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J Thorac Cardiovasc Surg 2002;123:881-888
© 2002 The American Association for Thoracic Surgery
Surgery for Acquired Cardiovascular Disease (ACD) |
From the Department of Cardiovascular Surgerya and the Division of Cardiovascular Medicine,b Stanford University School of Medicine, Stanford, Calif, and the Laboratory of Cardiovascular Physiology and Biophysics,c Research Institute of the Palo Alto Medical Foundation, Palo Alto, Calif.
Supported by grants HL-29589 and HL-67025 from the National Heart, Lung, and Blood Institute. Drs Timek, Tibayan, Dagum, and Lai are Carl and Leah McConnell Cardiovascular Surgical Research Fellows. Drs Timek, Tibayan, and Dagum were supported by National Heart, Lung, and Blood Institute Individual Research Service Awards HL-10452, HL-67563, and HL-10000, respectively. Dr Timek was also a recipient of the Thoracic Surgery Foundation Research Fellowship Award. Dr Lai was supported by a fellowship from the American Heart Association, Western States Affiliate.
Received for publication May 15, 2001. Revisions requested July 13, 2001; revisions received Dec 4, 2001. Accepted for publication Dec 12, 2001. Address for reprints: D. Craig Miller, MD, Falk Cardiovascular Research Center, Stanford University School of Medicine, Stanford, CA 94305-5247 (E-mail: dcm{at}stanford.edu).
Objective: Ring annuloplasty prevents acute ischemic mitral regurgitation in sheep, but it also abolishes normal mitral annular and posterior leaflet dynamics. We investigated a novel surgical approach of simple septal-lateral annular cinching with sutures to treat acute ischemic mitral regurgitation.
Methods: Nine adult sheep underwent implantation of multiple radiopaque markers on the left ventricle, mitral anulus, and mitral leaflets. A septal-lateral transannular suture was anchored to the midseptal mitral anulus and externalized to a tourniquet through the midlateral mitral anulus and left ventricular wall. Open-chest animals were studied immediately postoperatively. Acute ischemic mitral regurgitation was induced by means of proximal left circumflex artery snare occlusion, and 3 progressive steps of septal-lateral annular cinching (each 2-3 mm suture tightening for 5 seconds) were performed with the transannular suture. Biplane videofluoroscopy for 3-dimensional marker coordinates and transesophageal echocardiography were performed continuously before and during left circumflex ischemia and septal-lateral annular cinching.
Results: Acute left circumflex ischemia caused ischemic mitral regurgitation (+0.5 ± 0.4 [baseline] vs +2.0 ± 0.7 [ischemia]; P = .005; scale, +0-4), which decreased progressively with each step of septal-lateral annular cinching and was eliminated during the third step (ischemic mitral regurgitation, +0.6 ± 0.5; P = not significant vs baseline). The third step of septal-lateral annular cinching decreased the septal-lateral diameter by 6.0 ± 2.6 mm (P = .005); however, mitral anulus area reduction (8.5% ± 1.0% and 6.9% ± 1.9% for ischemic mitral regurgitation and septal-lateral annular cinching step 3, respectively; P = .006) and posterior leaflet excursion (50° ± 9° and 44° ± 11° for regurgitation and annular cinching step 3, respectively; P = .002) throughout the cardiac cycle were affected only mildly. Normal mitral annular 3-dimensional shape was maintained with septal-lateral annular cinching.
Conclusions: Isolated 22% ± 10% reduction in mitral annular septal-lateral dimension abolished acute ischemic mitral regurgitation in normal sheep hearts while allowing near-normal mitral annular and posterior leaflet dynamic motion. Septal-lateral annular cinching may represent a simple method for the surgical treatment of ischemic mitral regurgitation, either as an adjunctive technique or alone, which helps preserve physiologic annular and leaflet function.
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