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(Circulation. 2005;112:I-383 – I-389.)
© 2005 American Heart Association, Inc.

Surgery for Valvular Heart Disease

Subvalvular Repair

The Key to Repairing Ischemic Mitral Regurgitation?

Frank Langer, MD; Filiberto Rodriguez, MD; Saskia Ortiz, MD; Allen Cheng, MD; Tom C. Nguyen, MD; Mary K. Zasio, BA; David Liang, MD, PhD; George T. Daughters, MS; Neil B. Ingels, PhD; D. Craig Miller, MD

From the Department of Cardiothoracic Surgery (F.L., F.R., S.O., A.C., T.C.N., M.K.Z., G.T.D., N.B.I., D.C.M.), and Division of Cardiovascular Medicine (D.L.), Stanford University School of Medicine, Stanford; and Laboratory of Cardiovascular Physiology and Biophysics (G.T.D., N.B.I.), Research Institute of the Palo Alto Medical Foundation, Palo Alto, Calif.

Correspondence to Dr D. Craig Miller, Department of Cardiothoracic Surgery, Falk Cardiovascular Research Center, Stanford University School of Medicine, 300 Pasteur Dr, Stanford, CA 94305. E-mail dcm{at}stanford.edu

Background— Residual or recurrent mitral regurgitation frequently occurs after mitral ring annuloplasty repair for ischemic mitral regurgitation (IMR), because annuloplasty primarily addresses annular dilatation. We describe a subvalvular repair technique addressing posterior papillary muscle (PPM) displacement.

Methods and Results— Ten sheep had radiopaque markers placed on the left ventricle (LV) and mitral apparatus. A suture was anchored at the right fibrous trigone, passed through the PPM tip and LV wall, and exteriorized through a tourniquet (STRING-1). A second suture was anchored transmurally in the high septum (anterobasal LV wall) and passed through the PPM and LV wall (STRING-2). Reversible posterolateral ischemia was induced by temporarily occluding the proximal circumflex artery. Under open chest conditions, 3D marker coordinates were obtained with biplane videofluoroscopy at baseline and during acute ischemia before and after tightening of each STRING using transesophageal echocardiography to grade IMR. IMR decreased (mean±SEM, 2.0±0.1 to 1.2±0.1; P<0.05) when STRING-1 was tightened, did not change after tightening STRING-2 (2.3±0.1 to 2.3±0.1), and decreased after tightening both sutures (STRING-1+2, 2.3±0.2 to 1.3±0.2; P<0.05). STRING-1 and STRING-1+2 (STRING-1, 1.7±0.4 mm; STRING-2, 0.7±0.5 mm; STRING-1+2, 1.5±0.3 mm; P<0.05) resulted in significant PPM basal repositioning. Tightening of any STRING sutures did not affect anterior mitral leaflet excursion.

Conclusions— Basal repositioning of the PPM with STRING-1 reduced acute IMR without concomitant annular reduction. This technique may be a useful adjunct if residual IMR is likely after undersized ring annuloplasty.

Key Words: ischemic mitral regurgitation • mitral valve • mitral valve repair