Chordal Replacement for Both Minimally Invasive
and Conventional Mitral Valve Surgery Using
Premeasured Gore-Tex Loops
Ulrich Otto von Oppell, FCS (SA), PhD, and Friedrich W. Mohr, MD, PhD
Herzzentrum, University of Leipzig, Leipzig, Germany, and Department of Cardiothoracic Surgery, University of Cape Town,
Cape Town, South Africa
Part of the complexity of mitral valve chordal replace-
ment with expanded polytetrafluoroethylene (ePTFE) su-
tures is determining the correct replacement chordal
length and knotting the ePTFE suture without sliding the
knot. We describe a technique of measuring the required
chordal length and making a “premeasured” Gore-Tex
chordal loop that abolishes problems of inadvertently
altering chordal length during fixation. This improves
the reproducibility of chordal replacement surgery, and
can be used both via conventional and minimally inva-
(Ann Thorac Surg 2000;70:2166–8)
© 2000 by The Society of Thoracic Surgeons
tures (W. L. Gore & Associates Inc, Flagstaff, AZ) is an
established technique with good long-term results [1, 2].
Various techniques have been described to assist the
surgeon to establish the correct replacement chordal
length, and include tying a loop at the level of the
opposing leaflet , the use of a small tourniquet , or
weaving the suture through the leaflet to the mitral
annulus  and thereafter readjusting the length while
the ventricle is filled under pressure.
Fixing the ePTFE suture at the correct length can also
be difficult as ePTFE sutures are slippery and knots tend
to slide. Techniques of tying ePTFE at the determined
length include bringing each arm of the suture through
the leaflet edge at least twice to create friction [2, 6],
locking each side on the second pass , or using hemo-
static clips  or forceps  to temporarily fix the suture.
We describe a new technique of using “premeasured”
ePTFE loops to replace diseased chordae that enables the
surgeon to more easily determine the required length of
the replacement chordae and abolish problems of inad-
vertently altering chordal length during fixation.
eplacement of diseased mitral valve chordae with
expanded polytetrafluoroethylene (ePTFE) CV5 su-
Chordal replacement with ePTFE sutures is usually done
for prolapse of one or two segments of the anterior leaflet
of the mitral valve. In the majority of patients, an adjacent
normal nonprolapsing segment of either the anterior or
posterior mitral leaflet will provide a reference point for
the correct plane of leaflet apposition.
A new custom-made ePTFE replacement chordae is
made by first determining the required length, by mea-
suring the distance between the correct plane of apposi-
tion on an adjacent nonprolapsing segment and the
respective papillary muscle (Fig 1), using a ruler or
measuring device (03-5409; Geister, Tuttlingen, Germa-
ny), or by transesophageal echocardiography (TEE). One
to three loops, as required, of CV5 ePTFE (Gore-Tex) is
then made to this “premeasured” length, using a vernier
caliper or measuring device as a template (Geister), by
tying a knot over a small pledget (Fig 2). The caliper arms
should be narrow and the pledget relatively flat not to
affect the final measured loop length or, alternatively, the
loop length adjusted by the width of the caliper arms and
pledget. Both ePTFE suture needles are then passed back
through the pledget twice, so that the size of the knot will
not alter the total length and that the pledget will provide
a secure platform, once this ePTFE loop is secured to the
papillary muscle (Fig 2). The needles are then passed
anterior to posterior on the respective papillary muscle
and tied over a second pledget (Fig 3). One now has a
correct “premeasured” ePTFE loop secured to the papil-
A second length of ePTFE is then used to fix the
“premeasured” ePTFE loop to the prolapsing segment of
the mitral leaflet, preferably to the atrial surface with the
knot on the ventricular surface (Fig 3).
This technique of using “premeasured” Gore-Tex loops
as chordal replacements was used in 10 consecutive
patients requiring chordal shortening/replacement as
part of their mitral valve repair between August and
December 1999. All patients had prolapse of the anterior
mitral leaflet, and 40% additionally had prolapse of
posterior mitral leaflet segments. The required Gore-Tex
Accepted for publication May 25, 2000.
Address reprint requests to Dr von Oppell, Department of Cardiothoracic
Surgery, School of Medicine, University of Cape Town, Cape Town, 7925,
South Africa; e-mail: email@example.com.
© 2000 by The Society of Thoracic Surgeons
Published by Elsevier Science Inc
loops varied from 11 to 27 mm, and most commonly, 20-
or 22-mm lengths were used. In no patient did the
Gore-Tex chordae have to be altered after insertion. All
patients additionally had at least a ring annuloplasty
performed as part of the corrective repair. The postrepair
TEE showed no or trivial mitral regurgitation in 90% of
patients, and trivial to mild in 1 patient.
Repair of anterior leaflet prolapse was successfully
managed by the above technique even through a small 4-
to 6-cm minimally invasive right anterior lateral thora-
cotomy with video assistance in 50% of these patients.
Repair of complex mitral valve prolapse usually requires
more than one corrective measure. The standard maneu-
ver of correcting prolapse of the posterior mitral leaflet is
by quadrangular resection of the prolapsing segment
with or without an additional sliding leaflet technique.
Associated annular dilatation is usually corrected by a
ring annuloplasty. Prolapse of the anterior mitral leaflet
has been corrected by triangular leaflet resection, short-
Fig 1. A ruler or measuring device measures the distance (X), be-
tween the leaflet edge and planned site of implantation of the artifi-
cial chordae on the papillary muscle, using a normal valve segment
either adjacent or on the opposite leaflet to the prolapsing segment
as a reference.
Fig 2. A vernier calliper type device with narrow jaws is used as a
template to make a Gore-Tex loop of the correct “premeasured”
length (X). (A) The “premeasured” loop is secured by knotting over
a felt pledget. (B) The two suture arms are then brought twice
through the pledget so that the knot does not add further length to
the “loop” when secured to the papillary muscle.
Fig 3. The “premeasured” Gore-Tex chordal loop is secured to the
papillary muscle as illustrated and tied over a second pledget. The
end of the loop is then secured to the atrial side of the prolapsing
leaflet segment, with a second Gore-Tex suture that is knotted on the
ventricular aspect of the leaflet.
Ann Thorac Surg
HOW TO DO IT
PREMEASURED GORE-TEX CHORDAL LOOPS
VON OPPELL AND MOHR
ening of papillary muscles, chordal shortening, and
transposition or replacement techniques. Since the intro-
duction of ePTFE as a chordal substitute in 1985 , this
has become the preferable technique used by many
surgeons with excellent long-term durability [2, 8]. The
CV 5 Gore-Tex suture retains flexibility similar to a native
chordae and has a breaking strength greater than normal
chordae , and replaces diseased chordae that could
potentially rupture or elongate again in the future. Diffi-
culties of assessing and tying the Gore-Tex chordae at the
correct length have remained a concern for many
The ability to perform complex mitral valve repairs
through minimally invasive video-assisted approaches
has been questioned or deemed to be impossible. As
such, it is important to develop new techniques that
facilitate and improve these endoscopic techniques al-
lowing predictable outcomes even in more complex
This method of making a “premeasured” Gore-Tex
chordal loop assists in making chordal replacement less
subjective. The addition of an annuloplasty further in-
creases the width of leaflet apposition, and therefore, if in
doubt, erring on the side of making the loop slightly
shorter or implanting the loop up to 5 mm further down
the papillary muscle is recommended. Furthermore, if
more than one chordae is required in any segment or
adjacent segment, the “premeasured” Gore-Tex chordae
can be made with additional loops, further simplifying
multiple chordal replacements.
The use of pledgets or knots on the atrial side of a
leaflet or multiple passes through the free edge fre-
quently results in some distortion of the leaflet in the
“appositional zone.” In contrast, securing the loop to the
atrial surface of the leaflet with knotting on the ventri-
cular side as we have described results in a curved
nondistorted free edge of the leaflet similar to a normal
This chordal replacement technique can be used
through both conventional and minimally invasive ap-
proaches to the mitral valve and, in our opinion, simpli-
fies chordal replacement through the latter.
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HOW TO DO IT
PREMEASURED GORE-TEX CHORDAL LOOPS
VON OPPELL AND MOHRAnn Thorac Surg