90 Artificial Chordae Tendinae: Long-Term Changes Salvatore Privitera, M.D., ∗ # Jagdish Butany, M.B.B.S., M.S.,¶# Candice Silversides, M.D.,‡# Richard L. Leask, Ph.D.,¶# and Tirone E. David, M.D.†# ∗ Division of General Surgery, †Division of Cardiac Surgery, ‡Division of Cardiology, ¶Department of Pathology, Toronto General Hospital, University Health Network, #University of Toronto, Toronto, Ontario, Canada ABSTRACT Background and Aim: We present the clinical and pathological findings of a patient who under- went mitral valve repair, with synthetic chordae, for rheumatic disease 13 years earlier. Methods: Echocardio- graphic, pathologic, and histologic examination of a previously repaired mitral valve using artificial chordae tendinae. Results and Conclusions: Extensive fibrosis and thickening, consisting of fibroblasts and mature collagen, in time surrounds the artificial chorda rendering it indistinguishable from its native counterparts on gross examination and even during echocardiography. (J Card Surg 2005;20:90-92) A 59-year-old woman presented in cardiogenic shock caused by severe aortic insufficiency due to biopros- theic aortic valve failure, and mitral stenosis (valve area 1.7 cm 2 ) with moderate regurgitation. Past medical his- tory includes aortic valve replacement and mitral valve repair with synthetic polytetrafluoroethylene (PTFE) chordae for rheumatic heart disease 13 years earlier. During her current hospitalization, she underwent a Bentall procedure (for an ascending aortic aneurysm), in addition to mitral valve replacement (MVR; mechan- ical) and tricuspid valve repair for intractable conges- tive heart failure, and respiratory failure. Intraoperative Address for correspondence: Jagdish Butany, M.B.B.S., M.S., F.R.C.P.C., Toronto General Hospital, 200 Elizabeth Street E4- 322, Toronto, Ontario M5J 3R2. Fax: 416-586-9901; e-mail: jagdish.butany@uhn.on.ca Figure 1. TEE demonstrating an area of nodular thickening (which in retrospect probably represents the proximal end of the previously constructed synthetic chorda [arrow]). LA = left atrium; LV = left ventricle. transesophageal echocardiography (TEE) revealed sig- nificant mitral valve pathology with a thickened region on the ventricular surface of the leaflet (Fig. 1), along with a mildly dilated left ventricle (LV). Postoperative TEE revealed trace tricuspid regurgitation, LV function of 2/4, and normal right ventricular function. After 2 weeks in the intensive care unit, for renal failure and pulmonary edema, she gradually improved and was dis- charged 3 weeks postsurgery. PATHOLOGY The explanted mitral valve showed changes consis- tent with a postinflammatory, likely rheumatic, pro- cess. 1 The valve exhibited fibrosis, commissural fu- sion, and loss of the posterior leaflet scallops. The flow surfaces were smooth and the free margins