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Background
Since reduction annuloplasty alone for ischemic mitral regurgitation (MR) cannot prevent late recurrence of MR or improve survival for those with left ventricular (LV) dysfunction, and the surgical approach to this etiology is still controversial, we conducted a study to assess the efficacy of the additional papillary muscle approximatio...
Context in source publication
Context 1
... details of the procedure were described elsewhere [13]. The papillary muscles were entirely approximated side-by- side (complete PMA) through an LV incision or partially from the tips to the mid-parts (incomplete PMA) through the mitral or aortic valve using pledgetted mattress sutures of 3-0 polypropylene (Figure 1). The method was selected based on the presence of a myocardial scar lesion on the anterior LV wall. ...Similar publications
Aims:
The transcatheter mitral valve interventions (TRAMI) registry was established in order to assess safety and efficacy of catheter-based mitral valve interventional techniques in Germany, and prospectively enrolled 828 MitraClip patients (median age 76 years, median log. EuroSCORE I 20.0%) between August 2010 and July 2013. We present the 1-ye...
This paper presents a case study of a 30-year-old male patient with dyspnea on exertion had echocardiographic diagnosis of aortic subvalvar stenosis. Discrete mitral regurgitation and aortic valve dysplasia with mild to moderate insufficiency and hypertrophic cardiomyopathy were also noted. During surgery, a rare condition was identified: presence...
Transcatheter therapy for valvular heart disease (VHD) as an alternative for surgery, as the standard of care, has emerged rapidly over the last 10 years. Since the first transcatheter heart valve (THV) implantation in pulmonary position, in 2000, and in aortic position, in 2002, an enormous number of high-risk patients have undergone percutaneous...
MV repair in the rheumatic population is feasible with acceptable long-term results. Incidence of mitral stenosis (MS) following mitral valve (MV) repair for severe rheumatic mitral regurgitation (MR) and usefulness of percutaneous transluminal mitral valvuloplasty in these patients is not described in literature. We report a case of successful PTM...
Introduction and objectives: The Spanish Society of Thoracic and Cardiovascular Surgery Valve Repair
Working Group presents the third annual activity report in reconstructive surgery of the mitral, aortic
and tricuspid valves performed in Spain in 2013.
Methods: Datawere obtained using aweb-based survey forwhich participationwas voluntary. The num-...
Citations
... However, the corresponding papillary muscle may sometimes be small and fragile, and artifcial chordal reconstruction may need to be performed from other large papillary muscles [20]. Mitral valve repair with subvalvular apparatus intervention, such as approximation of the papillary muscle for ventricular functional mitral regurgitation, has also been performed [21,22]. For these surgical procedures, it may be useful to clearly visualize the papillary muscle morphology in preoperative imaging studies, so that the papillary muscle for suturing the artifcial chordae can be determined preoperatively. ...
Background. The morphology of the papillary muscles of the left ventricle is highly variable. Few studies have investigated papillary muscle morphology using imaging. Objective. This study aimed to assess papillary muscle morphology with primary mitral regurgitation (MR) using cardiac computed tomography (CT). Methods. We examined 116 patients who underwent robotic mitral valve repair for primary MR using preoperative cardiac CT. Papillary muscle morphology was assessed using CT images and compared with operative findings. Results. CT images of papillary muscles were consistent with the operative findings during robotic mitral valve repair in all cases. Both the anterolateral papillary muscle (APM) and posteromedial papillary muscle (PPM) groups were identified in all cases, and the middle papillary muscle (MPM) group was identified in 24.1% of cases. The PPM group had a higher proportion of complex morphologies with more heads and bases than the APM group (head: p < 0.001 and base: p < 0.001 ). The PPM group had smaller papillary muscle sizes than the APM group. The MPM group in most patients had one base and one head (78.6%). Papillary muscle sizes were significantly smaller in the order of the APM, PPM, and MPM groups ( p < 0.001 ). Conclusions. Cardiac CT allowed clear visualization and accurate assessment of papillary muscle morphology in the left ventricle. It may be useful to obtain the papillary muscle variations preoperatively using CT imaging in procedures involving the papillary muscles such as mitral valve repair.
... Complete approximation of the papillary muscles from the tip to the base is associated with a longer survival than incomplete approximation (only the tip) 57) . This also suggests that an LV incision, which is required for complete approximation, contributes to better outcomes by excluding scars on the incision line. ...
Chronic ischemic mitral regurgitation (MR) is a functional valvular disorder that occurs secondary to left ventricular remodeling due to old myocardial infarction or chronic myocardial ischemia. The presence of ischemic MR promotes further left ventricular remodeling and results in adverse outcomes. The goals of ischemic MR treatment are durable control of MR, left ventricular reverse remodeling, and improvement of the survival. However, surgical repair of the mitral valve alone may fail to achieve these goals. Furthermore, the mid-term mortality rate after endovascular repair remains high, although its survival benefit over medication was proven in a recent randomized trial. Therefore, to achieve these goals, treatment should target not only the mitral valve but also the left ventricle. In addition to maximally tolerated medical treatment and complete coronary revascularization, surgical procedures targeting the left ventricular should be added to mitral procedure to minimize the risk of adverse outcomes. Chordal preservation in the replacement of the mitral valve and subvalvular procedure is known to achieve left ventricular remodeling. Left ventriculoplasty can ameliorate adverse effects related to myocardial scarring. Despite the lack of evidence, such procedures have the potential to improve outcomes and may contribute to establishing an optimal treatment strategy. In this paper, the relationship between the pathological conditions of ischemic MR, predictors of adverse outcomes, and the effect of each treatment option was summarized by reviewing the literature.
... Wakasa et al. reported, in patients with a transmural scar of the anterior LV wall, a complete side-by-side PMA through an anterior LV incision. The combined subvalvular repair and reconstruction of left ventricular wall was associated with concomitant MV annuloplasty [68] (Figures 4(a) and 4(b)). ...
... In another report by Wakasa et al. [68], 90 patients with IMR were studied. 30 patients received annuloplasty alone while 60 patients had combined subvalvular repair without (n = 26) or with (n = 34) left ventriculoplasty. ...
Background
Mitral valve disease surgery is an evolving field with multiple possible interventions. There is an increasing body of evidence regarding the optimal strategy in secondary mitral regurgitation where the pathology lies within the ventricle. We conducted a systematic review to identify the benefits and limitations of each surgical option.
Methods
A systematic review of the literature was performed to identify pertinent randomized controlled trials (RCTs), propensity-matched observational series, and meta-analyses which were considered initially and followed by unmatched observational series using the MEDLINE, Ovid EMBASE, and Cochrane Library.
Results
We identified 6 different strategies for treating secondary mitral valve regurgitation; mitral valve replacement, restrictive mitral annuloplasty, surgical revascularisation (with and without mitral annuloplasty), subvalvular procedures (papillary muscle approximation, papillary muscle relocation, Ring and String procedure), and procedures directly targeting the mitral valve (edge-to-edge repair and anterior leaflet enlargement) alongside transcatheter heart valve therapy. We also highlighted the role of left ventricular assist devices in the management of this condition. The benefits and limitations of each intervention are highlighted.
Conclusion
There is currently no unanimous and shared strategy for the optimal treatment of patients with secondary IMR. The management of patients with secondary mitral regurgitation must be entrusted to a multidisciplinary Heart Team to ensure ideal intervention and patient matching for the best outcomes.
... This approach builds on the evidence that our group reported in human patients that lateral separation of the papillary muscles is a strong driver of FMR in heart failure. 3,4 Despite some early successful attempts at adopting this technique into mainstream surgical practice, 22,23 mechanistic data to support its further adoption remain lacking. ...
Background: Undersizing mitral annuloplasty (UMA) to repair functional mitral regurgitation lacks durability, as it forces leaflet coaptation without relieving the sub-leaflet tethering forces. In this biomechanical study, we demonstrate that papillary muscle approximation (PMA) prior to UMA can drastically relieve tethering forces and improve valve function, without the need for significant annular downsizing.
Methods: An ex vivo model of functional mitral regurgitation (FMR) was used, in which pig mitral valves were geometrically perturbed to induce FMR, and the repairs were performed. Nine pig mitral valves were studied as follows: normal(baseline), functional mitral regurgitation (FMR), true-sized annuloplasty to 30mm (TSR), and undersized annuloplasty to 26mm (DSR); and concomitant papillary muscle approximation (PMA) at both ring sizes. Mitral regurgitation, valve kinematics, and chordal forces were measured and compared between groups.
Results: FMR geometry induced a 16.31±7.33% regurgitant fraction, compared to none at baseline. 30mm/TSR reduced regurgitation to 6.05±5.63% and a 26mm/DSR to 5.06±6.76%. Addition of papillary muscle approximation prior to either rings, reduced regurgitation to 3.87±6.79% with the true sized ring (TSR+PMA), and 3.71±6.25% with the downsized ring (DSR+PMA). Peak anterior and posterior marginal chordal forces were elevated to 0.09±0.1N and 0.12±0.1N respectively with FMR, which were not reduced by annuloplasty of either sizes. Addition of PMA, reduced the forces significantly to 0.23±0.02N and 0.51±0.04N.
Conclusion: This biomechanical study, demonstrates that papillary muscle approximation relieves tethering forces and when added to annuloplasty, and mobilizes the leaflets to achieve a good valve closure. Such a result could be achieved without the need for extensive annular downsizing.
... Initially, sharing the same surgical principle and ensuring good results when performed in addition to rMVA, surgeon preference and experience were the major determinants of choice between the two aforementioned techniques [61]. ...
Dysfunction of the left ventricle (LV) with impaired contractility following chronic ischemia or acute myocardial infarction (AMI) is the main cause of ischemic mitral regurgitation (IMR), leading to moderate and moderate-to-severe mitral regurgitation (MR). The site of AMI exerts a specific influence determining different patterns of adverse LV remodeling. In general, inferior-posterior AMI is more frequently associated with regional structural changes than the anterolateral one, which is associated with global adverse LV remodeling, ultimately leading to different phenotypes of IMR. In this narrative review, starting from the aforementioned categorization, we proceed to describe current knowledge regarding surgical approaches in the management of IMR.
... Despite unabated enthusiasm in this hypothesis [5][6][7][8][9] , there is no data that confirms that leaflets grow (i.e. increase in size, mass and cellularity) and not plainly elongate, as most soft tissues do, when tethered. The second hypothesis has spawned research into restoring inter-papillary muscle dimensions with papillary muscle approximation as a simple surgical or interventional approach to restore physiological force balance, and correct the regurgitation [10][11][12][13][14] . Since elevated systolic inter-papillary muscle J o u r n a l P r e -p r o o f separation and reduced diastolic-to-systolic interpapillary muscle shortening can stretch the mitral leaflet edges, and restrict the formation of a vertical coaptation shelf, a technique to approximate the muscles may ameliorate valve dysfunction. ...
... Завершается реконструкция ремоделирующей аннулопластикой или гиперкоррекцией с использованием полужестких или жестких опорных колец (рис. 9) [51]. ...
p>The optimal treatment strategy for secondary mitral regurgitation of type IIIb (A. Carpentier classification) remains debatable. The use of a standard surgical technique for treating secondary mitral regurgitation and undersized ring annuloplasty demonstrates suboptimal results in several patients (about 30% of the patients exhibit postoperative hemodynamically significant mitral regurgitation with the absence of effective reverse remodelling of the left ventricle). Such suboptimal results are associated with the unification of only the mitral valve reconstruction technique, irrespective of the state of the left ventricle (degree of dysfunction, dilatation, tethering/tenting, and papillary muscle displacement); this is not entirely justified because of the disease complexity (valve and ventricular), and it is crucial to influence both the components of the disease. Particularly, modern researchers are inclined toward the need of using additional reconstructive interventions on the subvalvular structures that contribute to a more effective reverse remodelling of the left ventricle.
Here, we present a review of recent studies on the surgical treatment of functional mitral insufficiency of type IIIb (A. Carpentier classification) with effects on the subvalvular structures (pupillary muscle relocation and approximation).
Revised 19 April 2020. Revised 5 May 2020. Accepted 28 May 2020.
Funding: The study did not have sponsorship.
Conflict of interest: Authors declare no conflict of interest.</p
... In the presence of a transmural scar of the anterior LV wall, we perform a complete side-by-side PMA through an anterior LV incision (Fig. 5). In all patients, concomitant MV annuloplasty with a true-or undersized semi-rigid or rigid ring is performed [55]. ...
... The efficacy of PMA has been investigated in several observational studies and 1 RCT [55][56][57][58][59]. The RCT compared RMA + PMA (n = 48) to RMA alone (n = 48) for patients with severe ischaemic MR [59]. ...
... The MVP was conducted for all 10 patients. Briefly, papillary muscles were approximated side-by-side from the basis to the heads using three pledgeted mattress sutures (complete PMA) [9]. A CV-3 expanded polytetrafluoroethylene (ePTFE) suture was placed between the site of the chordal attachment of the approximated papillary muscles and the middle of the anterior mitral annulus. ...
Objectives
The slope in the preload recruitable stroke work relationship is a highly linear, load-insensitive contractile parameter. However, the perioperative change of the slope has not been reported before. We examined the perioperative slope from a steady-state single beat in patients with functional mitral regurgitation and assessed the correlation with brain natriuretic peptide (BNP) levels.
Methods
The study included 16 patients with non-ischemic dilated cardiomyopathy and refractory heart failure: 10 patients underwent mitral valve plasty and left ventricular plasty (MVP + LVP group) and 6 patients who underwent mitral valve replacement and papillary muscle tugging approximation (MVR + PMTA group). The left ventricular ejection fraction was assessed by the modified Simpson method; the slope was assessed by the single-beat technique using transthoracic echocardiography. BNP levels were measured by chemiluminescent immunoassay.
Results
The left ventricular ejection fraction and slope did not significantly change from pre- to early post-surgery in the MVP + LVP group. Both the left ventricular ejection fraction and slope significantly increased 6 months after surgery in the MVR + PMTA group. Postoperative BNP level was low in the MVR + PMTA group. While the postoperative left ventricular ejection fraction did not correlate with BNP levels, the postoperative slope significantly correlated with BNP level after surgery in the MVP + LVP group and in the total functional mitral regurgitation group.
Conclusions
The change of slope was dependent on surgical procedures. In functional mitral regurgitation, the slope may be a more sensitive parameter in reflecting the left ventricular contractile function than the left ventricular ejection fraction.
... Non-physiological high tension imposed on the papillary muscle tip or head in PMA can induce suture detachment and/or papillary muscle head rupture. Wakasa et al. advocated that the papillary muscle should be approximated until the basal papillary muscle in PMA [38]. Insufficient traction of the papillary muscles in PMR may also cause MR failure, suture detachment, and/ or papillary muscle head rupture [39]. ...
The purpose of this study was to evaluate the surgical results of papillary muscle approximation (PMA) and papillary muscle relocation (PMR) for functional mitral regurgitation (FMR) and to compare the effects of both procedures on the change in mitral regurgitation (MR) and echocardiogram parameters associated with tethering. Eighteen patients with moderate-to-severe FMR (MR grade ≥2) who underwent PMA or PMR were retrospectively analyzed. Underlying diseases were ischemic cardiomyopathy, idiopathic dilated cardiomyopathy, and aortic valve disease for seven, six, and five patients, respectively. Eleven patients underwent PMA and seven patients underwent PMR. Mitral annuloplasty and surgical ventricular restoration were performed concomitantly for 18 and 6 patients, respectively. None of these patients died in the hospital. Three patients died during the late period; two of these deaths were cardiac related. The rate of 3 years of freedom from cardiac-related death was 89%. After a mean follow-up of 33 months, MR grade was significantly improved compared with preoperative values (3.0 ± 0.8 to 0.7 ± 1.2; p < 0.01). Recurrence of MR grade ≥2 occurred in three patients and the rate of 3 years of freedom from recurrence of MR grade ≥2 was 87%. During follow-up, tenting height (1.1 ± 0.2 to 0.7 ± 0.2 cm; p < 0.01), tenting area (2.2 ± 0.7 to 0.9 ± 0.5 cm²; p < 0.01), and anterior leaflet tethering angle (39° ± 11° to 26° ± 8°; p < 0.01) were significantly improved compared with preoperative values. Posterior leaflet tethering angle significantly deteriorated from 40° ± 7° to 53° ± 15° (p < 0.01); however, it did not further deteriorate compared with the early postoperative value of 55° ± 16° (p = 0.7). There was no difference in echocardiogram parameters associated with tethering between PMA and PMR throughout the observation period. Both methods were associated with lasting relief of MR and reverse left ventricular remodeling. There was no difference between PMA and PMR regarding the effect on mitral valve competence. Both methods allowed durable mitral repair and good clinical outcomes.
