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Anchor at 6 O'clock: The Most Secure Coupling of an Annuloplasty Device to the Posterior Ring
Aram K. Smolinsky.
Assuta Medical Center, Tel Aviv, Israel.

OBJECTIVE: The tissue at the posterior rim of the mitral valve is quite flimsy. Simple sutures there quite often feel unsafe. Yet, pledgeting the suture above the leaflet shortens its height. The chordae underneath the leaflet are commonly avoided as "the dark forest thou shall not enter", because of the fear of catching chordae with the sutures. This presentation introduces a safe technique to anchor the annuloplasty device very securely just at the weakest and flimsiest point, just on 6 O'clock point, with a sub-leaflet/sub ring pledget, without interfering with chordae function.
METHODS: The chordae originate from two groups of papillary muscles. Those which originate from the antero- lateral group are attached to the P1 and lateral half of P2 segment. Those which originate from the postero-medial group are attached to the medial half of P2 and P3. Both groups are attached similarly to the anterior leaflet as well. One has to understand that the fields of attachments do not overlap. Thus there is a safe place just at the middle of the rim of the base of P2, free of chordae in the way of the sutures, which allow us safe positioning of a pledget there. To double check there is no such interference one has to note that while sliding the suture, no folds appear on P2, parallel to the rim ( f- in the figure). If they do, then one has to check and free sutures entangled in the pledget.
RESULTS: Our experience with this method exceeds 15 years. It nullified the phenomenon of early or late posterior dehiscence of annuloplasty device. It proved safe and nearly foolproof.
CONCLUSIONS: By employing basic anatomic finding of chordae distribution, a single pledget can be safely positioned below the ring and leaflet, to provide the ultimate secure anchor at 6 O'clock.

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