Papillary Muscle Approximation for Functional Ischemic Mitral Regurgitation

doi:10.1016/j.athoracsur.2007.04.056

The Annals of Thoracic Surgery

Volume 84, Issue 6, December 2007, Pages 2130-2131

https://doi.org/10.1016/j.athoracsur.2007.04.056 Get rights and content

In patients with ischemic left ventricular dysfunction and functional mitral regurgitation, surgical treatment of mitral insufficiency remains a challenging issue. Several procedures have been described to restore a near to natural alignment between the mitral annulus and the laterally displaced papillary muscles. We report a new approach to relocate the displaced papillary muscles toward the mitral annulus and to reduce tethering in 8 patients, providing satisfactory initial results. Echocardiography showed mild or no mitral regurgitation at the follow-up (mean, 11.4 ± 3.6 months; range = 7 to 14 months). This procedure is believed to be technically easy and beneficial in terms of mitral repair.

Section snippets

Technique

Through a median sternotomy, cardiopulmonary bypass is established with ascending aorta and bi-caval cannulation. Warm-blood antegrade cardioplegia is used for myocardial protection. The mitral valve is exposed through the left interatrial groove cardiotomy. Once papillary muscle displacement is established and the valve is analyzed as anatomically normal, a single 2-0 U-shaped stitch reinforced by two patches of autologous pericardium is passed through the posterior and anterior papillary

Comment

Between December 2005 and July 2006, 8 patients (6 men and 2 women) with functional ischemic mitral regurgitation were operated on with this technique. Their mean left ventricular ejection fraction was 36 ± 12% (range, 20 to 60). Five patients (63%) were in New York Heart Association functional class III or IV. Preoperative echocardiographic assessment showed a mitral regurgitation grade of 3 in 6 patients and a grade of 2 in 2 patients. The mean left ventricular end-diastolic diameter was 62 ±

References (8)

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There are more references available in the full text version of this article.

Cited by (54)

Description, Feasibility, and Histological Assessment of the Vsling, a Novel Transcatheter Ventricular Repair Device
2022, Structural Heart
Citation Excerpt :
This remodeling reduces the effectiveness of ventricular contraction and, in some patients, distorts the geometric positioning of the papillary muscles, tethering the mitral valve leaflets to prevent effective coaptation, resulting in secondary or functional mitral regurgitation (FMR). Surgical papillary muscle repositioning (PMR) (also known as papillary muscle apposition) when combined with mitral annuloplasty has been shown to improve LV function and reduce FMR.3-8 Ventricular reshaping, referring to therapies that correct, compensate for, and/or prevent ventricular remodeling, offers the potential to improve ventricular function and prognosis in patients with heart failure with reduced ejection fraction, with or without significant FMR.
Reshaping the dilated left ventricle using a surgically implanted papillary muscle sling has been shown to provide long-term improvement in cardiac function compared to annuloplasty alone in patients with systolic heart failure. A papillary muscle sling which can be implanted via a transcatheter approach has the potential to make this treatment more widely available to patients.
The Vsling transcatheter papillary muscle sling device was evaluated in a chronic animal model (sacrificed at 30 and 90 days), in a simulator, and in a human cadaver.
The Vsling device was successfully implanted in 10 pigs, 6 simulator procedures, and 1 human cadaver. Procedure complexity and device usability were rated as reasonable or better by 6 interventional cardiologists. Gross and histological analysis in chronic pigs through 90 days demonstrated near-complete endothelial coverage with mild inflammation and small hematoma formation but without adverse tissue reactions, thrombi, or embolization.
Preliminary feasibility and safety of the Vsling implant and implantation procedure have been demonstrated. Human trials are planned to begin in the summer of 2022.
Commentary: The mitral valve and the left ventricle in functional mitral regurgitation: The puppet and the puppeteer
2021, JTCVS Open
Papillary Muscle Heads Focalization for Functional Mitral Valve Regurgitation
2020, Annals of Thoracic Surgery
Mitral valve annuloplasty has been the gold standard for treatment of functional mitral valve regurgitation. However, annuloplasty for functional mitral regurgitation may cause augmented posterior leaflet tethering, which results in functional anterior prolapse. Herein we added papillary muscle heads focalization for such patients. All separated papillary muscle heads are sutured together, and the roots of chordae at each papillary muscle are unifocalized on both sides. Stitches are positioned at the same distances from corresponding leaflet edges to adjust the height of leaflet edges in each segment. This is a simple and effective technique to correct for functional anterior prolapse after annuloplasty.
Functional mitral regurgitation repair through the approach of the subvalvular apparatus. Mid-term results
2017, Cirugia Cardiovascular
El tratamiento quirúrgico de la insuficiencia mitral funcional continúa siendo objeto de amplio debate dada su elevada morbimortalidad y la ausencia de consenso acerca de la mejor opción terapéutica (reparación vs. sustitución). Presentamos nuestra experiencia a medio plazo en su tratamiento mediante reparación valvular con abordaje del aparato subvalvular.
Entre los años 2012 y 2016 se intervino en nuestro centro a un total de 16 pacientes con insuficiencia mitral de mecanismo iiib de Carpentier con un EuroSCORE logístico medio del 10,81%. En todos ellos se llevó a cabo una anuloplastia mitral restrictiva, junto con reposicionamiento del músculo papilar posteromedial en 14 casos y reaproximación de los músculos papilares en 2 casos. En 12 pacientes se llevó a cabo otro procedimiento asociado.
El tiempo de seguimiento medio fue de 29,5 meses. Hubo 2 muertes perioperatorias. No hubo más fallecimientos durante el seguimiento. La recurrencia de insuficiencia mitral > 2 fue del 12,5% (2 pacientes). Únicamente los 2 pacientes con insuficiencia mitral > 2 reingresaron en algún momento del seguimiento por insuficiencia cardíaca, permaneciendo el resto en clase funcional i-ii/iv.
El abordaje del aparato subvalvular en la reparación de la insuficiencia mitral funcional se presenta como una alternativa válida en el tratamiento de este tipo de insuficiencia, ofreciendo buenos resultados en lo que a evolución postoperatoria y tasa de recidiva a medio plazo se refiere.
Surgical treatment of functional mitral regurgitation still remains an issue widely debated due to its high morbidity and mortality and the absence of consensus about the best therapeutic option (repair vs replacement). We present our mid-term experience in its treatment with a repair approaching de subvalvular apparatus.
Between 2012 and 2016, 16 patients were operated on in our hospital with a moderate to severe mitral regurgitation due to a Carpentier's type IIIb mechanism. The mean logistic EuroSCORE was 10.81%. In all of them a restrictive ring annuloplasty was carried out, along with the relocation of the posteromedial papillary muscle in 14 patients and the approximation of the papillary muscles in 2 patients. Other procedures were carried out in 12 of these 16 patients.
The mean follow up period was 29.5 months. There were 2 perioperative deaths. There were no more deaths during the follow up. The recurrence of mitral regurgitation > 2 was 12.5% (2 patients). Only these 2 patients with a mitral regurgitation > 2 in the follow up echocardiograms needed hospital readmission at some point due to decompensated heart failure, remaining the rest of them in NYHA class i-ii/iv.
Approaching the subvalvular apparatus in the repair of functional mitral regurgitation seems to be a valuable option in the treatment of this kind of regurgitation, offering optimal results in terms of survival at discharge and in recurrence at mid-term follow up.
Slope in preload recruitable stroke work relationship predicts survival after left ventriculoplasty and mitral repair in patients with idiopathic cardiomyopathy
2015, Journal of Cardiology
Citation Excerpt :
Thus, procedures in addition to mitral annuloplasty appear to be necessary for the large LV. To eliminate recurrence of MR and heart failure symptoms in such high-risk patients, some groups, including ours, have developed several submitral procedures such as left ventriculoplasty (LVP) and reported acceptable midterm results [6–15]. Thus far, however, there exist no guidelines that recommend LVP concomitant with MVP, and Batista-type LVP is even a class III recommendation in the AHA guidelines [16].
Left ventriculoplasty (LVP) and mitral valve plasty (MVP) are sometimes effective for patients with idiopathic dilated cardiomyopathy (DCM) who are not eligible for heart transplantation. Strict patient selection is warranted for these controversial procedures.
The subjects were 18 patients with idiopathic DCM and mitral regurgitation who had not been indicated for heart transplantation due to either older age or patient refusal, and who underwent LVP and MVP. Their mean age was 57 ± 14 years and 50% were dependent on catecholamine infusion. The preload recruitable stroke work (PRSW) relationship and its slope (Mw) were estimated by a single-beat technique using transthoracic echocardiography. There were one 30-day mortality and six (33%) hospital deaths due to heart failure. The one-year survival rate was 50%. Left ventricular end-diastolic dimension (LVDd) decreased from 77 ± 11 to 68 ± 11 mm (p = 0.001) whereas the ejection fraction did not change. Preoperative Mw was significantly higher in one-year survivors than that in non-survivors (54 ± 17 erg cm⁻³ 10³ vs. 31 ± 10 erg cm⁻³ 10³, p = 0.005). Preoperative LVDd was not different between the groups. The cut-off value of 42 erg cm⁻³ 10³ for Mw predicted one-year survival with high sensitivity (100%) and specificity (77%).
Mw, the slope in the PRSW relationship, may predict survival after LVP and MVP in patients with idiopathic DCM.
Leaflet-chordal relations in patients with primary and secondary mitral regurgitation
2015, Journal of the American Society of Echocardiography
The strategy for mitral valve (MV) repair has recently focused on the restoration of the submitral apparatus. However, the relationship between geometric changes of the submitral apparatus and the mitral leaflets has not been systematically investigated. The aim of this study was to determine the relationships among chordal length (CL) and LV size and leaflet surface area (LSA) in normal subjects, patients with primary (degenerative) mitral regurgitation (PMR), and patients with functional (secondary) mitral regurgitation (FMR).
A total of 72 patients who underwent three-dimensional transesophageal echocardiography, including: 27 with PMR with isolated P2 flail leaflet, 25 with FMR with greater than mild mitral regurgitation, and 20 with normal mitral valves. LSA was quantified at midsystole from full-volume midesophageal views. CL was calculated by averaging the lengths of eight primary chords from transgastric full-volume data sets using multiplanar reconstruction.
Both CL and LSA in the PMR group were significantly longer compared with the FMR and normal control groups. No difference in CL was noted between patients with FMR and normal subjects. In all three groups, CL and LSA did not correlate with LV systolic or diastolic dimensions. Although CL did not correlate with LSA in the FMR group, a moderate correlation (R = 0.62) was observed in the PMR group.
In patients with FMR with greater than mild mitral regurgitation, the chords retain normal length, despite LSA and LV enlargement. In patients with PMR with flail P2 scallops, CL elongation of primary chords is associated with larger LSA but not with LV dimensions. This information may have implications for clinical strategies for mitral valve repair surgery, including the submitral approach and percutaneous procedures.

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How to do itPapillary Muscle Approximation for Functional Ischemic Mitral Regurgitation

Section snippets

Technique

Comment

J Am Coll Cardiol

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

How to do it
Papillary Muscle Approximation for Functional Ischemic Mitral Regurgitation