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Ann Thorac Surg 2003;76:1556-1563
© 2003 The Society of Thoracic Surgeons

Original article: cardiovascular

Annuloplasty ring selection for chronic ischemic mitral regurgitation: lessons from the ovine model

Joseph H. Gorman, III, MDa*, Robert C. Gorman, MDa, Benjamin M. Jackson, MDa, Yoshiharu Enomoto, MDa, Martin G. St. John-Suttonb, L. Henry Edmunds, Jr, MDa

a Harrison Department of Surgical Research, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
b Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA

Accepted for publication May 20, 2003.

* Address reprint requests to Dr Joseph H. Gorman, Department of Surgery, 6 Silverstein Pavilion, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
e-mail: gormanj{at}uphs.upenn.edu

BACKGROUND: Chronic ischemic mitral regurgitation (CIMR) is poorly understood and repair operations are often unsatisfactory. This study elucidates the mechanism of CIMR in an ovine model.

METHODS: Sonomicrometry array localization measured the three-dimensional geometry of the mitral annulus and subvalvular apparatus in five sheep before and 8 weeks after a posterior infarction of the left ventricle that produced progressive severe CIMR.

RESULTS: End systolic annular area increased from 647 ± 44 mm2 to 1,094 ± 173 mm2 (p = 0.01). Annular dilatation occurred equally along the anterior (47.0 ± 5.6 mm to 60.2 ± 4.9 mm, p = 0.001) and posterior (53.8 ± 3.1 mm to 68.5 ± 8.4 mm, p = 0.005) portions of the annulus. The tip of the anterior papillary muscle moved away from both the anterior and posterior commissures by 5.2 ± 3.2 mm (p = 0.021) and 7.3 ± 2.2 mm (p = 0.002), respectively. The distance from the tip of the posterior papillary muscle to the anterior commissure increased by 11.0 ± 5.7 mm (p = 0.032) while the distance from the tip of the posterior papillary muscle to the posterior commissure remained constant.

CONCLUSIONS: Progressive dilatation of both the anterior and posterior mitral annuli, increased annular area, and asymmetric ventricular dilatation combine to cause CIMR by distortion of mitral valve geometry and tethering of leaflet coaptation. Therefore complete ring annuloplasty may be superior to partial annuloplasty in the treatment of CIMR.




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