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J Thorac Cardiovasc Surg 2008;135:1169-1172
© 2008 The American Association for Thoracic Surgery
Brief Communication |
a Department of Cardiac Surgery, University General Hospital of Valencia, Valencia, Spain
b Unit of Cardiac Magnetic Resonance, University General Hospital of Valencia, Valencia, Spain
Received for publication September 19, 2007; accepted for publication December 18, 2007. * Address for reprints: Rafael García Fuster, MD, PhD, C/Artes Gráficas n° 4,esc. izda, pta 3. 46010 Valencia, Spain. (Email: rgfuster{at}terra.com).
The incidence and severity of ischemic mitral regurgitation (MR) are higher with posteroinferior infarctions. More localized remodeling without important left ventricular (LV) dilation can result in greater geometric changes with displacement of the posterior papillary muscle (PPM).1
A variety of techniques have been advocated to correct these changes.2-4
Cardiac magnetic resonance (CMR) has emerged as a new technique that provides detailed information about LV and mitral valve morphology and function with precise myocardial scar assessment.5
We report a combined diagnostic-surgical approach for the management of patients with ischemic MR secondary to posteroinferior infarction. It is based on cardiac catheterization, CMR, and perioperative transesophageal echocardiography followed by a 3-staged surgical procedure: selective scar plication, restrictive annuloplasty, and coronary artery bypass grafting.
Between December of 2005 and December of 2006, 4 male patients (median age: 57 years, 51–63 years) underwent this procedure. All had grade 3 to 4+ MR at rest and isolated inferior-posterolateral postinfarction scarring detected by CMR (
Figure 1, A), mainly localized in segments 4, 5, 10, and 11 (American Heart Association Consensus about LV walls segments).5 Segment 10 (corresponding to PPM) was dyskinetic, and the other 3 segments were akinetic-dyskinetic. Most viable segments were hypokinetic. Echocardiographic evidence of restrictive leaflet motion (type IIIb) was demonstrated.
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Figure 2, A). Both edges were approximated, and the thin infarcted wall was completely invaginated (Figure 2, B).
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After a mean follow-up of 16 months, MR was absent in 3 patients and trivial in 1 patient. New York Heart Association class decreased from III/IV to II. LV ejection fraction improved from 37% ± 2% to 55% ± 6%. Preoperative cine CMR does not reveal advanced global LV remodeling (end-diastolic and end-systolic LV volumes: 183 ± 4 mL and 106 ± 2 mL preoperatively vs 171 ± 3 mL and 92 ± 4 mL postoperatively, respectively) but important local geometric changes with systolic apical displacement of the PPM and marked leaflet tethering (tenting height: 12 ± 3 mm, tenting area: 1.6 ± 0.5 cm2, PPM distance from anterior mitral annulus: 6.3 ± 0.3 cm). Postoperatively, this PPM displacement was corrected, the tenting height was 4 ± 2 mm, and MR disappeared. See
Table 1 for patient data and
Figure 3 for CMR imaging views.
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Ring annuloplasty is the standard approach for ischemic MR, but recent studies have demonstrated that MR can persist or recur in relation to continued remodeling. Important geometric changes and tethering may be responsible for unsuccessful repair, and some predictors of recurrent MR have been advocated: tenting height greater than 11 mm or tenting area greater than 1.6 cm2. Annuloplasty alone is not enough in these cases, and adjunctive techniques are needed.2-4 We report a 3-staged procedure: selective infarct plication, restrictive annuloplasty, and coronary artery bypass grafting. The objective of plication is restoring local 3-dimensional LV and mitral geometry and eliminating the otherwise deleterious effect of the akinetic-dyskinetic scarred segments. Since the original report of infarct plication based on 3-dimensional echocardiography findings by Liel-Cohen and colleagues2 in a sheep model of ischemic MR, this is one of the first studies presenting infarct plication guided by CMR for ischemic MR in humans. In our patients, despite the important localized LV remodeling and tethering, the results were successful at mid-term follow-up.
Ramadan and colleagues3 proposed an "everting plication" without annuloplasty, but the avoidance of annuloplasty is not a complete solution because annular dilation is generally present and the infarction may involve the posterior annulus.
Direct relocation of the PPM4 tries to recover the normal mitral geometry, but papillary muscles can be infarcted and fragile, and in patients without significant enlargement of the left atrium and ventricle, the approach of the subvalvular area may be difficult.
Our selective scar plication combined with annuloplasty and coronary artery bypass grafting may be useful in patients with ischemic MR secondary to posteroinferior isolated infarction with localized LV geometric changes. CMR may be an important diagnostic technique to guide the decision-making process. Our initial experience has been encouraging, but future studies with a greater number of patients and long-term follow-up are warranted.
Appendix
Supplementary data
Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.jtcvs.2007.12.017
References
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  G. A. Figtree, J. Lonborg, S. M. Grieve, M. R. Ward, and R. Bhindi Cardiac Magnetic Resonance Imaging for the Interventional Cardiologist J. Am. Coll. Cardiol. Intv., February 1, 2011; 4(2): 137 - 148. [Abstract] [Full Text] [PDF]
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