Prolapse treatment: Gore-Tex versus native chordae (figure 4)
After having resected excess tissue, the new P2 leaflet requires the free edge to be supported, treating thereby the prolapse component either with native chordal transfer or with artificial chordae. Several patients require both. First of all, secondary chordae are often, at the adequate length, when compared to the reference point. The reference point is sometimes not obvious , but rarely and sits at the level of P1 , close to the indentation in between P1 and P2 . Transferring and reattaching them relieves the burden of finding the adequate length which remains an issue when using multiple artificial chordae. We detach the secondary chordae along with some tissue of the ventricular aspect of the leaflet, allowing with a mattress suture of 5/0 monofilament to reattach it at the free edge level. Most often 2 or 3 transferred chordae are sufficient to support the free edge adequately. So far, we never saw such reimplanted chord failing neither at an early stage nor in a later reoperation for another purpose. The number of native or artificial chordae used per patient, in our experience, is rather small when compared to others (mean = 2, range: 1-4; [1] ). The reason that our use of chordae, either artificial or native, is limited, is related to the fact that we address only the prolapse and do not intend to address other issues such as excess tissue at the same time.
In our experience the use of native chordae is always preferable to artificial substitutes, however artificial neo chordae are indicated whenever adequate native chordae are not available. When using artificial chordae we take great care not to cross P2 midline , chordae arising from the anterior papillary muscle remain at the level of P1 and at the lateral aspect of P2 , whereas those arising from the posterior papillary muscle remain at the level of P3 or at the postero medial aspect of P2 . We use routinely an interlocked suture to avoid the slippery effect of the artificial chordae and tie them under the tension of the water test to avoid any over correction This being said, others[5,6] use Gore-Tex chords on a regular basis, whether or not associated with resection techniques, and provide good long-term results [5] .