The role of papillary muscle relocation in ischemic mitral valve regurgitation.

Aim of our study was to compare the results of combined approach papillary muscles relocation (PPMr) + mitral annuloplasty (MA) vs only restrictive annuloplasty (RA) in ischemic mitral regurgitation, guided by 3-dimensional (3D) echocardiography. Sixty-nine patients with severe ischemic mitral regurgitation who had PPMr + MA and coronary artery bypass grafting were matched 1:1 with patients who underwent isolated RA and coronary artery bypass grafting. A comprehensive pre- and postoperatory 2-dimensional and 3D transesophageal echocardiographic examination followed by a 3D offline assessment of the mitral valve apparatus was performed. Five-year freedom from cardiac-related event in the PPMr + MA group and isolated RA group was 83% ± 2.1% and 65.4% ± 1.2%, respectively (P < 0.001). Recurrent mitral regurgitation equal to or greater than moderate occurred in 2 (2.8%) and 8 (11.5%) in PPMr + MA group and RA group, respectively (P < 0.02). The PPMr promoted a significant reversal in left ventricle remodeling compared with the isolated RA. PPMr + MA reduce the tenting area and the coaptation depth with respect to RA, with less incidence of recurrent mitral regurgitation.

Fattouch K ，Murana G ，Castrovinci S ，Nasso G ，Speziale G ... -  《-》

Papillary muscle relocation in conjunction with valve annuloplasty improve repair results in severe ischemic mitral regurgitation.

The incidence of recurrent mitral regurgitation (MR) after restrictive annuloplasty (RA) was 5% to 20% in several reports. There are many opinions in favor of adding subvalvular procedures to RA to reduce the tenting forces and improve the repair results. From March 2003 to May 2010, 55 patients with severe ischemic MR who had undergone papillary muscle (PPM) relocation in conjunction with mitral annuloplasty in our institutions were enrolled. The patients were matched 1:1 with those who underwent isolated RA using the propensity score. The mean left ventricular ejection fraction was 42% ± 6%. The mean tenting area and coaptation depth was 3.2 ± 0.6 cm(2) and 1.3 ± 0.2 cm, respectively. The study endpoints were early mortality and clinical and echocardiographic outcomes, freedom from cardiac-related deaths, and cardiac-related events. In-hospital death occurred in 5 patients (4.5%), without a statistically significant difference between the 2 groups (P = .72). The 5-year freedom from cardiac-related deaths and cardiac-related events in the PPM relocation group versus the RA group was 90.9% ± 1.8% versus 89% ± 1.6% (P = .82) and 83% ± 2.1% versus 65.4% ± 1.2% (P < .001), respectively. Recurrent MR equal to or greater than moderate occurred in 2 (3.7%) and 6 (11.5%) patients in the PPM relocation group and RA group (P = .01), respectively. Moreover, we found statistically significant differences for the postoperative mean tenting area and coaptation depth in both groups (P < .001). PPM relocation in conjunction to mitral annuloplasty is an easy and safe method and can be performed without an increase in-hospital mortality. This technique reduced the tenting area and coaptation depth compared with isolated RA, leading to improvement in the incidence of recurrent MR. The PPM group of patients experienced fewer cardiac-related events.

Fattouch K ，Lancellotti P ，Castrovinci S ，Murana G ，Sampognaro R ，Corrado E ，Caruso M ，Speziale G ，Novo S ，Ruvolo G ... -  《-》

Papillary muscle relocation and mitral annuloplasty in ischemic mitral valve regurgitation: midterm results.

The surgical approach for ischemic mitral regurgitation remains unclear. Many studies are in favor of adding the subvalvular procedure to mitral annuloplasty to reduce recurrent mitral regurgitation. This study reports the clinical and echocardiographic outcomes of papillary muscle relocation combined with mitral annuloplasty. From 2003, 115 patients with severe ischemic mitral regurgitation who underwent papillary muscle relocation plus nonrestrictive mitral annuloplasty and coronary artery bypass grafting were retrospective analyzed. Patients' mean age was 52±12.8 years, New York Heart Association class III or IV was 71%, and preoperative left ventricular ejection fraction was 43%±6%. The study end points were New York Heart Association functional class, reversal in left ventricle remodeling, reduction of mean tenting area and mean coaptation depth, freedom from cardiac-related deaths and events, and freedom from recurrent mitral regurgitation. Follow-up data were obtained in all patients and were 100% complete. Mean follow-up was 45±6 months. Five-year freedom from cardiac-related death and events was 91.3%±1.6% and 84%±2.2%, respectively. Recurrent mitral regurgitation more than moderate occurred in 3 patients (2.7%). Reversal in left ventricular remodeling, measured by a change in the end-diastolic and systolic diameter, was observed in our patients (P<.05). The postoperative mean tenting area and mean coaptation depth were 1.1±0.2 cm2 and 0.5±0.2 cm, respectively; 95% of the patients were in New York Heart Association functional class I and II. In patients with ischemic mitral regurgitation, papillary muscle relocation plus nonrestrictive mitral annuloplasty promotes a significant reversal in left ventricular remodeling, with a considerable decrease in tenting area and coaptation depth. Our approach is a durable method to reduce the recurrence of mitral insufficiency.

Fattouch K ，Castrovinci S ，Murana G ，Dioguardi P ，Guccione F ，Nasso G ，Speziale G ... -  《-》

Mitral valve annuloplasty and papillary muscle relocation oriented by 3-dimensional transesophageal echocardiography for severe functional mitral regurgitation.

The study of the mitral valve apparatus and its modifications during functional mitral regurgitation (FMR) is better revealed by 3-dimensional (3D) transesophageal echocardiography (TOE). To plan mitral valve repair by annuloplasty and papillary muscle (PPM) relocation, we proposed a valve repair procedure oriented by the new main features obtained by real-time 3D TOE reconstruction of the mitral valve apparatus. Since January 2008, 25 patients with severe FMR before mitral valve repair were examined. Mean coaptation depth and mean tenting area were 1.3 ± 0.2 cm and 3.2 ± 0.5 cm(2), respectively. Intraoperative 2D and 3D TOE were performed, followed by a 3D offline reconstruction of the mitral valve apparatus. A schematic mitral valve apparatus model was obtained. A geometric model like a truncated cone was traced in according to the preoperative measurements. The size of the prosthetic ring was selected preoperatively according to the anterior leaflet surface. The expected truncated cone after annuloplasty was retraced. A conventional normal coaptation depth about 0.6 cm was used to detect the new position of the PPM tips. Offline reconstruction of the mitral valve apparatus and respective truncated cone were feasible in all patients. The expected position of the PPM tips desirable to reach a normal tenting area with a coaptation depth 0.6 cm or less was obtained in all patients. After surgery, all parameters were calculated and no statistically significant difference was found compared with the expected data. PPM relocation plus ring annuloplasty reduce mitral valve tenting and may improve mitral valve repair results for patients with severe FMR. This technique may be easily and precisely guided by preoperative offline 3D echocardiographic mitral valve reconstruction.

Fattouch K ，Murana G ，Castrovinci S ，Mossuto C ，Sampognaro R ，Borruso MG ，Bertolino EC ，Caccamo G ，Ruvolo G ，Lancellotti P ... -  《-》

A Comparison of 2 Mitral Annuloplasty Rings for Severe Ischemic Mitral Regurgitation: Clinical and Echocardiographic Outcomes.

Controversies regarding the choice of annuloplasty rings for treatment of ischemic mitral regurgitation still exist. Aim of the study is to compare early performance of 2 different rings in terms of rest and exercise echocardiographic parameters (transmitral gradient, systolic pulmonary artery pressure, and mitral valve area), clinical outcomes, and recurrence of mitral regurgitation. From January 2008 till December 2013, prospectively collected data of patients who underwent coronary artery bypass grafting and undersizing mitral valve annuloplasty for severe chronic ischemic mitral regurgitation at our Institution were reviewed. A total of 93 patients were identified; among them 44 had semirigid Memo 3D ring implanted (group A) whereas 49 had a rigid profile 3D ring (group B). At 6 months, recurrent ischemic mitral regurgitation, equal or more than moderate, was observed in 4 and 6 patients in the group A and B, respectively (P = 0.74). Group A showed certain improved valve geometric parameters such as posterior leaflet angle, tenting area, and coaptation depth. Transmitral gradient was significantly higher at rest in the group B (P < 0.0001). During exercise, significant increase of transmitral gradient and systolic pulmonary artery pressure was observed in group B (P < 0.0001). Mitral valve area was not statistically significantly smaller at rest in between groups (P = 0.09); however, it significantly decreased with exercise in group B (P = 0.01). At midterm follow-up, patients in group B were more symptomatic. In patients with chronic ischemic mitral regurgitation, use of semirigid Memo 3D ring when compared to the rigid Profile 3D may be associated with early improved mitral valve geometrical conformation and hemodynamic profile, particularly during exercise. No difference was observed between both groups in recurrent mitral regurgitation.

Fattouch K ，Moscarelli M ，Castrovinci S ，Guccione F ，Dioguardi P ，Speziale G ，Lancellotti P ... -  《-》