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Ann Thorac Surg 2006;81:2324-2325
© 2006 The Society of Thoracic Surgeons

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How to do it

New Surgical Approach to Reduce Tethering in Ischemic Mitral Regurgitation by Relocation of Separate Heads of the Posterior Papillary Muscle

^a Department of Thoracic and Cardiovascular Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima City, Kagoshima, Japan
^b Department of Cardiology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima City, Kagoshima, Japan

Accepted for publication March 16, 2005.

^_* Address correspondence to Dr Ueno, Department of Thoracic and Cardiovascular Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima City, Kagoshima, 890-8520 Japan (Email: tueno{at}m.kufm.kagoshima-u.ac.jp).

	Abstract

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The surgical treatment of chronic ischemic mitral regurgitation remains a challenging issue. Several procedures have been developed to correct displacement of the papillary-ventricular complex and to reduce tethering-induced regurgitation. We report a geometric approach to relocate the laterally displaced posterior papillary muscle towards the mitral annulus. This procedure is believed to be technically easy and useful, especially in cases in which the displaced posterior papillary muscle contributes to tethering-induced regurgitation.

	Introduction

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Because geometric and functional abnormalities in the valvular-ventricular complex may contribute to the ischemic mitral regurgitation, standard procedures for ischemic mitral regurgitation have not yet been established. Mitral annuloplasty alone may not be sufficient to prevent the recurrence of regurgitation [1]. Several other procedures on subvalvular apparatus were shown to be useful for the correction of ischemic mitral regurgitation [2–5]. As a supplemental procedure to annuloplasty, we present here a unique approach to reduce tethering by relocation of the posterior papillary muscle (PM) toward the mitral valve by folding the adjacent left ventricular (LV) wall.

	Technique

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A 67-year-old man was transferred to our hospital by ambulance under intraaortic balloon pump support. Coronary angiography showed occlusion of the left anterior descending artery and right coronary artery, and 90% stenosis of a large diagonal branch. Echocardiography demonstrated broad akinesis of the anteroseptal and postero-inferior wall associated with moderate mitral regurgitation. The LV end-diastolic and end-systolic volumes were 175 mL (index, 109 mL/m²) and 124 mL (index, 78 mL/m²), respectively; the calculated LV ejection fraction was 29%.

Intraoperative transesophageal echocardiography demonstrated that the tethering on medial posterior leaflet by the laterally displaced posterior papillary muscle (PPM) contributed to mitral regurgitation in addition to the enlargement of the mitral annulus. Under cardioplegic arrest, the infarcted LV wall between the left anterior descending artery and a diagonal branch was incised. The anterior papillary muscle appeared almost intact. The PPM had two heads, a large and a small one separated by a distance of approximately 1 cm. The large head appeared to consist mostly of scar tissue and the small one was a mixture of several grades of infarcted tissue. To correct tethering originating mainly from the PPM, its larger head was anchored to the anterior papillary muscle by placing two pericardium-pledgetted 3-0 Nespolene sutures (Alfresa Pharma, Co, Tokyo, Japan) (papillary realignment) to lift the large head toward the mitral valve. Because the small head of the PPM was located apart from the large head, it was impossible to approximate it together with the large head.

As a new approach to lift the subvalvular apparatus and to shorten the tethering distance toward the mitral annulus, an autologous pericardium-pledgetted 3-0 Nespolene suture was passed to one side of the small PPM base from the LV lumen to the outside, and then from outside to inside toward another side of the PPM base, and then it was tied (Fig 1). Consequently the whole small PPM, which had been laterally deviated, was shifted medially and directed toward the mitral valve. The LV wall outside the base of the small PPM, in which local dimpling was created by the previously mentioned procedure, was reinforced by placing a felt-pledgetted 3-0 Nespolene suture. Consequently the small head of the PPM was relocated and the tethering distance was shortened.

View larger version (26K): [in this window] [in a new window]   Fig 1. Method of our regional left ventricular plication through left ventriculotomy. A large head of the posterior papillary muscle was anchored to the anterior papillary muscle by the papillary realignment technique. To reduce tethering originated from a small head of the posterior papillary muscle, one 3-0 Nespolene suture (Alfresa Pharma, Co, Tokyo, Japan) pledgetted by autologous pericardium was inserted from one side of the base of the posterior papillary muscle 2 from inside to outside of the LV lumen and passed the LV wall toward another side of its base, and was then tied. These combined procedures consequently contributed to shortening of the tethering length. The small posterior papillary muscle as a whole was elevated with this procedure (arrow).

An echocardiography performed 1 week postoperatively did not detect tethering of the mitral valve and regurgitation. The coaptation of the mitral valve, which had been dislocated toward the apex preoperatively, was reversed to the original level of the mitral annulus. Although follow-up echocardiography 7 weeks later showed dilatation of the LV chamber to approximately its preoperative size (possibly due to progressive LV remodeling), mitral regurgitation due to tethering was not detected.

	Comment

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For correction of displacement of the PPM, several procedures have been developed, including papillary muscle imbrication during LV plasty [2], relocation of the PPM by a traction suture [3], placement of a PM sling [4], and PM realignment through apical left ventriculotomy [5]. The concept of our method, to relocate the PPM toward the mitral valve and reduce the tethering distance, is basically similar to that of LV plication [6] or revision of ventricular remodeling by placing a patch device over the infarcted posterolateral region to reposition the displaced PM [7]. Our method is different in that LV plication is performed at a highly localized region of the infarcted LV wall as opposed to the entire region in previous methods. Our method is also unique in that we use two different techniques for reduction of tethering to the large and small heads of the PPM, depending on their anatomical characteristics.

To reposition the laterally displaced PPM toward the mitral valve, we performed standard papillary realignment for its large head and regional LV plication (our new approach) for its small head. Although both procedures were supposed to work to terminate tethering of the mitral valve, it was hard to tell which procedure worked to what degree. Our method is technically easy and should be quite useful in cases such as ours in which the displaced PPM was separated into multiple heads with considerable distance and each head contributed to tethering and mitral regurgitation to various degrees. It is noteworthy that despite LV dilatation as a consequence of progressive remodeling, tethering of the mitral valve was still attenuated, and there was physiologic coaptation and no recurrence of regurgitation on follow-up echocardiography.

There are a few limitations to our method. First, our method is better suited to cases requiring simultaneous ventriculoplasty for LV remodeling and dilatation by ischemia. Through a left atrial approach, our method may be technically demanding. Second, the LV wall adjacent to the base of the PPM should be adequately thin to be inverted without excessive wall tension. With the same reason as previously described, our method would not be indicated in the cases without transmural myocardial infarction. Although our surgical method is believed to be physiologic in that it is aimed at geometric correction of the laterally displaced PPM and its consequent mitral regurgitation, further clinical experience with this procedure may be necessary to establish its significance.

	References

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1. McGee EC, Gillinov AM, Blackstone EH, et al. Recurrent mitral regurgitation after anuloplasty for functional ischemic mitral regurgitation J Thorac Cardiovasc Surg 2004;128:916-924.[Abstract/Free Full Text]
2. Menicanti L, Donato MD, Frigiola A, et al. Ischemic mitral regurgitationintraventricular papillary muscle imbrication without ring during left ventricular restoration. J Thorac Cardiovasc Surg 2002;123:1041-1050.[Abstract/Free Full Text]
3. Kron IL, Green GR, Cope JT. Surgical relocation of the posterior papillary muscle in chronic ischemic mitral regurgitation Ann Thorac Surg 2002;74:600-601.[Abstract/Free Full Text]
4. Hvass U, Tapia M, Baron F, Pouzet B, Shafy A. Papillary muscle slinga new functional approach to mitral repair in patients with ischemic left ventricular dysfunction and functional mitral regurgitation. Ann Thorac Surg 2003;75:809-811.[Abstract/Free Full Text]
5. Nair RU, Williams SG, Nwafor KU, Hall AS, Tan LB. Left ventricular volume reduction without ventriculectomy Ann Thorac Surg 2001;71:2046-2049.[Abstract/Free Full Text]
6. Liel-Cohen N, Guerrero JL, Otsuji Y, et al. Design of a new surgical approach for ventricular remodeling to relieve ischemic mitral regurgitationInsights from 3-dimensional echocardiography. Circulation 2000;101:2756-2763.[Abstract/Free Full Text]
7. Hung J, Guerrero JL, Handschumacher MD, Supple G, Sullivan S, Levine RA. Reverse ventricular remodeling reduces ischemic mitral regurgitationEcho-guided device application in the beating heart. Circulation 2002;106:2594-2600.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Tetsuya Ueno Ryuzo Sakata Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ueno, T. Articles by Tei, C. Search for Related Content PubMed PubMed Citation Articles by Ueno, T. Articles by Tei, C. Related Collections Myocardial infarction