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.