Differences in mitral valve-left ventricle dimensions between a beating heart and during saline injection test.

OBJECTIVE: Saline injection test performed during mitral valvuloplasty is popular; however, discrepancies are sometimes noticed between the 'naked eye' findings of regurgitation during the saline injection test and the echocardiographic findings after surgery. These discrepancies may arise due to the geometric differences in the mitral valve-left ventricular complex between the saline-injected left ventricle (LV) and the beating LV. Therefore, to elucidate these differences, we compared the three-dimensional geometries between these two conditions. METHODS: Sonomicrometry crystal markers were implanted in seven mongrel dogs at the mitral annulus, edge of the mitral leaflets between scallops, tips of papillary muscles, and LV apex under cardiopulmonary bypass. Geometric data of the LV were acquired during the saline injection test and in the beating heart. RESULTS: The commissural width was greater and the annular height was lesser during the saline injection test than in the beating heart (20.5+/-5.1mm vs 17.2+/-2.2mm, p<0.01 and 5.5+/-1.8mm vs 7.3+/-2.2mm, p<0.05, respectively), indicating that the saddle-shaped mitral annulus was flattened during the test. Additionally, the middle scallop width and the distance between the papillary tips were greater during the test (14.0+/-4.2mm vs 11.3+/-3.6mm, p<0.05 and 22.9+/-5.9mm vs 11.6+/-5.0mm, p<0.01, respectively), implying that the middle scallop was stretched by the traction of the chordae. The distance between the papillary tips and the mitral annular plane remained constant in both the conditions (19.3+/-2.6mm vs 18.6+/-6.2mm, not significant). CONCLUSIONS: The saline injection test could aid in determining the length of the reconstructed chordae. However, the test may provide inaccurate data of the mitral-LV dimensions due to the flattened annulus and overstretched leaflets.

Chordal "translocation" for functional mitral regurgitation with severe valve tenting: an effort to preserve left ventricular structure and function.

OBJECTIVE: The chordal cutting method is performed for mitral valve tenting in functional mitral regurgitation, such as ischemic mitral regurgitation. However, the method may interfere with the mitral valvular-ventricular continuity. To maintain the continuity and the natural force direction between the papillary muscles and the mitral annulus after chordal cutting, we developed "translocation" of the secondary chordae tendineae. METHODS: Six mongrel dogs had sonomicrometry crystal markers implanted in the left ventricle, mitral annulus, and papillary muscle tips. After the secondary chordae tendineae of the anterior mitral leaflet from each papillary muscle were resected, each papillary muscle tip was connected to the mid-anterior mitral annulus with 4-0 polypropylene sutures, and then the sutures were taken out of the left atrium to control the chordal tension. The condition under which the artificial chordae were released was defined as "redundant." The chordal tension of 15 g of weight was defined as "taut," whereas the tension for 2-mm chordal shortening after "taut" was defined as "tight." After the dogs were weaned from cardiopulmonary bypass, hemodynamic and 3-dimensional data were acquired under the condition of "redundant," and then "taut," "tight," and "redundant." RESULTS: End-systolic elastance increased from 1.81 +/- 0.24 mm Hg/mL to 2.69 +/- 0.89 mm Hg/mL (P = .015) between "redundant" and "taut," and this was maintained between "taut" and "tight." However, preload recruitable stroke work increased from 41.3 +/- 12.0 mm Hg to 58.1 +/- 19.7 mm Hg (P = .005) between "redundant" and "taut," and was reduced to 51.7 +/- 22.9 mm Hg (P = .037) between "taut" and "tight." CONCLUSION: "Translocation" of the secondary chordae tendineae after chordal cutting improved left ventricular systolic function compared with simple chordal cutting.

Traumatic pericardial rupture involved with complication by blunt chest trauma.

A 65-year-old man who had sustained a blunt chest trauma in a traffic accident demonstrated a mass in the left hilum by chest radiography. Emergency surgery demonstrated a rupture of the left-side pericardium with herniation of the heart into the left pleural cavity along with a right ventricular rupture. The tear in the right ventricle was sutured using 4-0 polypropylene with felt and the pericardial rupture was repaired with an expanded polytetrafluoroethylene sheet. A 31-year-old man who had been crushed against a tree while skiing 5 years and 6 months earlier was diagnosed as having severe tricuspid valve regurgitation and tricuspid valve replacement was performed. Large left pericardial defect was found and repaired with an equine pericardial patch. In both cases, a bridging of phrenic nerve was found in the pericardial defect that was regarded as a traumatic rupture.