrst. Also in patients having calciﬁed or consolidated

Figure 1: Glutaraldehyde-treated autologous pericardium was trimmed into a
narrow pentagon shape. The sharp point (A) was directly attached to either theanterior or posterior papillary muscle according to the location of the defective
leaﬂet. The side edges (BC, DE) and basal edge (CE) were sutured to theremnant leaﬂets and the annulus.

leaﬂets and chordae, diseased leaﬂets and chordae were trimmed
off. After debridement of infected or consolidated tissue not appropriate for subsequent reconstruction, this technique was indicated when coaptation zone of the leaﬂets and corresponding
chordae became widely defective in 2 or more mitral segments
by Carpentier’s classiﬁcation.
The repair technique was modiﬁed according to the location of
the lesion: posterior, commissure or anterior leaﬂet.
Firstly, as the basic technique for reconstruction of posterior
leaﬂet and chordae, harvested pericardium was trimmed into a
narrow pentagon shape (Fig. 1). The trapezoidal lower half of thenarrow pentagon corresponded to neo-leaﬂet and the upper triangular part to chordae tendineae. The height of pericardium wasadjusted to that of adjacent normal leaﬂets and chordae when
they keep normal structure. When leaﬂet augmentation was
intended to replace consolidated leaﬂet and chordae, the totalheight of the pericardium was trimmed about 1–1.5 cm longer
than the distance between the mitral annulus and the papillarymuscle. As a result, the total height of the pentagonal pericardium
became 4-5 cm. The width of the base was adjusted to that of thedefective leaﬂet after placing several annular compression sutures
if appropriate. The tip of the pericardium was directly attached tothe corresponding papillary muscle with a pledgeted CV4
Gore-Tex or 4–0 polypropylene mattress suture. The side edges
were then sutured to the remnant leaﬂets on both sides with 5-0
polypropylene sutures. The base of the pericardium was sutured
to the annulus with 5-0 or 4-0 polypropylene sutures, thus

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Variables

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ADULT CARDIAC

reconstructing the defective leaﬂets and chordae en bloc. In two
re-do cases for dehiscence of the previous resection and suture
repair on the posterior leaﬂet, a gap between the leaﬂets was supplemented in the same manner (Fig. 2). To reconstruct wider areaof the posterior leaﬂet, the autologous pericardium was trimmed
into the shape of double pentagons joined in parallel (Fig. 3). One
head of the pericardium was attached to the anterior papillarymuscle and the other to the posterior papillary muscle. The rest of
the procedures were completed in the same manner.
Secondly, for extensive commissural lesion because of endocarditis, wide triangle-shaped pericardium was used to supplement
the defective area between A3 and P3 across the posterior commissure (Fig. 4). The anterior part of the pericardial patch acted aspart of the anterior leaﬂet and the posterior part acted as part ofthe posterior leaﬂet, being naturally folded at the commissurearea, as shown on postoperative echocardiography.
Finally for anterior leaﬂet, this technique was indicated whenrough zone and corresponding chordae were lost extensively
because of endocarditis. Also for type IIIa lesion with consolidatedrough zone and chordal fusion and thickening, this technique wasindicated after shaving off consolidated chordae and rough zone.
A basic unit to reconstruct anterior leaﬂet and chordae was atriangle-shaped pericardium. When the lesion was located in theright or left half of the anterior leaﬂet, the summit of trianguleshaped pericardium was attached to the corresponding papillarymuscle. Then the base of the triangle was sutured to the remnantof the anterior leaﬂet using interrupted 5–0 polypropylene
sutures, thus reconstructing rough zone and chordae seamlessly(Fig. 5). Usually, the height of the triangle was 3–3.5 cm. When
whole anterior leaﬂet and chordae were diffusely affected, theFigure 3: Autologous pericardium was trimmed into a double-pentagon shape. One head (A) was sutured to the anterior papillary muscle and the other (D) was
sutured to the posterior papillary muscle.

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Figure 2: A 40-year-old woman who underwent previous extensive resection
and suture repair of P2 and P3 for endocarditis showed dehiscence of posterior
leaﬂet and ﬂexible ring 9 months after initial operation (A). A gap in the posterior leaﬂet was supplemented using pentagon autologous pericardium. The tipof the pericardium was ﬁxed to the dorsal surface of the posterior papillarymuscle (B).

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Figure 5: A 63-year-old woman with mitral regurgitation because of treated endocarditis 30 years ago underwent repair of mitral valve through right small thoracotomy. All marginal chordae tendineae arising from the posterior papillary muscle and connected to the anterior leaﬂet disappeared leaving only one thickened secondary chorda. Thickening and shrinkage of the rough zone of A2 and A3, jet lesion in the opposing posterior leaﬂet and the posterior atrial wall were observed (A).
The base of the triangle-shaped pericardium was sutured to the rough zone from A2 to A3 with interrupted 5–0 sutures and the summit to the posterior papillarymuscle (B). Saline test showed competent valve (C). A 30-sized Carpentier Edwards Physio II ring was placed (D).

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Figure 4: When the leaﬂet became defective across the commissure area, one piece of wide triangle-shaped pericardium was used to reconstruct the anterior, commissure and posterior leaﬂets en bloc.

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Postoperative care and patient follow-up
Anticoagulation with warfarin was continued during the ﬁrst threemonths postoperatively and continued thereafter if the patient had
atrial ﬁbrillation. Transthoracic echocardiography was recorded
before discharge, and at out-patient follow-up. Data of latest study
were employed.
Statistical data were calculated using SPSS 17.0 (IBM Japan,
Tokyo, Japan).

RESULTS
All patients were discharged on foot. There was no stroke, wound
infection, re-exploration for bleeding or respiratory failure.
Operative data are summarized in Table 1. No patient was converted to valve replacement. In 18 patients, this procedure was
employed after attempted repair with conventional techniques,
which prolonged average procedure time. Two patients underwent
second run of cardiopulmonary bypass because of residual leak.
One was repaired with additional stitches on the suture line of the
pericardium and one with an edge-to-edge stitch at commissure.

Table 2: Reconstruction technique depending on thetype and location of the lesions
Location

Shape ofpericardium

Type of lesion(number of cases)

Anterior leaflet

Triangle

Healed IE (1),Consolidating deg. (1),Congenital MS (1),Consolidating deg. (1),Rheumatic (2)Congenital cleft (1),
Active IE (3)Active IE (1), redo (2),MAC (2), healed IE (1)Consolidating deg. (4),Active IE (2), MAC (1),Consolidating deg. (2)Double triangles

Commissure
Posterior

Wide triangle
Narrow pentagon

Double pentagons

IE: infectious endocarditis; MAC: mitral annular calcification; MS: mitral
stenosis; deg.: degeneration.

Five of 8 patients who underwent Maze procedure were converted
to sinus rhythm. As a result, 4 patient had post-operative atrial ﬁbrillation and received continual anti-coagulation.
During follow-up (1–59 months; mean, 12.7 months), mitral regurgitation was less than moderate in all patients but one. In a
63-year-old female patient who underwent reconstruction ofposterior leaﬂets with double-pentagon pericardium for active
endocarditis, recurrence of severe mitral regurgitation suddenly
occurred 8 months after the operation. Urgent re-do surgery
revealed detachment of a pericardial leg from the anterior papillary muscle. Because the detached pericardium kept its original
shape and had suture knot on it and the papillary muscle was also
intact, disruption of suture material (CV4 Gore-Tex) was suspected.
The mitral valve was successfully re-repaired with re-attachment

ADULT CARDIAC

pericardium was trimmed into a “W” shape joining two triangles
in parallel. Each summit of the double triangle-shaped pericardium was attached to anterior and posterior papillary muscle andthe base to remnant anterior leaﬂet after debridement of sclerotic
rough zone (Fig. 6).
Reconstruction techniques depending on the type and locationof the lesions are summarized in Table 2.
Size of prosthetic ring was decided according to inter-trigon
distance in the usual manner. Undersized annuloplasty was not
performed in any case because sufﬁcient leaﬂet tissue was createdwith the pericardium. In active endocarditis or in type IIIa lesions
accompanying stenosis, prosthetic ring was not used as long as
valve competence was obtained without it.

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Figure 6: For diffuse type IIIa lesion with thickening and fusion of rough zone and chordae (A), diseased chordae were cut and the rough zone was shaved off (B). A “W”pericardium (C) was sutured to both papillary muscle and the remnant edge of the anterior leaﬂet to construct pliable coaptation zone and chordae seamlessly (D).

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T. Ito et al. / European Journal of Cardio-Thoracic Surgeryof the pericardium to the anterior papillary muscle with 4–0 polypropylene sutures and placement of 34 size Cosgrove band
(Edwards Lifescience) that was not originally employed because of
infected mitral annulus. Recurrent infection or hemolysis did notoccur. One embolic event occurred. A 66-year-old female patientwith rheumatic mitral stenosis and regurgitation who underwent
anterior leaﬂet reconstruction and the Maze procedure suffered
minor brain infarction 1 month postoperatively, although she wasin sinus rhythm and under adequate anti-coagulation. She recovered without neurological sequelae. In this patient, post-operative
mitral valve area was 1.21 cm2, and moderate stenosis persisted.

Echocardiographic data

DISCUSSION
When mitral leaﬂet and corresponding chordae became widely
defective, simultaneous reconstruction of leaﬂet and chordae issometimes necessary for successful valve repair. Some surgeons
have used Gore-Tex suture and GTAP in combination to reconstruct extensively destructed valve area because of endocarditis[6, 7]. This method is naturally conceivable because this is a combination of two commonly used techniques. However, adequate
adjustment of the lengths of multiple artiﬁcial chordae seems to
be technically demanding, and multiple knots on the coaptation
zone could disturb valve competence. In addition, using two different foreign materials does not have theoretical advantages interms of durability, because total durability of this complex isdecided by the shorter one of them. Therefore, use of pericardium
also for the chordal part of the mitral valve seems rational whencorresponding leaﬂet needs reconstruction with a pericardium. A
seamless structure may also be advantageous to prevent regurgitation. Because leaﬂet zone and chordal zone of the pericardium
have no apparent distinction, the opposing leaﬂet can contact any
part of the smooth and seamless pericardial leaﬂet–chordae
complex, creating an adequate area of coaptation. Strict adjustment of the length of the pericardium is therefore not necessary.
Historically, seamless reconstruction of chordae and leaﬂet with
one piece of pericardium is not a totally new concept. In 1949,
Templeton et al. reported replacement of posterior tricuspid valve
leaﬂet and chordae with a piece of T-shaped pericardium in adog model [8]. However, report of systematic application ofthis method cannot be found, and its relevance in clinical setting

Conclusion
Defective mitral leaﬂets and chordae were reconstructed seamlessly with a piece of pericardium, and short to mid-term followup results were promising.
Conﬂict of interest: none declared.

REFERENCES[1] Zussa C, Frater RWM, Polesel E, Galloni M, Valfré C. Artiﬁcial mitral valve
chordae: experimental and clinical experience. Ann Thorac Surg 1990;50:
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[2] Chauvaud S, Jebara V, Chachques JC, el Asmar B, Mihaileanu S, Perier P et al.
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[3] Ng CK, Nesser J, Punzengruber C, Pachinger O, Auer J, Franke H et al.
Valvuloplasty with glutaraldehyde-treated autologous pericardium in patientswith complex mitral valve pathology. Ann Thorac Surg 2001;71:78–85.
[4] Shomura Y, Okada Y, Nasu M, Koyama T, Yuzaki M, Murashita T et al. Late
results of mitral valve repair with glutaraldehyde-treated autologous pericardium. Ann Thorac Surg 2013;95:2000–5.
[5] Ito T, Maekawa A, Sawaki S, Fujii G, Hoshino S, Hayashi Y. Reconstruction of
mitral valve chordae and leaﬂets with one piece of autologous pericardium
in extensively destructed mitral valve due to active infective endocarditis.
Gen Thorac Cardiovasc Surg 2013;61:571–3.
[6] Araji OA, Barquero JM, Almendro M, Gutierrez MA, Garcia-Borbolla M,
Velázquez CJ et al. Replacement of A2 and A3 by pericardium due to endocarditis of the anterior leaﬂet of the mitral valve. Ann Thorac Surg 2009;87:653–4.
[7] Shin H, Mori M, Yamabe K, Iwanaga S. Reconstruction of the free margin of
the anterior mitral leaﬂet with autologous pericardium in active infected
endocarditis. Eur J Cardiothorac Surg 2011;39:784–5.
[8] Templeton JY, Gibbon JH. Experimental reconstruction of cardiac valve by
venous and pericardial grafts. Ann Surg 1949;129:161–76.
[9] Kassem S, Al-Faraidy K, Elkady Y, Takriti A. Face-to-face single patch: a
new technique to repair the commissures of the mitral valve. J Thorac
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The last echocardiographic study was performed 9.7 months (range
1–50) postoperatively on average. Mitral valve regurgitation wasnone or mild in all patients except one who needed re-operation.
Mean mitral valve area estimated from pressure half time was 2.84
(range 1.23–6.47, 95% CI 2.37–3.29) cm2. Except for one patient
who had moderate mitral stenosis as mentioned above, all patients
had a mitral valve area larger than 2.1 cm2. Average peak transmitral inﬂow speed was 145 cm/s (range 79–194, 95% CI 131–160).
Maximal and mean pressure gradients were 9.0 mmHg (range 2.5–
15, 95% CI 7.3–10.6) and 2.0 mmHg (range 1–5, 95% CI 1.6–2.4), respectively. Average ejection fraction was 62% (range 48–81, 95% CI
58–67). There was no sign of shrinkage, calciﬁcation or elongationof the pericardial leaﬂet-chordae on echocardiography, and the
pericardium kept pliability. Systolic anterior movement of mitralvalve or accelerated blood ﬂow in left ventricular outﬂow was notobserved throughout repeated studies.

is not yet clear. We have already reported the mid-term results of
our ﬁrst case operated in 2009 [5], and Kassem et al. reported asimilar method for reconstruction of commissural part in 2012 [9].
A possible drawback of this technique is potential inﬂow obstruction by a ﬂat pericardium that does not have a chord structure. One
patient with rheumatic mitral stenosis and regurgitation showed
moderate post-operative mitral stenosis, although regurgitation was
well controlled. Enough mobilization of leaﬂet with thorough debridement of consolidated tissue and commissurotomy seemednecessary before adopting this technique. In the rest of the patients,
no sign of mitral stenosis was shown on postoperative echocardiography, presumably because the replaced area was limited compared with all remnant mitral structures those were pliable enough.
Another drawback is that systolic anterior movement of the anterior
leaﬂet could occur if the reconstructed posterior leaﬂet is too large.
Care should be taken to avoid oversizing of the pericardium orchoosing an annular ring that is too small.
Finally, longevity of this repair depends on that of the pericardium. Our longest follow-up is only 5 years, case number islimited and this is an observational study without control group.
We applied this technique for patients who otherwise had valve
replacement, and therefore, comparison with valve replacement
in larger series and long-term follow-up are necessary to draw deﬁnitive conclusions.
However, we consider that this procedure is relatively easy to
perform and worth trying especially in young patients instead ofimmediate valve replacement.