Mitral Suture Annuloplasty Corrects both Annular and Subvalvular Geometry in Acute Ischemic Mitral Regurgitation

Frederick A. Tibayan, Filiberto Rodriguez, Frank Langer, David Liang, George T. Daughters3, Neil B. Ingels, D. Craig Miller
Department of Cardiovascular and Thoracic Surgery, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, Laboratory of Cardiovascular Physiology and Biophysics, Research Institute of the Palo Alto Medical Foundation, Palo Alto, CA, USA
 

Background and aim of the study: Papillary muscle displacement is an important element in the pathogenesis of ischemic mitral regurgitation (IMR). The effects of standard ring annuloplasty on subvalvular geometry are incompletely understood. The hypothesis was tested that annular reduction with a Paneth-type suture annuloplasty would correct both annular and papillary muscle geometric abnormalities during acute left ventricular (LV) ischemia.
Methods: Eight adult sheep underwent insertion of an adjustable, double-suture Paneth-type mitral annuloplasty and radiopaque markers on the left ventricle, mitral annulus, leaflet edges, and anterior (APM) and posterior (PPM) papillary muscle tips. Immediately after surgery, 3-D marker coordinates were determined during Control conditions and during proximal left circumflex occlusion before and after tightening the annuloplasty suture.
Results: Acute IMR (MR grade 0.3 ± 0.3 to 2.1 ± 0.4, Control versus Ischemia) was associated with end-systolic LV dilatation (+27 ± 16 ml, change relative to Control), greater septal-lateral (+4.6 ± 3.1 cm) and commissure-commissure

(+3.3 ± 1.6 cm) mitral annular diameters, longer anterior (+1.5 ± 0.9 cm) and posterior (+0.6 ± 0.9 cm) papillary muscle tethering distances, greater distance from the APM to the anterior commissure (+0.9 ± 0.8 cm), and shorter distance from the PPM to the posterior commissure (-1.3 ± 1.5 cm). Suture annuloplasty corrected the annular and subvalvular changes, and IMR returned to Control levels (0.5 ± 0.5); only LV end-systolic volume (ESV) was different from Control (+ 25 ± 18 ml) (mean ± SD, p <0.05 versus Control by RMANOVA and Dunnett’s test).
Conclusion: Suture annuloplasty corrected ischemia-induced end-systolic distortions of the entire valvular-ventricular complex (i.e. inter-leaflet separation, mitral annular dilatation in both axes, and papillary muscle displacements), and abolished acute IMR, independent of any change in ESV. A better understanding of the effects of annular reduction on papillary muscle geometry may lead to improved subvalvular mitral repair techniques.
The Journal of Heart Valve Disease 2004;13:414-420
 
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