LEGEND
Fig. 1 – (A) Scanning electron micrograph of external aspect of the endothelial cells of the chorda, obtained from a 23‐year‐old subject (×3170). (B) The elastic fibers, situated underneath the endocardium which was removed (×1720). (C) Interior of a split chorda. Waves of collagen fibrils with similar dimensions (10.7 μm) to the reflections shown in (A) and undulations in (B) (×3260).
From Millington‐Sanders et al.4, with permission.
Fig. 2 – Failure after isolated restrictive mitral annuloplasty for ischemic MR. (A) Transthoracic echocardiography. The AL is short (21 mm) and tethered (red arrow) and is not able to coapt with the PL. There is moderate MR. (B and C) Transoesophageal echocardiography. There is a significant tenting volume, which pushes the mitral valve inside the left ventricle. The AL has reduced mobility and cannot coapt with the PL due to chordal tethering.
MR, mitral regurgitation; AL, anterior leaflet; PL, posterior leaflet.
From Calafiore et al.26, with permission.
Fig. 3 – Primary mitral regurgitation due to PL prolapse. Transoesophageal echocardiography. (A) There is wide PL prolapse, with a short (22 mm) and tethered (red arrow) AL. (B and C) The tethered portion of the AL is in the A3 area (red arrow), seen from the atrial and ventricular side. (D) After surgery, the PL prolapse was corrected, positioning the PL in a vertical position and the AL was augmented with a pericardial patch. Its length increased to 32 mm, with a coaptation length of 10 mm and a mean gradient of 1.5 mmHg.
PL, posterior leaflet; AL, anterior leafelt.
From Calafiore et al.26, with permission.
Fig. 4 – Primary mitral regurgitation due to AL chordal rupture. Transoesophageal echocardiography, 2D and 3D reconstruction. There is a severe mitral regurgitation due to chordal rupture of AL (A). There is a tethering of the AL second-order chordae (arrow, A, B). The correction included use of artificial chordae and second-order chordae cutting. The AL recovered its normal shape (C).
AL, anterior leaflet.
Fig. 5 – Patient with severe dilated cardiomyopathy. (A) Severe mitral regurgitation, with a long AL and tethering of the second‐order chordae (B, red arrow). Three‐dimensional reconstruction of mitral annulus and leaflets in systole. (C) The AL is moved toward the apex and the second‐order chords are tethered (red arrow). (D) After mitral annuloplasty and second‐order cutting through aortotomy, the AL coapts with the posterior leaflet with a coaptation length of 9 mm. Chordal tethering disappeared.
AL, anterior leaflet.
From Calafiore et al.27, with permission.
Fig. 6 – Transthoracic echocardiography. A, Preoperative: AL prolapse and mild second‐order chord tethering (arrow). B, at discharge: no MR, but still a mild second‐order chord tethering (arrow). C, after 6 months: moderate to severe MR due to AL prolapse with increased second‐order chord tethering (arrow). Transoeasphageal 3D reconstruction of the mitral annulus and the mitral valve leaflets. D and E, the AL is attracted toward the apex (arrow). F, second‐order chord tethering, previously mild, became severe (arrow). The attraction toward the apex prevents AL coaptation with the posterior leaflet, pushing the AL tip into the left atrium.
AL, anterior leaflet; MR, mitral regurgitation; 3D, three‐dimensional.
From Calafiore et al36. with permission.