Ann Thorac Surg 2007;83:963
© 2007 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Invited commentary
Donald Glower, MD
Department of Surgery, Duke University Medical Center, Box 3851, Durham, NC 27710
(Email: glowe001{at}mc.duke.edu).
This study [1] is a refreshingly high-quality randomized trial with blinded echocardiographic review. The technique described is potentially applicable to routine mitral replacement. Chordal preservation (ie, preservation of the posterior leaflet chords in particular) has been shown to essentially eliminate the dreaded complication of ventricular-annular separation. Chordal preservation has also been shown to better preserve ventricular function and dimensions compared with chordal resection. Yet in many cases in which the posterior leaflet or annulus, or both, are involved with bulky disease, chordal preservation can be difficult at best. The papillary muscle repositioning technique described here could potentially replace or supplement chordal preservation in these difficult cases.
Optimizing suture length has been difficult while placing artificial chords in mitral repair. Similarly, achieving the correct distance or tension between the base of the papillary muscle and the annulus could be challenging in the papillary muscle repositioning technique, especially given that the lengths of the resected chords of the papillary muscles themselves can vary. Yet, by simply attaching the heads of the papillary muscles to the annulus, the authors reported no such problems. As has been seen in left ventricular aneurysm resection, leaving the left ventricular cavity too small with papillary muscle repositioning could theoretically impair stroke volume, whereas leaving the distance from the annulus to the base of the papillary muscle excessively long may be of little benefit.
Why sutures were better than native chords in this study is unclear. It is likely that the authors reduced cavitary volume by reducing the distance from the base of the papillary muscle to the annulus with the papillary muscle repositioning technique. It may be important that this series examined only patients with left ventricular ejection fraction less than 40% and mitral regurgitation. Whether the technique would apply to patients with mitral stenosis or normal left ventricular function is unclear. This series is also too small to know whether papillary muscle repositioning will eliminate ventricular-annular separation, and the 2-year intermediate-term results will need to be supplemented with longer term follow-up. The authors are nonetheless to be congratulated for an intriguing, well-designed study that could benefit many patients.
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- Yousefnia MA, Mandegar MH, Roshanali F, Alaeddini F, Amouzadeh F. Papillary muscle repositioning in mitral valve replacement in patients with left ventricular dysfunction Ann Thorac Surg 2007;83:958-963.[Abstract/Free Full Text]
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Papillary Muscle Repositioning in Mitral Valve Replacement in Patients With Left Ventricular Dysfunction
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