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J Thorac Cardiovasc Surg 2006;131:868-877
© 2006 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Posterior mitral leaflet extension: An adjunctive repair option for 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 of the Palo Alto Medical Foundation, Palo Alto, Calif

Read at the 85th Annual Meeting of the American Association for Thoracic Surgery, San Francisco, Calif, April 2005.

Received for publication May 5, 2005; revisions received October 31, 2005; accepted for publication November 28, 2005.

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

BACKGROUND: Residual or recurrent mitral regurgitation frequently occurs after mitral valve repair for ischemic mitral regurgitation with an annuloplasty ring. Because annuloplasty primarily addresses annular dilatation, we studied an adjunctive technique that might correct restricted leaflet (Carpentier type IIIb) systolic closing motion, which often accompanies annular dilatation in patients with ischemic mitral regurgitation.

METHODS: Six sheep had radiopaque markers placed on the left ventricle, mitral leaflets and annulus, and mitral subvalvular apparatus. A pericardial patch was sutured into the middle scallop of the posterior mitral valve leaflet and furled in with a reefing stitch placed in the radial axis. Posterolateral left ventricular myocardial ischemia was created by using proximal circumflex occlusion to induce acute ischemic mitral regurgitation. Under open-chest conditions, 3-dimensional marker coordinates were measured by using biplane videofluoroscopy at baseline and during acute ischemia both before and after release of the reefing stitch (leaflet extension); transesophageal echocardiography was used to grade ischemic mitral regurgitation.

RESULTS: Leaflet apical systolic tethering was not improved by leaflet extension, but ischemic mitral regurgitation decreased (control, 0.9 ± 0.3^*; ischemia, 2.4 ± 0.3; leaflet extension, 1.5 ± 0.3; ^* P < 0.002). Posterior mitral valve leaflet midline length (control, 1.45 ± 0.09^*; ischemia, 1.53 ± 0.10; leaflet extension, 1.83 ± 0.13^*; ^* P < 0.001) and posterior mitral valve leaflet middle scallop area (control, 1.66 ± 0.20 cm^{2 *}; ischemia, 1.91 ± 0.22 cm²; leaflet extension, 2.36 ± 0.22 cm^{2 *}; ^* P < 0.006) increased with leaflet extension because of patch unfurling (mean ± 1 standard error of the mean; repeated-measures analysis of variance, Dunnet post-hoc test vs ischemia).

CONCLUSIONS: Posterior mitral valve leaflet extension ameliorated acute ischemic mitral regurgitation but did not correct the abnormal apically restricted systolic posterior mitral valve leaflet closing motion. This technique might be a useful adjunct repair in combination with ring annuloplasty for ischemic mitral regurgitation, but the clinical role of this adjunct remains to be defined in patients.

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