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\begin{document}

\title{ARTIFICIAL CHORDAE FOR ANTERIOR LEAFLET PROLAPSE: ARE ALL THE ROADS
LEADING TO ROME?}



\author[1]{Antonio Calafiore}%
\author[2]{Antonio Totaro}%
\author[3]{Sotirios Prapas}%
\author[2]{Diego Magnano}%
\author[4]{Stefano Guarracini}%
\author[5]{Massimo Di Marco}%
\author[6]{Michele Di Mauro}%
\affil[1]{John Paul II Foundation for Research and Treatment}%
\affil[2]{Gemelli Molise}%
\affil[3]{Henry Dunant Hospital Center}%
\affil[4]{Private Hospital Pierangeli Srl}%
\affil[5]{Affiliation not available}%
\affil[6]{Maastricht UMC+}%


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  \date{June 17, 2024}


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\textbf{ARTIFICIAL CHORDAE FOR ANTERIOR LEAFLET PROLAPSE: ARE ALL THE
ROADS LEADING TO ROME?}

Antonio Maria Calafiore (a), MD, Antonio Totaro (a), MD, Sotirios Prapas
(b), MD, Diego Magnano, MD (a), Stefano Guarracini (c), PhD, Massimo Di
Marco (d), MD, Michele Di Mauro (c,e), PhD

\begin{enumerate}
\tightlist
\item
  Department of Cardiovascular Diseases, Gemelli Molise, Campobasso,
  Italy
\item
  Division of Cardiac Surgery A, Henry Dunant Hospital, Athens, Greece
\item
  Department of Cardiology, ``Pierangeli'' Hospital, Pescara, Italy
\item
  Department of Cardiology, ``S Spirito'' Hospital, Pescara, Italy
\item
  Cardio-Thoracic Surgery Department, Cardiovascular Research Institute
  Maastricht (CARIM), Maastricht University Medical Centre (MUMC),
  Maastricht, The Netherlands
\end{enumerate}

\emph{Corresponding author:}

Antonio Maria Calafiore, MD

Deaprtment of Cardiovascular Diseases

Largo Agostino Gemelli 1, 86100 Campobasso, Italy

Tel: +39 0874 312403

e-mail: am.calafiore@gmail.com

Use of artificial chordae (AC) to correct the prolapse of anterior
leaflet (AL) due to chordal elongation or rupture, is a method that is
widely recognized as the best solution for a complex pathology. Chordal
transposition was first proposed\textsuperscript{1}, followed by
edge-to-edge\textsuperscript{2}. Over time, the application of
artificial chordae tendinae, proposed by Frater et
al\textsuperscript{3}, found progressively the favor of the scientific
community. However, it was perceived initially as a difficult operation,
as there was not an accepted technique to obtain the correct length of
the new chordae. With time, many strategies were published and results
were so good that recent papers reported that AC use for AL provided
similar results than isolated PL prolapse\textsuperscript{4,5}.

Nasso et al\textsuperscript{6} proposed a new technique to adjust the
correct length of the AC. The Authors have to be congratulated for the
development of a simple strategy, easy to apply. However, a few
considerations have to be done. The papillary muscles are relaxed in
diastole and the distance between their tips and the mitral annulus can
be different, in these conditions, from the distance present in the
working heart\textsuperscript{7}. This different position can cause, as
in strategy proposed by the Authors, the length of the AC to be shorter
than needed. But the problem of the correct length of the artificial
chordae is perhaps even more complicated. We described two techniques,
based on opposite principles, that clinically worked both well. In the
first one\textsuperscript{8} the length of the artificial chordae was
based on the length of the prolapsing chordae minus the distance between
the annular plane and the tip of the anterior leaflet positioned in the
left atrium. In the second one\textsuperscript{9} the artificial chordae
were 5 mm longer than the prolapsing chordae. The concepts of these
techniques are totally opposite, but both were working well. Whereas the
first method is more anatomic, the second one includes a factor that can
be, in our opinion, important. Artificial chordae are not extensible,
whereas native chordae are. Chordae are based on highly crimped collagen
fibers, that, during systole, increase their period (the distance
between the initial and final point of a wave) and, consequently,
increase their length. This happens every single heartbeat. When the
mitral area is covered only by the anterior leaflet, the coaptation
length is long and 2-3 mm more or less are not influent. When both
leaflets move, the length of the artificial chordae can make the
difference between a good and a failed repair.

We are waiting for the long term echocardiographic results of the
technique described by Nasso et al\textsuperscript{6}, that, for its
simplicity, can find huge diffusion. Many techniques are described in
the literature\textsuperscript{10}, all of them supported by good
results, as that one described by the Authors. Perhaps it is necessary
to be more openminded and to accept the concept that, any technique we
use, can work and that mistakes in choosing the correct length can be
forgiven if the coaptation length is long. It seems that all the roads
lead to Rome!

\textbf{REFERENCES}

1. Carpentier A. Cardiac valve surgery--the ''French correction''. J
Thorac Cardiovasc Surg 1983;86:323-37.

2. Maisano F, Torracca L, Oppizzi M, et al. The edge-to-edge technique:
a simplified method to correct mitral insufficiency. Eur J Cardiothorac
Surg 1998;13:240-5; discussion 5-6.

3. Zussa C, Frater RW, Polesel E, Galloni M, Valfre C. Artificial mitral
valve chordae: experimental and clinical experience. Ann Thorac Surg
1990;50:367-73.

4. Iqbal K, Haque IU, Shaikh VF, et al. Mitral Valve Repair for
Anterior/Bi-leaflet Versus Posterior Leaflet Degenerative Mitral Valve
Disease: A Systematic Review and Meta-analysis. Curr Probl Cardiol
2022;47:101355.

5. Brescia AA, Watt TMF, Rosenbloom LM, et al. Anterior versus posterior
leaflet mitral valve repair: A propensity-matched analysis. J Thorac
Cardiovasc Surg 2021;162:1087-96 e3.

6. Nasso G, Di Bari N, Bonifazi G, et al. A new technique to adjust the
length of the artificial chordae during mitral anterior leaflet repair.
J Card Surg 2022, in press.

7. Nonaka M, Marui A, Fukuoka M, et al. Differences in mitral valve-left
ventricle dimensions between a beating heart and during saline injection
test. Eur J Cardiothorac Surg 2008;34:755-9.

8. Calafiore AM. Choice of artificial chordae length according to
echocardiographic criteria. Ann Thorac Surg 2006;81:375-7.

9. Calafiore AM, Scandura S, Iaco AL, et al. A simple method to obtain
the correct length of the artificial chordae in complex chordal
replacement. J Card Surg 2008;23:204-6.

10. Di Mauro M , Bonalumi G , Giambuzzi I , Messi P , Cargoni M ,
Paparella D , Lorusso R , and Calafiore AM. Mitral Valve Repair with
Artificial Chords: Tips \& Tricks. J Card Surg 2022 print ahead (doi:
https://doi.org/10.22541/au.165700807.78180638/v1)

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