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J Thorac Cardiovasc Surg 2000;119:774-783
© 2000 The American Association for Thoracic Surgery

SURGERY FOR ACQUIRED CARDIOVASCULAR DISEASE

RING ANNULOPLASTY PREVENTS DELAYED LEAFLET COAPTATION AND MITRAL REGURGITATION DURING ACUTE LEFT VENTRICULAR ISCHEMIA

From the Department of Cardiovascular and Thoracic Surgery,^a The Division of Cardiovascular Medicine, and the Department of Anesthesia,^b Stanford University School of Medicine, Stanford, Calif; Cardiology Section,^c Department of Veterans Affairs Medical Center, Palo Alto, Calif; and the Department of Cardiovascular Physiology and Biophysics,^d Research Institute of the Palo Alto Medical Foundation, Palo Alto, Calif.

Supported by grants HL-29589 and HL-48837 from the National Heart, Lung, and Blood Institute. Drs Timek, Glasson, Green, Dagum, and Komeda are Carl and Leah McConnell Cardiovascular Surgical Research Fellows. Drs Timek and Glasson are also recipients of fellowship awards from The Thoracic Surgery Foundation for Research and Education. Drs Green and Dagum were also supported by National Heart, Lung, and Blood Institute Individual Research Service Awards HL-09569 and HL-10000, respectively.

Presented in part at the Seventy-first American Heart Association Annual Scientific Sessions, Dallas, Tex, November 1998.

Address for reprints: D. Craig Miller, MD, Department of Cardiovascular and Thoracic Surgery, Falk Cardiovascular Research Center, Stanford University School of Medicine, Stanford, CA 94305-5247 (E-mail: dcm{at}leland.stanford.edu ).

Objective: Incomplete mitral leaflet coaptation during acute left ventricular ischemia is associated with end-diastolic mitral annular dilatation and ischemic mitral regurgitation. Annular rings were implanted in sheep to investigate whether annular reduction alone is sufficient to prevent mitral regurgitation during acute posterolateral left ventricular ischemia.
Methods: Radiopaque markers were inserted around the mitral anulus, on papillary muscle tips, and on the central meridian of both mitral leaflets in three groups of sheep: control (n = 5), Physio ring (n = 5) (Baxter Cardiovascular Div, Santa Ana, Calif), and Duran ring (n = 6) (Medtronic Heart Valve Div, Minneapolis, Minn). After 8 ± 1 days, animals were studied with biplane videofluoroscopy before and during left ventricular ischemia. Annular area was calculated from 3-dimensional marker coordinates and coaptation defined as minimal distance between leaflet edge markers.
Results: Before ischemia, leaflet coaptation occurred just after end-diastole in all groups (control 17 ± 41, Duran 33 ± 30, Physio 33 ± 24 ms, mean ± SD, P > .2 by analysis of variance). During ischemia, regurgitation was detected in all control animals, and leaflet coaptation was delayed to 88 ± 8 ms after end-diastole (P = .02 vs preischemia). This was associated with increased end-diastolic annular area (8.0 ± 0.9 vs 6.7 ± 0.6 cm², P = .004) and septal-lateral annular diameter (2.9 ± 0.1 vs 2.5 ± 0.1 cm, P = .02). Mitral regurgitation did not develop in Duran or Physio sheep, time to coaptation was unchanged (Duran 25 ± 25 ms, Physio 30 ± 48 ms [both P > .2 vs preischemia]), and annular area remained fixed.
Conclusion: Mitral annular area reduction and fixation with an annuloplasty ring eliminated delayed leaflet coaptation and prevented mitral regurgitation during acute left ventricular ischemia after ring implantation.

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