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J Thorac Cardiovasc Surg 2006;131:233-235
© 2006 The American Association for Thoracic Surgery
Brief Communication |
Department of Cardiothoracic Surgery, Hayama Heart Center, Kanagawa, Japan
Received for publication June 25, 2005; revisions received August 30, 2005; accepted for publication September 9, 2005. * Address for reprints: Tadashi Isomura, MD, PhD, Department of Cardiothoracic Surgery, Hayama Heart Center, 1898 Shimoyamaguchi, Hayama, Kanagawa, 240-0116, Japan (Email: isomura{at}hayamaheart.gr.jp).
Functional mitral regurgitation (FMR) accompanying nonischemic dilated cardiomyopathy (DCM) has a poor prognosis, and its surgical management is still controversial. We report a novel surgical approach that consists of the repair of papillary muscle geometry and annuloplasty with a semirigid ring and partial resection of the dilated left ventricle (LV). Mid-term postoperative results of our surgical approach included no recurrence of FMR, effective reduction of the LV volume and shape, and improvement of pulmonary artery pressure.
Clinical Summary
A 42-year-old man was admitted to our center for an easy fatigability on effort. On admission, echocardiogram demonstrated a dilated LV associated with severe mitral valve regurgitation. End-systolic volume index (ESVI) and end-diastolic volume index (EDVI) were 139.5 and 160.5 mL/m2, respectively. Although severe regurgitation was present either at the mitral (3+) or tricuspid valve (3+), ejection fraction (EF) was decreased to 13 percentages, and pulmonary artery systolic pressure (PAP) was increased to 39 mm Hg. Preoperative gated single photon emission computed tomography quantification confirmed the diagnosis of DCM and showed the spherical shape of the dilated LV. Coronary angiography showed normal coronary findings.
The mitral valve was approached via right-side left atriotomy. The annulus was dilated, and severe central leakage was noticed. Mitral valve plasty was performed with a 28-mm Physio ring (Baxter Healthcare Corp, Irvine, Calif). The LV cavity was then opened from the apex to the middle part, with an incision parallel to the left anterior descending artery. The papillary muscles were visualized. With the use of 0-0 Ti-Cron (Davis & Geck, Danbury, Conn), a mattress suture with pledgets was first placed on the base of anterior-lateral papillary muscle, hitched the LV free wall between both papillary muscles, and then ran through the base of the posterior-medial papillary muscles. The second mattress suture was placed in the same manner, 1 to 2 cm above the first one. The mattress sutures were tied over with second pledgets, and there was no gap between the bases of the anterior and posterior papillary muscles (Figure 1). Next, ventricular restoration was performed with an on-pump beating heart without aortic crossclamp. The LV muscle of the anterior-lateral wall was excised. A purse-string suture was applied in the transitional zone at the base of 2 papillary muscles. The LV cavity was then closed without a patch in 2 layers by using monofilament sutures. Tricuspid valve annuloplasty was performed with a 32-mm Carpentier-Edwards Classic ring (Edwards Lifesciences, Irvine, Calif).
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In this article, we report the results of mitral valve repair combined with partial left ventriculotomy on a patient who had an end-stage DCM with severe FMR. The aim of this surgical approach is a synthetic repair for the pathology of DCM. We suggest that the integrity of the mitral component could be essential for a better prognosis after LV restoration surgery.
1,2
Geometrically, FMR in DCM is composed of an annular factor (eg, annular dilatation) and a subvalvular factor (eg, sphericalization of the LV, leaflet tethering geometry, and papillary muscle discoordination).
3-5
From these points of view, we proposed that FMR in DCM could be treated by 2 different approaches: (1) reduction of the anterior and posterior annular distance to prevent the tethering effect of mitral leaflets and (2) plication of the interpapillary myocardium muscles during LV restoration to decrease the distance of both papillary muscles and to reserve the coaptation of mitral leaflets and additively restore the dilated LV, cooperating with partial volume reduction. In this surgical procedure, the first goal was achieved by using ring annuloplasty, and the second, by papillary muscle positioning with 2 mattress sutures and partial resection of the dilated LV.
ESVI and EDVI were successfully reduced after surgery. Both EF and PAP were markedly improved at 6 months, and the patient's New Yolk Heart Association functional class improved from IV to I. Nevertheless, it is still difficult to clarify which factor (annular or subvalvular) has the stronger association with FMR, and 3-dimensional repair of FMR seems to be effective to boost ventricular restoration in LV surgery.
In conclusion, our combined surgical procedure aims to restore the LV and to improve the LV function in patients with DCM. To determine the durability of this procedure, long-term follow-up is needed.
References
This article has been cited by other articles:
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  H. Suma, H. Tanabe, T. Uejima, T. Isomura, and T. Horii Surgical ventricular restoration combined with mitral valve procedure for endstage ischemic cardiomyopathy Eur. J. Cardiothorac. Surg., August 1, 2009; 36(2): 280 - 285. [Abstract] [Full Text] [PDF]
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