(Circulation. 2000;101:2756.)
© 2000 American Heart Association, Inc.
Basic Science Reports |
Design of a New Surgical Approach for Ventricular Remodeling to Relieve Ischemic Mitral Regurgitation
Insights From 3-Dimensional Echocardiography
From the Cardiac Ultrasound Laboratory and Cardiovascular Surgical Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
Correspondence to Robert A. Levine, MD, FACC, Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, VBK 508, Boston, MA 02114. E-mail rlevine{at}partners.org
Background—Mechanistic insights from 3D echocardiography (echo) can guide therapy. In particular, ischemic mitral regurgitation (MR) is difficult to repair, often persisting despite annular reduction. We hypothesized that (1) in a chronic infarct model of progressive MR, regurgitation parallels 3D changes in the geometry of mitral leaflet attachments, causing increased leaflet tethering and restricting closure; therefore, (2) MR can be reduced by restoring tethering geometry toward normal, using a new ventricular remodeling approach based on 3D echo findings.
Methods and Results—We studied 10 sheep by 3D echo just after circumflex marginal ligation and 8 weeks later. MR, at first absent, became moderate as the left ventricle (LV) dilated and the papillary muscles shifted posteriorly and mediolaterally, increasing the leaflet tethering distance from papillary muscle tips to the anterior mitral annulus (P<0.0001). To counteract these shifts, the LV was remodeled by plication of the infarct region to reduce myocardial bulging, without muscle excision or cardiopulmonary bypass. Immediately and up to 2 months after plication, MR was reduced to trace-to-mild as tethering distance was decreased (P<0.0001). LV ejection fraction, global LV end-systolic volume, and mitral annular area were relatively unchanged. By multiple regression, the only independent predictor of MR was tethering distance (r2=0.81).
Conclusions—Ischemic MR in this model relates strongly to changes in 3D mitral leaflet attachment geometry. These insights from quantitative 3D echo allowed us to design an effective LV remodeling approach to reduce MR by relieving tethering.
Key Words: mitral valve • regurgitation • ischemia • echocardiography • surgery
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D. T. Lai, F. A. Tibayan, T. Myrmel, T. A. Timek, P. Dagum, G. T. Daughters, D. Liang, N. B. Ingels Jr, and D. C. Miller Mechanistic Insights Into Posterior Mitral Leaflet Inter-Scallop Malcoaptation During Acute Ischemic Mitral Regurgitation Circulation, September 24, 2002; 106(12_suppl_1): I-40 - I-45. [Abstract] [Full Text] [PDF]
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I. L. Kron, G. R. Green, and J. T. Cope Surgical relocation of the posterior papillary muscle in chronic ischemic mitral regurgitation Ann. Thorac. Surg., August 1, 2002; 74(2): 600 - 601. [Abstract] [Full Text] [PDF]
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Y. Otsuji, T. Kumanohoso, S. Yoshifuku, K. Matsukida, C. Koriyama, A. Kisanuki, S. Minagoe, R. A. Levine, and C. Tei Isolated annular dilation does not usually cause important functional mitral regurgitation: Comparison between patients with lone atrial fibrillation and those with idiopathic or ischemic cardiomyopathy J. Am. Coll. Cardiol., May 15, 2002; 39(10): 1651 - 1656. [Abstract] [Full Text] [PDF]
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E. Messas, J. L. Guerrero, M. D. Handschumacher, C.-M. Chow, S. Sullivan, E. Schwammenthal, and R. A. Levine Paradoxic Decrease in Ischemic Mitral Regurgitation With Papillary Muscle Dysfunction: Insights From Three-Dimensional and Contrast Echocardiography With Strain Rate Measurement Circulation, October 16, 2001; 104(16): 1952 - 1957. [Abstract] [Full Text] [PDF]
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E. Messas, J. L. Guerrero, M. D. Handschumacher, C. Conrad, C.-M. Chow, S. Sullivan, A. P. Yoganathan, and R. A. Levine Chordal Cutting: A New Therapeutic Approach for Ischemic Mitral Regurgitation Circulation, October 16, 2001; 104(16): 1958 - 1963. [Abstract] [Full Text] [PDF]
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T. A. Timek and D. C. Miller Experimental and clinical assessment of mitral annular area and dynamics: what are we actually measuring? Ann. Thorac. Surg., September 1, 2001; 72(3): 966 - 974. [Abstract] [Full Text] [PDF]
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J. Raman, A. Dixit, M. Storer, D. Hare, and B. F. Buxton Geometric endo-ventricular patch repair of inferior left ventricular scars improves mitral regurgitation and clinical outcome Ann. Thorac. Surg., September 1, 2001; 72(3): S1055 - 1058. [Abstract] [Full Text] [PDF]
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