Double Accessory Left Atrial
Chordae Tendineae Resulting in
Mitral Regurgitation
Tae Sik Kim, MD, Kwang Ree Cho, MD, and
Dal Soo Lim, MD
Departments of Thoracic and Cardiovascular Surgery, and
Cardiology, Sejong General Hospital, Sejong Heart Institute,
Bucheon City, Republic of Korea
The presence of accessory left atrial chordae tendineae
inserting into the mitral valve leaflet is extremely rare.
Two long and thin accessory chordae tendineae, one
arising from the left atrial dome and the other from the
inferior interatrial septum, were incidentally identified
during corrective surgery for severe mitral regurgitation
from A3 prolase. Triangular resection of the A3 portion of
the anterior mitral valve leaflet including the double
accessory chordae tendineae and primary repair followed
by posterior ring annuloplasty was successfully
performed.
(Ann Thorac Surg 2014;97:e5–6)
Ó 2014 by The Society of Thoracic Surgeons
A
ccessory left atrial chordae tendineae could be a
cause of mitral valve regurgitation, as reported in a
previous study with autopsy cases [1].
A 67-year-old man presented with progressive shortness
of breath and exertional dyspnea. He had no past medical
history of infective endocarditis. Transthoracic echocardiography revealed severe mitral valve regurgitation with
A3 prolapse in the anterior mitral valve leaflet (AMVL)
from chordal rupture. His left ventricular systolic function
was preserved, with 60 mm of end-diastolic dimension.
His coronary angiography was normal.
Intraoperative
transesophageal
echocardiography
showed a fibrous bandlike structure in the left atrium,
extending from the AMVL (Fig 1).
After setting up the standard cardiopulmonary bypass,
the left atrium was accessed though the interatrial groove.
Two white, long, slender chordae tendineae inserting into
the free edge of the A3 portion of the AMVL were identified. One chorda originated from the left atrial dome
and the other originated from the inferior interatrial
septum near the fossa ovalis (Fig 2). The A3 portion of the
AMVL was thickened with redundant tissue from longlasting mitral regurgitation. There were no definitive
ruptured chordae tendineae from the left ventricular
papillary muscles. The prolapse of the A3 portion of the
AMVL was confirmed with a saline injection test for
leakage. Mitral valve repair was performed with
Fig 1. Intraoperative transesophageal echocardiography showing the
thin aberrant chordae tendineae (white arrow) extending from the
anterior mitral valve leaflet to the dome of the left atrium.
triangular resection of the A3 portion of the AMVL
including the accessory chordae tendineae, followed by
double-layered primary repair using 5-0 PROLENE
polypropylene (Ethicon, Somerville, NJ) continuous suture. Posterolateral commissuroplasty was added to prevent mitral regurgitation from commissural distortion.
Posterior mitral ring annuloplasty was reinforced using a
28-mm sized Colvin–Galloway Future Annuloplasty
Mitral Band (Medtronic, Inc, Minneapolis, MN). The
pathologic examination of the leaflet tissue including
Accepted for publication Aug 21, 2013.
Address correspondence to Dr Cho, Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Sejong Heart Institute, 28,
489-gil, Hohyeon-ro, Sosa-gu, Bucheon-si, Gyeonggi-do, 422-711, Republic of Korea; e-mail: ckrym@hanmail.net.
Ó 2014 by The Society of Thoracic Surgeons
Published by Elsevier Inc
Fig 2. Operative view showing the V-shaped aberrant mitral valve
chordae tendineae connecting the free edge of the anterior mitral valve
leaflet with the left atrial wall (dome and interatrial septum).
0003-4975/$36.00
http://dx.doi.org/10.1016/j.athoracsur.2013.08.049
e6
CASE REPORT
KIM ET AL
DOUBLE ACCESSORY CHORDAE TENDINEAE
Ann Thorac Surg
2014;97:e5–6
reported. Similar to previous reports, double accessory
chordae tendineae in our case also produced significant
mitral regurgitation from stretching of the mitral valve
leaflet. These two long chordae tendineae might hold the
free edge of the A3 portion of the AMVL in a scallop
shape during the diastolic phase, permitting the atrial
kicking motion to contribute to the development of mitral
regurgitation. As a result of mitral regurgitation, the free
margin of the A3 portion of the AMVL might be thickened as time goes by. We present a rare double accessory
left atrial chordae tendineae resulting in mitral
regurgitation.
Fig 3. Pathologic specimen showing the A3 portion of the anterior
mitral valve leaflet with two white and long accessory chordae
tendineae.
accessory chordae tendineae demonstrated the degenerative change of the mitral valve (Fig 3). The patient was
discharged on the seventh postoperative day without
any complication. Echocardiographic follow-up at 3
months demonstrated no residual mitral regurgitation.
Comment
There have been several reports of a single accessory left
atrial chorda tendinea of the AMVL [2–5]. To the best of
our knowledge, a double accessory chordae tendineae
resulting in mitral valve regurgitation has never been
References
1. Kuboki K, Ohkawa S, Maeda S, et al. Clinicopathologic study
of mitral regurgitation due to abnormal chordate tendineae [in
Japanese]. J Cardiol 1996;27:187–95.
2. Sherif HM, Banbury MK. Accessory left atrial chordae: an
unusual cause of mitral valve insufficiency. J Thorac Cardiovasc Surg 2010;139:e3–4.
3. Taglieri C, Botta L, Roghi A, Alberti A. Unusual insertion of a
mitral chord causing severe valve regurgitation. Eur J Cardiothorac Surg 2010;38:387.
4. Aksu HU, Uslu N, Aslan M, Gul M, Aksu H. Mitral insufficiency caused by left atrial chordae. Echocardiography
2012;29:E87–90.
5. Ivanova V, Anreddy S, Bailey S, Schuett A, HughesDoichev R. A case of severe mitral regurgitation due to an
unusually long aberrant chorda tendinea straddling the
anterior mitral leaflet. Echocardiography 2012;29:E156–8.