To the editor: Rupture of mitral chordae tendineae often happens in adults resulting in mitral insufficiency. Here we reported a 6-year-old girl with acute rupture of mitral valve chordae tendineae, which rarely happens in children. In this case, we used a novel method to reconstruct her chordae tendineae.
A 6-year-old girl was found intermittently irritable and palpitated with fever for 4 days. Echocardiography (Figure 1A) showed prolapse of posterior mitral valve and severe regurgitation, with left ventricular enlargement and pulmonary hypertension.
After medication of cardiotonic, diuretic, vasodilator, we did an operation on her in October 2010 with general anesthesia and cardiopulmonary bypass (CPB). In surgery, we found mitral chordae tendineae of posterior valve ruptured, with prolapse of valve, annular enlargement and severe mitral insufficiency (Figure 1B). So firstly, we used 5/0 Prolene line to connect the two ends of ruptured chordae tendineae. Secondly, we sutured corresponding papillary muscle with 5/0 Gore tex line, above which a slip knot was tied. Thirdly, we used the same line to suture the edge of prolapsed valve, then we filled the left ventricle with water. When the mitral valve float up and closed tight without regurgitation, we adjusted the length of artificial chordae tendineae (the 5/0 Gore tex line) and tied knots, which ensured valves closing well after heart rebeat.1 Finally, we used 3/0 Prolene line to contract mitral annular ring.
Intraoperative transesophageal echocardiography (TEE) showed satisfying mitral function without regurgitation. The patient recovered well after surgery while Echo showed increased echogenicity at posterior mitral valve which was well connected with papillary muscles by artificial chordae tendineae. Up to now, 35-month followup show no regurgitation in Doppler scanning which indicates satisfying heart function.
In our case, the patient was only a six-year-old girl who was the youngest domestic patient that had been reported. Moreover, neither did our patient have any historical medical record such as infective endocarditis, rheumatic inflammation nor obvious trauma or violent exercise which indicate that it is an extremely rare case. The ruptured chordae tendineae in our case was a relatively thicker in posterior valve compared with our previous cases indicating that rupture of a single chordae tendineae also leads to prolapse of valve cusp, severe regurgitation and acute heart failure.
Partial or complete rupture of dysplastic chordae tendineae results in mitral regurgitation. Even slight rupture, which can lead to unbalanced stress of mitral valve and an chordae tension increase, has probability to induce new rupture.2 For aged males, mucoid degeneration of valves and chordae tendineae are the main reasons of extension or rupture of chordae tendineaes. Secondary causes include infective, ischemic and rheumatic diseases of mitral valve, thyroid hyperfunction trauma and so on. Oliveira et al3 reported that idiopathic chordae rupture accounts for 74.6% in etiopathogenisis. For secondary cases, it is 25.4% (infective endocarditis for 13.2%, rheumatic valve disease for 8.9% and coronary heart disease for 2.3%). The rupture mainly involves posterior valves which acounts for 54%, anterior valves for 36% and the above both for 10%.
Valvuloplasty keeps autologous heart valves and the accessory parts intact, protects the succession between mitral annulus and papillary muscle, helps improvement and recovery of left ventricular function,4 and prevents the occurrence of complications induced by anticoagulation after valve replacement.5 Child patients should firstly choose valvuloplasty.
1. Castillo JG, Anyanwu AC, El-Eshmawi A, Gordon RE, Adams DH. Early rupture of an expanded polytetrafluoroethylene neochord after complex mitral valve repair: an electron microscopic analysis. J Thorac Cardiovasc Surg 2013; 145: 29-31.
2. Gregori Júnior F, de Godoy MF, Cordeiro CO, Murakami AN, Teruya R. Surgical repair of chordae tendineae rupture after degenerative valvular regurgitation using standardized bovine pericardium. Rev Bras Cir Cardiovasc 2013; 28: 36-46.
3. Oliveira DB, Dawkins KD, Kay PH, Paneth M. Chordal rupture. I: aetiology and natural history. Br Heart J 1983; 50: 312-317.
4. Leroux AA, Moonen ML, Pierard LA, Kolh P, Amory H. Animal models of mitral regurgitation induced by mitral valve chordae tendineae rupture. J Heart Valve Dis 2012; 21: 416-423.
5. Kim MM, Yu JJ, Yun TJ, Kim YH. Mitral regurgitation due to chordae tendineae rupture in an infant with aortic coarctation. Pediatr Cardiol 2012; 33: 162-164.