Papillary Muscle Approximation for Ischemic Mitral Valve Regurgitation

Abstract In patients with ischemic left ventricular dysfunction and functional mitral regurgitation, the surgical treatment of the mitral insufficiency remains a challenging issue. Several procedures were described to restore a more normal alignment between the mitral annulus and the laterally displaced papillary muscles. We report a new approach to relocate the displaced papillary toward the mitral annulus and to reduce tethering. This procedure is believed to be technically easy and beneficial in terms of mitral repair.     

New surgical approach to reduce tethering in ischemic mitral regurgitation by relocation of separate heads of the posterior papillary muscle

The surgical treatment of chronic ischemic mitral regurgitation remains a challenging issue. Several procedures have been developed to correct displacement of the papillary-ventricular complex and to reduce tethering-induced regurgitation. We report a geometric approach to relocate the laterally displaced posterior papillary muscle towards the mitral annulus. This procedure is believed to be technically easy and useful, especially in cases in which the displaced posterior papillary muscle contributes to tethering-induced regurgitation.     

Annular or subvalvular approach to chronic ischemic mitral regurgitation?

OBJECTIVE: We sought to investigate whether annular or subvalvular interventions corrected chronic ischemic mitral regurgitation differently. METHODS: Sheep underwent placement of markers on the left ventricle, mitral annulus, papillary muscles (anterior and posterior), and both leaflet edges. A transannular suture (septal-lateral annular cinching) was anchored to the midseptal mitral annulus and externalized through the midlateral mitral annulus. Another suture (papillary muscle repositioning) from the posterior papillary muscle was passed through the mitral annulus near the posterior commissure and externalized. After 7 days, 3-dimensional marker data were obtained before inducing posterolateral myocardial infarction. After 7 weeks, animals in whom chronic ischemic mitral regurgitation developed (n = 10) were restudied before and after pulling septal-lateral annular cinching or papillary muscle repositioning sutures. End-systolic septal-lateral annular diameter and 3-dimensional displacement of the papillary muscles and leaflet edges were computed. RESULTS: Infarction increased mitral regurgitation (0.6 +/- 0.5 to 2.3 +/- 1.1); mitral annular septal-lateral dilation (4 +/- 1 mm); posterior papillary muscle displacement laterally (4 +/- 2 mm), posteriorly (9 +/- 3 mm), and toward the annulus (2 +/- 1 mm); posterior mitral leaflet apical tethering (3 +/- 1 mm); and interleaflet separation (+3 +/- 1 mm, P < .05 baseline vs chronic ischemic mitral regurgitation). Septal-lateral annular cinching reduced septal-lateral dimension (-9 +/- 3 mm), corrected lateral posterior papillary muscle displacement (4 +/- 1 mm) and septal-lateral interleaflet separation (-4 +/- 2 mm), and decreased mitral regurgitation (0.6 +/- 0.6, P < .05 septal-lateral annular cinching vs chronic ischemic mitral regurgitation) without affecting posterior leaflet restriction. Papillary muscle repositioning reduced septal-lateral diameter (-4 +/- 1 mm), moved the anterior papillary muscle closer to the annulus (2 +/- 1 mm), and relieved posterior leaflet apical restriction (2 +/- 1 mm, P < .05 papillary muscle repositioning vs chronic ischemic mitral regurgitation) but did not change lateral posterior papillary muscle displacement or decrease mitral regurgitation (1.9 +/- 1.2). CONCLUSIONS: Septal-lateral annular cinching moved the lateral annulus and the posterior papillary muscle closer to the septum and reduced mitral regurgitation unlike posterior papillary muscle repositioning, and thus the key mitral subvalvular repair component must correct posterior papillary muscle lateral displacement.     

Valve repair in mitral regurgitation complicated by severe annulus calcification

BACKGROUND: Valvuloplasty has significant advantages over valve replacement for mitral regurgitation, but the presence of severe calcification of the mitral valve apparatus has been thought to preclude successful valve reconstruction in general. The purpose of this report is to assess the results of valvuloplasty in patients with severe mitral regurgitation having extensive calcification extending from the mitral annulus to underlying myocardium and parts of the papillary muscles. METHODS: Thirty-seven adult patients with severe mitral regurgitation and calcification were operated on between April 1990 and January 1998. Twenty-six patients had degenerative disease, 4 had acute bacterial endocarditis, 6 had postrheumatic fever, and 1 patient had Marfan's disease. The valve repair comprised of en bloc decalcification with extensive leaflet debridement and reconstruction of the annulus. Autologous pericardium was used in patch-extended endocardial annuloplasty or leaflet repair. Valve competence was retained after correction of regurgitation by sliding atrioplasty, rotation paracommissural sliding plasty, cusp remodeling, or chordal repair. All patients required a prosthetic annuloplasty. RESULTS: Follow-up echocardiography at 47 months (range, 3 to 92 months) showed no or only trivial mitral regurgitation in 33 patients; 3 had grade I-II mitral regurgitation and 1 required valve replacement after 3 months. Freedom of reoperation at 1 and 5 years was 94.6%. At last examination, 33 patients were in New York Heart Association functional class I and 3 in class I-II; there has been no mortality and no thromboembolic events. CONCLUSIONS: Valvuloplasty can be safely and successfully carried out in patients suffering from regurgitation associated with severe calcification of the mitral apparatus. With encouraging beneficial midterm results, we suggest patients with calcified valves should not be excluded from mitral repair.     

Transventricular mitral valve operations

We report transventricular mitral valve operations in 2 patients with severe mitral regurgitation and postinfarction left ventricular rupture and pseudoaneurysm. The first patient had direct papillary muscle involvement necessitating replacement of the mitral valve. The second patient had indirect mitral involvement allowing for placement of an atrial mitral annuloplasty ring via the left ventricle. Both patients showed no mitral valve regurgitation after replacement or repair and had uneventful postoperative recoveries. These cases demonstrate a feasible, alternative, transventricular approach to mitral valve replacement and repair.     

Functional mitral regurgitation in chronic ischemic coronary artery disease: analysis of geometric alterations of mitral apparatus with magnetic resonance imaging

BACKGROUND: Patients with chronic coronary artery disease have double the mortality rate if the condition is combined with functional mitral regurgitation. An understanding based on geometric alterations of the mitral apparatus in functional mitral regurgitation is desirable. METHODS: Twenty-nine subjects were enrolled in the study, including 9 healthy volunteers (control group), 12 patients with chronic coronary artery disease without functional mitral regurgitation (CAD group), and 8 patients with chronic coronary artery disease with functional mitral regurgitation (CAD+FMR group). Cine magnetic resonance imaging was performed to acquire multiple short-axis cine images from base to apex. Left ventricular end-systolic volume, left ventricular ejection fraction, mitral area, and vertices of the mitral tetrahedron, defined by medial and lateral papillary muscle roots and anterior and posterior mitral annulus, were determined from reconstructed images at end-systole. Anterior-posterior annular distance, interpapillary distance, and annular-papillary distance (the distance from the anterior or posterior mitral annulus to the medial or lateral papillary muscle roots) were calculated. RESULTS: Left ventricular end-systolic volume was inversely associated with left ventricular ejection fraction (R(2) = 0.778). Left ventricular end-systolic volume was highly associated with distances related to ventricular geometry (R(2) = 0.742 for interpapillary distance, 0.792 for the distance from the anterior mitral annulus to the medial papillary muscle root, and 0.769 for distance from the anterior mitral annulus to the lateral papillary muscle root) but was moderately associated with distances related to annular geometry (R(2) = 0.458 for anterior-posterior annular distance and 0.594 for mitral area, respectively). Moreover, interpapillary distance of greater than 32 mm and distance from the anterior mitral annulus to the medial papillary muscle root of greater than 64 mm readily distinguished the CAD+FMR group from the other groups. CONCLUSION: In patients with coronary artery disease, an increase in left ventricular end-systolic volume is associated with inadequate approximation of the mitral tetrahedron during systole, which consequently leads to functional mitral regurgitation. Our study suggests that interpapillary distance and distance from the anterior mitral annulus to the medial papillary muscle root are sensitive to the increase in left ventricular end-systolic volume and reliably indicate the presence of functional mitral regurgitation.     

New surgical procedure for ischemic/functional mitral regurgitation: mitral complex remodeling

Although numerous surgical techniques have been developed for ischemic/functional mitral regurgitation, none has clearly improved patient outcome. We report the clinical application of a new mitral complex remodeling procedure for ischemic/functional mitral regurgitation that allows comprehensive remodeling of the entire mitral complex. The mitral complex remodeling procedure consists of three major concepts: division and reconstruction of secondary chords, undersized annuloplasty, and bilateral papillary muscle relocation.     

Papillary muscle repair surgery in ischemic mitral valve patients

BACKGROUND: Ischemic mitral regurgitation (MR), when ischemia/infarction has resulted in fibrotic degeneration and elongation of papillary muscles, carries a high risk for the patient and a technical challenge for the surgeon. We have developed a papillary-shortening plasty for this specific pathology. METHODS: Papillary muscle repair was performed in 88 patients (7.2%) where degenerated and fibrotic elongated papillary muscles were found, which resulted in a prolapse of one or more parts of the mitral valve leaflets (MR III-IV). All patients had a papillary muscle-shortening plasty using a pericardium pledged-reinforced polytetrafluoroethylene suture and a ring annuloplasty. Because the cause of regurgitation in this specific group of patients was ischemic, concomitant coronary bypass grafting was required in all patients, with 2.2 grafts/patient. RESULTS: There were five hospital deaths (5.7%). Postoperative mitral valve function was satisfactory in all patients: no residual mitral regurgitation (MR 0) was found in 80 patients (90.9%), mild regurgitation (MR I) in 5 patients (5.7%), and moderate regurgitation (MR I-II) was observed in 3 patients (3.4%). Within a short mean follow-up period of 18.6 months (3 to 40 months), there was one late death (1.2%). The actuarial freedom from reoperation and thromboembolic complications was 100%, but there were two anticoagulation-induced gastric bleeding complications (2.3%). All patients were in New York Heart Association functional class I or II at the time of follow-up. CONCLUSIONS: Our data show that careful assessment of papillary muscle pathology is mandatory, and that a papillary muscle-shortening plasty is a simple but valuable surgical tool to repair the mitral valve in this specific group of high-risk patients with ischemic mitral regurgitation.     

Modified edge-to-edge technique for correction of congenital mitral regurgitation in infants and children

Since 2008, 28 patients with congenital mitral regurgitation have undergone mitral valve repair with a modified edge-to-edge technique at our institution. The regurgitant mitral leaflet was sutured with a pledget-reinforced, horizontal mattress suture with No. 4-0 polypropylene on the ventricle side and a pledget-reinforced mattress suture with Gore-Tex sutures (W.L. Gore & Associates, Flagstaff, AZ) and Dacron pledgets (Chest, Shanghai) placed on the anterior and posterior annulus corresponding to the edge-to-edge suturing site. Early results are encouraging, but a longer follow-up is needed.     

Right ventricular reduction as an adjunct procedure in tricuspid valve repair

Functional tricuspid regurgitation secondary to mitral valve disease can not be attributed to the dilatation of the tricuspid annulus alone. Furthermore, geometrical changes of the right ventricle lead to tethering of the tricuspid valve leaflets and thereby to an incomplete leaflet coaptation. With this pathologic entity, conventional isolated tricuspid valve annuloplasty will presumably result in significant residual tricuspid regurgitation. The surgical goal should be the reduction of tricuspid annulus dilatation and annihilation of tethering forces on the tricuspid leaflets. In combination with conventional tricuspid valve annuloplasty, right ventricular reduction surgery, as demonstrated, may be effective in reaching these goals and hereby avoiding residual tricuspid regurgitation in this patient population.     

Papillary muscle sling: a new functional approach to mitral repair in patients with ischemic left ventricular dysfunction and functional mitral regurgitation

BACKGROUND: In patients with ischemic left ventricular dysfunction (LVD) and functional mitral regurgitation (FMR), restoring a more normal alignment between mitral annulus and laterally displaced papillary muscles (PM) may be beneficial in terms of mitral repair and regional dynamics. METHODS: Ten patients, 29 to 78 years old, with an ejection fraction of 25% to 45%, pulmonary hypertension greater than 60, and New York Heart Association Class III-IV, had their PMs drawn together by a tightly encircling loop using a 4-mm Gore-Tex tube. Associated mitral annuloplasty rings were only moderately undersized. Efficiency was essentially evaluated on reversal of mitral tenting and control of FMR. RESULTS: Postoperative echocardioraphy revealed changes in "tenting effect" from 14 +/- 2.8 mm to 4 +/- 1.41 mm. Regurgitation is none to trivial in 9 patients, and mild in 1 patient. The posterior left ventricular wall between the PMs is shortened as a result of the surgical remodeling and may be beneficial on local dynamics. CONCLUSIONS: Joining the PM side-by-side has an obvious immediate effect on mitral leaflet mobility by suppressing the tethering due to displacement of the PM. An eventual result on local ventricular dynamics needs confirmation.     

Correction of discrete subaortic stenosis with abnormal chordae tendineae

The case of a 52-year-old woman with subvalvular aortic stenosis and aortic regurgitation is presented. Mitral regurgitation was associated, due to insertion of two abnormal chordae tendineae at the apex of the anterior papillary muscle and at the free border of the subvalvular membranous annulus. This abnormality displaced the anterior papillary muscle, thus applying a traction at the mitral leaflet. The patient was operated on through a valve-sparing approach, in which the discrete subaortic stenosis was removed through aortotomy and the ectopic chordae were excised. Suture mitral annuloplasty completed the procedure. Aortic and mitral insufficiency almost disappeared at follow-up. From the examination of this case and from a review of pertinent literature it emerges that in event of similar complex congenital abnormalities without intrinsic valve disease, a conservative approach should be chosen so that valve replacement can be avoided.     

Simplified chordal reconstruction: 'oblique' placement of artificial chordae tendineae in mitral valve replacement.

We describe a novel chordal-sparing technique of mitral valve replacement using minimum number of artificial chordae tendineae in patients with rheumatic mitral stenosis. Continuity between the papillary muscles and mitral annulus is restored by placing two 3-0 expanded polytetrafluoroethylene mattress sutures: one for the anterior papillary muscle at the 9-10 o'clock position (as defined by mid-anterior annulus to be 0 o'clock) on the mitral annulus, and the other for the posterior papillary muscle at the 5-6 o'clock position.     

Papillary muscle elevation: an alternative subvalvular procedure for selective relocation of displaced posterior papillary muscle in posteroinferior infarction

Several subvalvular procedures have been developed for relocating one or both displaced papillary muscles. We describe an original procedure--papillary muscle elevation--in which we relocated the posterior papillary muscle selectively, through a small inferior ventriculotomy, and reduced the coaptation depth from 5 mm to zero. Our procedure can be considered for cases of posteroinferior infarction, which is a frequent cause of ischemic mitral regurgitation.     

Valvuloplasty with glutaraldehyde-treated autologous pericardium in patients with complex mitral valve pathology

BACKGROUND: Severe mitral regurgitation associated with complex mitral valve disease often precludes successful surgical repair. The feasibility and the results of valvuloplasty with glutaraldehyde-treated autologous pericardium remain largely unknown. METHODS: The cases of 63 patients who underwent operation within an 11-year period were studied. A pretreated autologous pericardial patch was used for leaflet extension plasty, for paracommissural plasty, as a substitute for part of the leaflet, and for reimplantation of ruptured papillary muscles to eliminate severe mitral regurgitation. Patients with a severely calcified annulus after en bloc decalcification had straddling endoventricular pericardial patch annuloplasty for reconstruction of the affected atrioventricular groove. Chordal replacement with a strip of pericardium was chosen if no suitable chordae were available. Pericardium-reinforced suture annuloplasty was used in patients with acute endocarditis resistant to medical therapy. Associated valvuloplasty procedures with Carpentier techniques were also employed. RESULTS: There were no operative deaths in this series. At a mean follow-up of 61.1 months (range, 4 to 132 months), mitral regurgitation was absent or trivial in 92.1% of patients by echocardiography. Freedom from reoperation was 95.2% at 1 year and 5 years. Thromboembolic events have not been detected. Thirty percent of patients returned to sinus rhythm. Two patients required valve replacement. CONCLUSIONS: Our beneficial results indicate that glutaraldehyde-treated autologous pericardium is suitable for valvuloplasty. It provides durable and predictable repair of valves that might otherwise need to be replaced because of the complex mitral valve disease. The technique is reliable, allows further efficacious repair possibilities, and improves postoperative outcomes. Whether it can prevent late deterioration and calcification requires more investigation.     

Mitral valve repair with papillary muscle sling for functional mitral regurgitation: application of double mitral ring concept in a case of ischemic cardiomyopathy and a case of idiopathic dilated cardiomyopathy

Functional mitral regurgitation (FMR) is a common complication in patients with ischemic heart disease or idiopathic dilated cardiomyopathy (DCM). We report successful application of a papillary muscle sling (PMS) to maintain the efficacy of undersized mitral annuloplasty (MAP) in two patients with FMR. A 5-mm expanded polytetrafluoroethylene tube was placed around the trabecular base of the papillary muscles and then tightened to make a sling that banded the two papillary muscles together. In case 1, a 57-year-old woman who had experienced anterolateral myocardial infarction underwent mitral valve reconstruction with undersized MAP and PMS in addititon to coronary revascularization for chronic ischemic mitral regurgitation. In case 2, we applied the same mitral valve procedure in a 65-year-old woman with idiopathic DCM. Neither had mitral insufficiency at an intermediate follow-up.     

End-stage cardiomyopathy and secondary mitral insufficiency surgical alternative with prosthesis implant and left ventricular remodeling

Secondary mitral insufficiency is a strong risk factor for death in end-stage cardiomyopathies. The possible correction of mitral regurgitation is now being accepted as an alternative to cardiac transplantation in a special subset of patients. We proposed a new surgical approach that consisted of implantation of a mitral prosthesis smaller than the annulus, as well as preservation and traction of the papillary muscles to reduce sphericity of the left ventricle. Between December 1995 and August 2001, 71 cases were operated on including the following etiologies: ischemic (38), idiopathic (29), Chaga's disease (2), viral (1), and postpartum (1). All patients were in an end-stage phase with more than two hospital admissions in the last three months; seven were in intensive care units receiving drugs and intra-aortic balloon counterpulsation, and one was in cardiogenic shock. The patients were analyzed according to clinical criteria, echocardiographic findings, and morphology of the left ventricle. Hospital mortality was 16.9% (12/71) and mid-term follow-up showed evidence of improvement in clinical status and some echocardiographic parameters. This technique, despite a high mortality rate (due to other clinical conditions at the time of surgery), offers a promising therapeutic alternative for the treatment of patients in refractory heart failure with cardiomyopathy associated with secondary mitral regurgitation.     

Surgical correction of posterior leaflet tethering in ischemic mitral regurgitation

Ischemic mitral regurgitation is a common complication in ischemic heart disease. It is generally accepted that intervention for the mitral valve is required if there is moderate to severe regurgitation. Generally, this would involve the placement of an annuloplasty ring or band to cinch down the dilated posterior annulus. More recently, attention has been drawn to the common problem of posterior leaflet tethering in these ischemic patients and the need to specifically address this pathology. A novel method has recently been described whereby the posteromedial papillary muscle is hitched up toward the annulus by a suture and then supported with a partially flexible annuloplasty ring. The purpose of this report is to show that this technique is easily performed and reproducible in other centres, and that it produces good short to medium term results. The report details the results achieved in six consecutive patients with at least moderate mitral regurgitation and posterior leaflet tethering.     

Bilateral pneumothorax and rupture of dissecting aortic aneurysm following a mitral valve replacement in Marfan syndrome: a case report]

A 12-year-old girl with Marfan syndrome was referred to our department because of severe mitral regurgitation. The patient was pale and in a pre-shock condition. The echocardiogram revealed a chordae rupture of the posteromedial papillary muscle at the posterior leaflet. A moderate dilatation of the aortic annulus (30 mm) and the ascending aorta (45 mm) without aortic regurgitation was also observed. Emergent mitral valve replacement was performed without replacement of the aortic valve or the ascending aorta. After two months, the patient developed bilateral pneumothorax, which was resistant to continuous suction therapy and finally required surgical treatments. Despite the relatively uneventful recovery, a lethal rupture of dissecting aortic aneurysm into the pericardial cavity, developed four months after the initial operation. We discussed the desired surgical approaches and respiratory problems in patients with connective tissue disorder.     

Are there indications for reconstructive surgery in severe mitral regurgitation after acute myocardial infarction?

From 1972 to 1988, early surgery were performed in 26 patients with acute mitral regurgitation (MR) unresponsive to medical management complicating a recent acute myocardial infarction (AMI). The indication was acute pulmonary oedema (11), major left ventricular insufficiency (5), cardiogenic shock (10). Surgery was performed within 3 weeks following AMI. Mitral lesions were as follows: rupture of chordae tendinae (9) of papillary muscle (6), haemorrhagic necrosis of one (17) or two (9) papillary muscles. The mitral annulus was never found to be enlarged. The LV posterior wall was necrotic in 23, with a septal rupture in 3 and a giant aneurysm in 5. Valve replacement was performed in all but one patient. The 30-day mortality included 8 patients (31%). The cause of death was myocardial insufficiency in 5, early thrombosis of a disk valve in 1 and unrelated complications in 2. One patient deteriorated rapidly and had a Jarvik device implanted. Late results (1 month-15 years) showed 4 cardiac related deaths within the first year. One patient had to be transplanted after 1 year. Two patients died of non-cardiac problems at 3 months and 5 years. The probability of survival at 5 years is 43% and at 10 years 22%. In conclusion, there are still indications for early surgery in MR post AMI. Anatomical lesions of both papillary muscles and ventricular wall do not allow conservative surgery and new non-invasive technics provide a more promising strategy in such desperately ill patients.