Morphology, microstructure and biomechanical properties of tendinous cords of heart – a systematic review of cadaveric studies

Abstract

Objectives: The rupture of tendinous cords (TC), affects the proper functioning of the atrioventricular (AV) valves and requires replacement by the prosthetic chordae. The morphology and ultrastructure of TC are vital to design prosthesis and to prevent the treatment failure. Methods: The databases like PubMed, Google Scholar, Science direct and Scopus were searched till June 2024. The keywords used were TC, chordae, TC anatomy, TC morphology, TC morphometry, TC histology, TC ultrastructure, TC blood supply, TC development, TC embryology, TC biomechanical properties, strut chordae, false chordae, basal TC, and subvalvular apparatus. Out of 2545 articles collected, 43 were finally included. Results: Majority of human studies were on the hearts from formalin-embalmed cadavers. There were more number of studies (28 studies) examining TC of left ventricle, than that of the right (8 studies). The number of chordae from anterior papillary muscle were greater in number than that from the posterior muscle in both the ventricles. In the left ventricle, anterior papillary muscle chordae were longer and broader. Maximum chordae inserted on the rough zone of mitral and tricuspid valves. Human chordae were structurally more rigid than the animal chordae. The arrangement of collagen bundles inside TC was orthogonal in human, but random and irregular in animal tissues. Conclusion: This review outlines the details on the morphology, ultrastructure, and biomechanical properties of TC which would aid formulate appropriate reparative procedures to prevent postoperative complications and recurrence.

Keywords

• chordae tendinae
• heart ventricles
• morphology
• papillary muscle
• review
• tendinous cords

References

1. Tunstall R (ed). Thorax. In: Standring S (ed). Gray’s anatomy - the anatomical basis of clinical practice. 42nd ed. Edinburgh (Scotland): Elsevier Churchill Livingstone; 2020. p. 1075–84.
2. Gunnal SA, Wabale RN, Farooqui MS. Morphological study of chordae tendinae in human cadaveric hearts. Heart Views 2015;16:1–12.
3. Millington-Sanders C, Meir A, Lawrence L, Stolinski C. Structure of chordae tendineae in the left ventricle of the human heart. J Anat 1998;192:573–81.
4. Chaudhary K, Roy M, Shinde M. Cadaveric study on papillary muscles of human tricuspid valve. International Journal of Anatomy 2017;6:71–4.
5. Degandt AA, Weber PA, Saber HA, Duran CMG. Mitral valve basal chordae: comparative anatomy and terminology. Ann Thorac Surg 2007;84:1250–5.
6. Gusukuma LW, Prates JC, Smith RL. Chordae tendineae architecture in the papillary muscle insertion. Int J Morphol 2004;22:267–72.
7. Wang K, McGlinn EP, Chung KC. A biomechanical and evolutionary perspective on the function of the lumbrical muscle. J Hand Surg Am 2014;39:149–55.
8. Ross CJ, Zheng J, Ma L, Wu Y, Lee CH. Mechanics and microstructure of the atrioventricular heart valve chordae tendineae: a review. Bioengineering (Basel) 2020;7:E25.

9. Aulakh K K, Aneja P S, Garg S. A study of morphology of the chordae tendineae of the left ventricle in human cadaveric hearts of North West Indian population. National Journal of Clinical Anatomy 2020;9:115–20.
10. Kavitha S, Anand A, Manjunath KY. Morphometric analysis of chorda tendinae of mitral valve in human hearts. International Journal of Current Research and Review 2014;6:1–6.
11. Kujur B, Thakur N, Prasad R. Morphological study of chordae tendineae of right ventricle in embalmed human cadavers. IOSR Journal of Dental and Medical Sciences 2016;15:72–6.
12. Mundra P. Morphology of chordae tendinae of mitral valve in adult Indian cadavers. Journal of Advanced Medical and Dental Sciences Research 2018;6:66–70.
13. Chen S, Sari CR, Gao H, Lei Y, Segers P, De Beule M, Wang G, Ma X. Mechanical and morphometric study of mitral valve chordae tendineae and related papillary muscle. J Mech Behav Biomed Mater 2020;111:104011.
14. Kumar BS, Selvi PG, Rekha G, Rajitha V, Anitha MR. Morphometry of chordae tendineae of mitral valves and annulopapillary distance for mitral allografts. International Journal of Medical Science and Public Health 2013;2:967–71.
15. Lam JH, Ranganathan N, Wigle ED, Silver MD. Morphology of the human mitral valve. I. Chordae tendineae: a new classification. Circulation 1970;41:449–58.
16. Rusted IE, Scheifley CH, Edwards JE. Studies of the mitral valve. I. Anatomic features of the normal mitral valve and associated structures. Circulation 1952;6:825–31.
17. Ożóg AK, Hołda MK, Bolechała F, Siudak Z, Sorysz D, Dudek D, Klimek-Piotrowska W. Anatomy of the mitral subvalvular apparatus. J Thorac Cardiovasc Surg 2018;155:2002–10.
18. Silver MD, Lam JHC, Ranganathan N, Wigle ED. Morphology of the human tricuspid valve. Circulation 1971;43:333–48.
19. Lim KO, Boughner DR. Mechanical properties of human mitral valve chordae tendineae: variation with size and strain rate. Can J Physiol Pharmacol 1975;53:330–9.
20. Lim KO, Boughner DR. Morphology and relationship to extensibility curves of human mitral valve chordae tendineae. Circ Res 1976;39:580–5.
21. Morse DE, Hamlett WC, Noble Jr. CW. Morphogenesis of chordae tendineae. I: scanning electron microscopy. Anat Rec 1984;210:629–38.
22. Sato I, Shimada K. Quantitative analysis of tenascin in chordae tendineae of human left ventricular papillary muscle with aging. Ann Anat 2001;183:443–8.
23. Victor S, Nayak VM. Variations in the papillary muscles of the normal mitral valve and their surgical relevance. J Card Surg 1995;10:597–607.
24. Van Mieghem NM, Piazza N, Anderson RH, Tzikas A, Nieman K, De Laat LE, McGhie JS, Geleijnse ML, Feldman T, Serruys PW, de Jaegere PP. Anatomy of the mitral valvular complex and its implications for transcatheter interventions for mitral regurgitation. J Am Coll Cardiol 2010;56:617–26.
25. David TE. Artificial chordae. Semin Thorac Cardiovasc Surg 2004;16:161–8.
26. Lincoln J, Alfieri CM, Yutzey KE. Development of heart valve leaflets and supporting apparatus in chicken and mouse embryos. Dev Dyn 2004;230:239–50.
27. Nakagawa Y, Furusho H, Miwa K, Yasuda T. A case of premature ventricular contraction originating at the aortomitral fibrous continuity and exiting from the anterolateral papillary muscle due to muscular chordae tendineae. HeartRhythm Case Rep 2023;9:38–42.
28. Layman TE, Edwards JE. Anomalous mitral arcade. A type of congenital mitral insufficiency. Circulation 1967;35:389–95.
29. Skwarek M, Hreczecha J, Dudziak M, Jerzemowski J, Grzybiak M. The morphology and distribution of the tendinous chords and their relation to the papillary muscles in the tricuspid valve of the human heart. Folia Morphol (Warsz) 2007;66:314–22.
30. Aktas EO, Govsa F, Kocak A, Boydak B, Yavuz IC. Variations in the papillary muscles of normal tricuspid valve and their clinical relevance in medicolegal autopsies. Saudi Med J 2004;25:1176–85.
31. Restivo A, Smith A, Wilkinson JL, Anderson RH. The medial papillary muscle complex and its related septomarginal trabeculation. A normal anatomical study on human hearts. J Anat 1989;163:231–42.
32. Wenink ACG. The medial papillary complex. Br Heart J 1977;39:1012–8.
33. Ozan H, Kocabiyik N, Demirel B, Yalcin B, Comert A. Pattern of connection between papillary muscle and chordae tendineae of left ventricle. Gulhane Medical Journal 2012;54:275.
34. Saha A, Roy S. Papillary muscles of left ventricle-morphological variations and its clinical relevance. Indian Heart J 2018;70:894–900.
35. Mestres CA, Bernal JM. Mitral valve repair: the chordae tendineae. J Tehran Heart Cent 2012;7:92–9.
36. Vendramin I, Milano AD, Pucci A, Lechiancole A, Sponga S, Bortolotti U, Livi U. Artificial chordae for mitral valve repair. J Card Surg 2022;37:3722–8.
37. Obadia JF, Casali C, Chassignolle JF, Janier M. Mitral subvalvular apparatus: different functions of primary and secondary chordae. Circulation 1997;96:3124–8.
38. Kosiński A, Grzybiak M, Dubaniewicz A, Kędziora K, Makarewicz W, Kozłowski D. False chordae tendineae in right ventricle of adult human hearts – morphological aspects. Arch Med Sci 2012;8:834–40.
39. Sakai T, Okita Y, Ueda Y, Tahata T, Ogino H, Matsuyama K, Miki S. Distance between mitral anulus and papillary muscles: anatomic study in normal human hearts. J Thorac Cardiovasc Surg 1999;118:636–41.
40. Kavitha S, Selvam V, Anand A, Manjunath KY. Morphometric analysis of annulo-papillary distances in left ventricle of human hearts. International Journal of Health Sciences and Research 2014;4:25–30.
41. Vidal Bde C, Mello ML. Structural organization of collagen fibers in chordae tendineae as assessed by optical anisotropic properties and Fast Fourier transform. J Struct Biol 2009;167:166–75.
42. Parto P, Tadjalli M, Ghazi SR. Light and ultrastructural study of the chordae tendineae in the heart of the ostrich (Struthio camelus). World Journal of Medical Sciences 2009;4:93–7.
43. Gupta S, Pathak A, Farooqui M, Prakash A. Histochemical study on the ventricles of heart in prenatal goat (Capra hircus). Indian Journal of Veterinary Anatomy 2020;32:32–4.
44. Ritchie J, Warnock JN, Yoganathan AP. Structural characterization of the chordae tendineae in native porcine mitral valves. Ann Thorac Surg 2005;80:189–97.
45. Tidball JG, Andolina KL. Structure and protein composition of sites of papillary muscle attachment to chordae tendineae in avian hearts. Cell Tissue Res 1992;270:527–33.
46. De Biasi S, Vitellaro-Zuccarello L, Blum I. Histochemical and ultrastructural study on the innervation of human and porcine atrio-ventricular valves. Anat Embryol (Berl) 1984;169:159–65.
47. Duran CM, Gunning AJ. The vascularization of the heart valves: a comparative study. Cardiovasc Res 1968;2:290–6.
48. Eliskova M, Oldrich E. How lymph is drained away from the human papillary muscle: anatomical conditions. Cardiolology 2008;81:371–7.
49. Ichikawa S, Uchino S, Hirata Y. Lymphatics of the cardiac chordae tendineae with particular consideration of their origin. Lymphology 1989;22:123–31.
50. Williams TH, Folan JC, Jew JY, Wang YF. Variations in atrioventricular valve innervation in four species of mammals. Am J Anat 1990;187:193–200.
51. Liao J, Vesely I. A structural basis for the size-related mechanical properties of mitral valve chordae tendineae. J Biomech 2003;36:1125–33.
52. Zuo K, Pham T, Li K, Martin C, He Z, Sun W. Characterization of biomechanical properties of aged human and ovine mitral valve chordae tendineae. J Mech Behav Biomed Mater 2016;62:607–18.
53. Pokutta-Paskaleva A, Sulejmani F, DelRocini M, Sun W. Comparative mechanical, morphological, and microstructural characterization of porcine mitral and tricuspid leaflets and chordae tendineae. Acta Biomater 2019;85:241–52.