This technique was first proposed by Messas, et al, and popularized by Borger, et al. [5, 6] Secondary chords attach to the basal and mid body of the mitral leaflet and typically restrict leaflet motion in chronic functional ischemic mitral regurgitation, particularly of the anterior leaflet, leading to the so called “seagull wing”. This bend in the anterior leaflet represents abnormal tethering by the basal chordae. Experimentally, cutting secondary chords relieved leaflet tethering and improved leaflet coaptation, reducing mitral regurgitation [5]. There is, however, some concern that cutting secondary chords may affect local haemodynamics, shear stress distribution, and left ventricular function [7, 8].

Borger, et al, describe cutting all secondary chords arising from the papillary muscle causing leaflet restriction, usually the posteromedial papillary muscle [6]. The chords are cut at their insertion to the anterior and posterior leaflets. An undersized annuloplasty ring is then implanted.

Follow-up echocardiography in Borger’s series revealed trivial or mild mitral regurgitation in 97 % of patients at 2 years. Long term results are awaited [6].

The edge-to-edge leaflet repair, first described by Alfieri, is used in many mitral valve lesions [9]. A suture is used to join the edges of the anterior and posterior leaflets creating a double orifice mitral valve. A mitral annuloplasty ring is implanted to improve long term durability. Recently, Bhudia, et al, reported that at 2 years, 24 % of patients who had undergone this procedure for functional ischemic mitral regurgitation had developed recurrent moderate-severe mitral regurgitation, and 23 % had moderate mitral regurgitation [10]. The authors recommended against the use of this technique in functional ischemic mitral regurgitation.