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J Thorac Cardiovasc Surg 2005;129:1266-1275
© 2005 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Annular or subvalvular approach to chronic ischemic mitral regurgitation?

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

Received for publication June 22, 2004; revisions received December 14, 2004; accepted for publication January 3, 2005.

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

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.

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