Ann Thorac Surg 2007;84:2130-2131. doi:10.1016/j.athoracsur.2007.04.056
© 2007 The Society of Thoracic Surgeons
How To Do It
Papillary Muscle Approximation for Functional Ischemic Mitral Regurgitation
Akhtar Rama, MD,
Levy Praschker, MD*,
Eleodoro Barreda, MD,
Iradj Gandjbakhch, MD
Department of Thoracic and Cardiovascular Surgery, University of Paris VI Pierre et Marie, Groupe Hospitalier Pitie-Salpêtrière, Assistance Publique—Hôpitaux de Paris, Paris, France
Accepted for publication April 16, 2007.
* Address correspondence to Dr Praschker, Department of Thoracic and Cardiovascular Surgery, Groupe Hospitalier Pitie-Salpêtrière, 47-83, Boulevard de l’Hôpital, Cedex 13, Paris, 75651, France (Email: beltranlevy{at}hotmail.com).
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Abstract
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In patients with ischemic left ventricular dysfunction and functional mitral regurgitation, surgical treatment of mitral insufficiency remains a challenging issue. Several procedures have been described to restore a near to natural alignment between the mitral annulus and the laterally displaced papillary muscles. We report a new approach to relocate the displaced papillary muscles toward the mitral annulus and to reduce tethering in 8 patients, providing satisfactory initial results. Echocardiography showed mild or no mitral regurgitation at the follow-up (mean, 11.4 ± 3.6 months; range = 7 to 14 months). This procedure is believed to be technically easy and beneficial in terms of mitral repair.
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Introduction
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Left ventricle dilatation occurs in a chronic process of ventricular remodeling in patients with ischemic left ventricular dysfunction, which subsequently favors abnormal displacement of the papillary muscles leading to an excessive tension of the mitral valve chordae, creating mitral insufficiency by incomplete closure [1, 2]. Due to these geometric and functional abnormalities of the valvular and subvalvular apparatus, standard procedures for ischemic mitral regurgitation have not been established. The recurrence of mitral regurgitation after mitral annuloplasty alone is high [3, 4], suggesting that the corrections should also focus on the mitral valve subvalvular apparatus. Therefore, several other procedures on the subvavluar apparatus have been described to correct functional ischemic mitral regurgitation [5–8], although technically demanding. With this in mind, we present a new approach as a supplementary procedure to the annuloplasty, an easy technique of papillary muscle approximation to the midline through a standard mitral valve approach.
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Technique
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Through a median sternotomy, cardiopulmonary bypass is established with ascending aorta and bi-caval cannulation. Warm-blood antegrade cardioplegia is used for myocardial protection. The mitral valve is exposed through the left interatrial groove cardiotomy. Once papillary muscle displacement is established and the valve is analyzed as anatomically normal, a single 2-0 U-shaped stitch reinforced by two patches of autologous pericardium is passed through the posterior and anterior papillary muscles and tightened, thus repositioning the papillary muscles to the midline (Figs 1 and 2).
The procedure is completed by mitral annuloplasty with a slightly undersized flexible ring and necessary coronary artery bypass grafts if needed.
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Fig 1. A single coated, braided, polyester 2-0 U-shaped suture reinforced by two patches of autologous pericardium is passed through the bodies of the posterior and anterior papillary muscles. (AP = anterior papillary muscle; CHO = mitral valve chordae; PP = posterior papillary muscle.)
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Fig 2. Mitral plasty final aspect with repositioning of the papillary muscles to the mid-line and insertion of flexible mitral ring. (AP = anterior papillary muscle; CHO = mitral valve chordae; PP = posterior papillary muscle.)
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Comment
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Between December 2005 and July 2006, 8 patients (6 men and 2 women) with functional ischemic mitral regurgitation were operated on with this technique. Their mean left ventricular ejection fraction was 36 ± 12% (range, 20 to 60). Five patients (63%) were in New York Heart Association functional class III or IV. Preoperative echocardiographic assessment showed a mitral regurgitation grade of 3 in 6 patients and a grade of 2 in 2 patients. The mean left ventricular end-diastolic diameter was 62 ± 11 mm (range, 45 to 77 mm). In all patients but 2, systolic pulmonary artery pressure was greater than 50 mm Hg (mean, 46 ± 5 mm Hg; range, 44 to 55). Concomitant coronary artery bypass grafting procedures were performed in all 8 patients. The mean coronary artery anastomosis per patient was 2.8 ± 0.5 (range, 2 to 3). Other procedures included linear suturing of a left ventricle aneurysm. Intraoperative transesophageal echocardiogram showed no mitral insufficiency at the end of the surgery. Two patients died during the postoperative period and both of them presented a postoperative pulmonary infection and sepsis, which led to multiorgan failure and death at days 16 and 21, respectively. At the follow-up (mean, 11.4 ± 3.6 months; range, 7 to 14 months) 1 patient died at 7 months postoperatively due to a hemorrhagic stroke. He was under anticoagulant therapy for atrial fibrillation. All other 5 patients discharged from the hospital were alive. All were in New York Heart Association functional class I. The echocardiography showed mild or no mitral regurgitation in all 6 patients. Mean left ventricular ejection fraction was 59 ± 17% (range, 35 to 75). Mean left ventricular end-diastolic diameter was 59.8 ± 3.8 mm (range, 57 to 65). No valve-related complication or reintervention was observed during follow-up. Functional ischemic mitral regurgitation is a dynamic process in which the ischemic left ventricular remodeling leads to papillary muscle displacement and annular dilation, tethering the mitral leaflets and restricting their ability to close effectively [1, 2]. A successful valve repair must target the dysfunction mechanism, as annuloplasty addresses only one of the components; the surgical strategy should also correct the papillary muscle displacement. With this in mind, a variety of techniques were proposed to achieve papillary muscle repositioning by infarct plication, by external constraint applied to reverse left ventricle remodeling locally, or by direct traction [4–8]. Although these techniques offered good results, they are both time consuming and technically demanding. In the present article, we propose a technique of papillary muscle approximation repositioning that is complementary to annuloplasty and can be used in all patients with functional ischemic mitral regurgitation, which is not time consuming and is technically easy with good initial results. Although our surgical method of papillary muscle approximation repositioning is believed to correct papillary muscle displacement by a more natural "papillary muscle-to-mitral annulus" alignment, further clinical assessment on left ventricle dynamics and recurrence of mitral regurgitation should be performed in long-term studies.
Functional ischemic mitral regurgitation is a complex issue in which mitral annulus dilatation and left ventricle remodeling interplay to create a dynamic lesion for which the best surgical approach is yet to be determined.
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Acknowledgments
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We would like to thank Martine Collomb for her assistance with the correction of this article.
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References
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- Otsuji Y, Handschumacher, MD, Liel-Cohen N, et al. Mechanism of ischemic mitral regurgitation with segmental left ventricular dysfunction: three-dimensional echocardiographic studies in models of acute and chronic progressive regurgitation J Am Coll Cardiol 2001;37:641-648.[Abstract/Free Full Text]
- Godley RW, Wann LS, Rogers EW, Feigenbaum H, Weyman AE. Incomplete mitral leaflet closure in patients with papillary muscle dysfunction Circulation 1981;63:565-571.[Abstract/Free Full Text]
- McGee EC, Gillinov AM, Blackstone EH, et al. Recurrent mitral regurgitation after annuloplasty for functional ischemic mitral regurgitation J Thorac Cardiovasc Surg 2004;128:916-924.[Abstract/Free Full Text]
- Kuwahara E, Otsuji Y, Iguro Y, et al. Mechanism of recurrent/persistent ischemic/functional mitral regurgitation in the chronic phase after surgical annuloplasty: importance of augmented posterior leaflet tethering Circulation 2006;114(1 Suppl):I529-I534.[Medline]
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- Hvass U, Tapia M, Baron F, Pouzet B, Shafy A. Papillary muscle sling: a 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]
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Abstract
Introduction
