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J Thorac Cardiovasc Surg 2004;127:654-663
© 2004 The American Association for Thoracic Surgery

Surgery for acquired cardiovascular disease

Does septal-lateral annular cinching work for chronic ischemic mitral regurgitation?

^a Department of Cardiovascular and Thoracic Surgery, Stanford University School of Medicine, Stanford, Calif, USA
^b Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, Calif, USA
^c Laboratory of Cardiovascular Physiology and Biophysics, Research Institute, Palo Alto Medical Foundation, Palo Alto, Calif, USA

Read at the Twenty-ninth Annual Meeting of The Western Thoracic Surgical Association, Carlsbad, Calif, June 18-21, 2003.

Received for publication June 17, 2003; revisions received September 3, 2003; accepted for publication September 12, 2003.

^* Address for reprints: D. Craig Miller, MD, Department of Cardiothoracic Surgery, Falk Cardiovascular Research Center, Stanford University School of Medicine, Stanford, CA 94305-5247, USA
dcm{at}stanford.edu

OBJECTIVES: Ring annuloplasty, the current treatment of choice for chronic ischemic mitral regurgitation, abolishes dynamic annular motion and immobilizes the posterior leaflet. In a model of chronic ischemic mitral regurgitation, we tested septal-lateral annular cinching aimed at maintaining normal annular and leaflet dynamics.

METHODS: Twenty-five sheep had radiopaque markers placed on the mitral annulus and anterior and posterior mitral leaflets. A transannular suture was anchored to the midseptal mitral annulus and externalized through the midlateral mitral annulus. After 7 days, biplane cinefluoroscopy provided 3-dimensional marker data (baseline) prior to creating inferior myocardial infarction by snare occlusion of obtuse marginal branches. After 7 weeks, the 9 animals that developed chronic ischemic mitral regurgitation were restudied before and after septal-lateral annular cinching. Anterior and posterior mitral leaflet angular excursion and annular septal-lateral and commissure–commissure dimensions and percent shortening were computed.

RESULTS: Septal-lateral annular cinching reduced septal-lateral dimension (baseline: 3.0 ± 0.2; chronic ischemic mitral regurgitation: 3.5 ± 0.4 [P < .05 vs baseline by repeated measures analysis of variance and Dunnett's test]; septal-lateral annular cinching: 2.4 ± 0.3 cm; maximum dimension) and eliminated chronic ischemic mitral regurgitation (baseline: 0.6 ± 0.5; chronic ischemic mitral regurgitation: 2.3 ± 1.0 [P < .05 vs baseline by repeated measures analysis of variance and Dunnett's test]; septal-lateral annular cinching: 0.6 ± 0.6; mitral regurgitation grade [0 to 4+]) but did not alter dynamic annular shortening (baseline: 7 ± 3; chronic ischemic mitral regurgitation: 10 ± 5; septal-lateral annular cinching: 6 ± 2, percent septal-lateral shortening) or posterior mitral leaflet excursion (baseline: 46° ± 8°; chronic ischemic mitral regurgitation: 41° ± 13°; septal-lateral annular cinching: 46° ± 8°).

CONCLUSIONS: In this model, septal-lateral annular cinching decreased chronic ischemic mitral regurgitation, reduced annular septal-lateral diameter (but not commissure–commissure diameter), and maintained normal annular and leaflet dynamics. These findings provide additional insight into the treatment of chronic ischemic mitral regurgitation.

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