How should a torn chordae tendineae be managed?

Management of Torn Chordae Tendineae

Prompt mitral valve surgery is the definitive treatment for symptomatic patients with acute severe mitral regurgitation (MR) due to ruptured chordae tendineae, with mitral valve repair being the preferred surgical approach over replacement. 1

Acute Presentation and Initial Stabilization

When a patient presents with acute severe MR from chordal rupture, immediate hemodynamic stabilization is critical before definitive surgery:

Medical Temporizing Measures

• Vasodilator therapy (sodium nitroprusside or nicardipine) reduces aortic impedance, thereby decreasing regurgitant flow while increasing forward cardiac output, though systemic hypotension often limits use 1
• Intra-aortic balloon counterpulsation lowers systolic aortic pressure to decrease LV afterload and increase forward output while supporting systemic circulation—this is almost always a bridge to surgery, not definitive therapy 1
• Percutaneous circulatory assist devices may stabilize patients with acute hemodynamic compromise before operation 1

Diagnostic Evaluation

• Transthoracic echocardiography (TTE) should be performed immediately in any patient with suspected acute MR and hyperdynamic LV function to assess severity and mechanism 1
• Transesophageal echocardiography (TEE) should be performed as soon as possible when TTE shows severe MR with no other cause for clinical deterioration, specifically looking for papillary muscle or chordal rupture 1

Surgical Intervention: The Definitive Treatment

Timing and Indications

• Urgent surgery is indicated even for partial papillary muscle rupture with hemodynamic stability, because this can suddenly progress to complete rupture 1
• Complete papillary muscle rupture causes torrential MR that is poorly tolerated and requires emergency surgery 1
• Ruptured chordae tendineae cases are usually amenable to mitral repair rather than replacement 1

Surgical Technique: Repair Over Replacement

Mitral valve repair should be the first choice because it preserves left ventricular function and avoids lifelong anticoagulation therapy 2

Reliable repair techniques include:

• Quadrangular resection and suture for posterior leaflet prolapse 2
• Annuloplasty to stabilize the repair and reduce annular dilation 2
• Artificial chordae using expanded polytetrafluoroethylene (Gore-Tex) sutures—5CV for anterior leaflet and 6CV for posterior leaflet and commissural areas 3
• Chordal reattachment or transposition when ruptured mitral chordae can be salvaged 1
• Leaflet resection for severely damaged tissue 1

Outcomes of Repair

• Repair is reliable even in patients with multiple lesions, with surgical results comparable to single-lesion cases 2
• At 10-year follow-up, freedom from MR >2+ is 88% and freedom from reoperation is 92% when artificial chordae are used 3
• Failures of repair are unrelated to the artificial chordae themselves 3

Chronic Primary MR from Chordal Rupture

For patients who present with chronic rather than acute MR from chordal rupture:

Baseline Evaluation

• TTE is indicated to assess LV size and function, RV function, left atrial size, pulmonary artery pressure, and mechanism and severity of primary MR 1
• A "normal" LVEF in MR is approximately 70% due to favorable loading conditions; LV dysfunction is inferred when LVEF declines toward 60% or when the left ventricle cannot contract to <40 mm diameter at end-systole 1
• Pulmonary artery systolic pressure approaching 50 mm Hg worsens prognosis 1

Surgical Timing in Chronic Cases

Surgery should be considered when:

• Symptoms develop (dyspnea, heart failure) 1
• LVEF declines toward 60% 1
• LV end-systolic diameter ≥40 mm 1
• Pulmonary hypertension develops (PA systolic pressure ≥50 mm Hg) 1

Special Considerations in Infective Endocarditis

When chordal rupture occurs in the context of infective endocarditis:

• Surgery is indicated for persistent worsening valvular insufficiency and ventricular dysfunction, or one or more embolic events during the first 2 weeks of antimicrobial therapy 1
• Vegetectomy (excision of discrete vegetations along with underlying leaflet tissue) followed by patch repair may be feasible in selected cases, particularly for mitral valve IE 1
• The incidence of reinfection of newly implanted valves is only 2-3%, far less than the mortality rate for uncontrolled heart failure—therefore, delaying surgery to extend preoperative antibiotics risks permanent ventricular dysfunction and should be discouraged 1

Common Pitfalls to Avoid

• Do not delay surgery in acute severe MR to "optimize" medical therapy—this risks permanent ventricular dysfunction and death 1
• Do not assume valve replacement is necessary—repair is feasible in most chordal rupture cases and has superior outcomes 2, 3
• Do not underestimate partial papillary muscle rupture—it requires urgent surgery due to risk of sudden progression to complete rupture 1
• Recognize that posterior marginal chordae are inherently weaker (35% thinner, fail at 43% less load) and rupture more frequently than anterior or basal chordae 4