WJCS  Vol.3 No.1 , March 2013
Ventricular Approach for Functional Mitral Regurgitation in Cardiomyopathy
Abstract: Background: The key mechanism of functional mitral regurgitation (FMR) in cardiomyopathy is leaflet tethering caused by displacement of the papillary muscles (PM) due to left ventricular dilatation. The attendant remodeling process is characterized by intraventricular widening between both PM. Recently, surgical ventricular restoration (SVR) has been proposed as a technique to reduce leaflet tethering by improving ventricular geometry. However, it is unknown how SVR improve FMR. Methods and Results: From 2003 to 2010, we surgically treated FMR in 100 patients with idiopathic dilated cardiomyopahy (DCM) or ischemic cardiomyopathy (ICM). Of those, we performed posterior wall exclusion procedures by either resection (the Batista procedure, n = 13) or plication (n = 19) to approximate papillary muscle distance in a total of 32 patients (DCM in 17, ICM in 15), and these patients formed the cohort of this study. There were two 30-day mortalities (6.3%). There was no significant change in left ventricular ejection fraction, however, the size of the left ventricle, degree of MR, tethering height and distance of PM significantly decreased after operation and well maintained at the mean follow up of 3.3 ± 2.1 years. Conclusions: Posterior wall resection or plication with PM approximation provides excellent reduction of leaflet tethering and MR. Thus, reduction of PM distance may be helpful to treat FMR due to leaflet tethering.
Cite this paper: K. Minakata, K. Yamazaki, S. Miwa, M. Funamoto, M. Kumagai, A. Marui and R. Sakata, "Ventricular Approach for Functional Mitral Regurgitation in Cardiomyopathy," World Journal of Cardiovascular Surgery, Vol. 3 No. 1, 2013, pp. 8-14. doi: 10.4236/wjcs.2013.31002.

[1]   E. Kuwahara, Y. Otsuji, Y. Iguro, T. Ueno, F. Zhu, N. Mizukami, et al., “Mechanism of Recurrent/Persistent Ischemic/Functional Mitral Regurgitation in the Chronic Phase after Surgical Annuloplasty: Importance of Augmented Posterior Leaflet Tethering,” Circulation, Vol. 114, No. S1, 2006, pp. I529-I534. doi:10.1161/CIRCULATIONAHA.105.000729

[2]   I. L. Kron, G. R. Green and J. T. Cope, “Surgical Relocation of the Posterior Papillary Muscle in Chronic Ischemic Mitral Regurgitation,” The Annals of Thoracic Surgery, Vol. 74, No. 2, 2002, pp. 600-601. doi:10.1016/S0003-4975(02)03749-9

[3]   U. Hvass, M. Tapia, F. Baron, B. Pouzet and A. Shafy, “Papillary Muscle Sling: A New Functional Approach to Mitral Repair in Patients with Ischemic Left Ventricular Dysfunction and Functional Mitral Regurgitation,” The Annals of Thoracic Surgery, Vol. 75, No. 3, 2003, pp. 809-811. doi:10.1016/S0003-4975(02)04678-7

[4]   E. Messas, J. L. Guerrero, M. D. Handschumacher, C. Conrad, C. M. Chow, S. Sullivan, et al., Chordal Cutting: A New Therapeutic Approach for Ischemic Mitral Regurgitation. Circulation, Vol. 104, 2001, pp. 1958-1963. doi:10.1161/hc4201.097135

[5]   M. Di Donato, S. Castelvecchio, J. Brankovic, C. Santambrogio, V. Montericcio and L. Menicanti, “Effectiveness of Surgical Ventricular Restoration in Patients with Dilated Ischemic Cardiomyopathy and Unrepaired Mild Mitral Regurgitation,” The Journal of Thoracic and Cardiovascular Surgery, Vol. 134, No. 6, 2007, pp. 1548-1553. doi:10.1016/j.jtcvs.2007.08.031

[6]   Y. Matsui, Y. Fukuda, Y. Naito and S. Sasaki, “Integrated Overlapping Ventriculoplasty Combined with Papillary Muscle Plication for Severely Dilated Heart Failure,” The Journal of Thoracic and Cardiovascular Surgery, Vol. 127, No. 4, 2004, pp. 1221-1223. doi:10.1016/j.jtcvs.2003.10.044

[7]   G. Buckberg, L. Menicanti, S. De Oliveira, T. Isomura and the RESTORE Team, “Restoring Papillary Muscle Dimensions during Restoration in Dilated Hearts,” Interactive Cardiovascular and Thoracic Surgery, Vol. 4, No. 5, 2005, pp. 475-477. doi:10.1510/icvts.2005.109868

[8]   T. Ueno, R. Sakata, Y. Iguro, H. Yamamoto, M. Ueno, T. Ueno, et al., “Mid-Term Changes of Left Ventricular Geometry and Function after Dor, SAVE, and Overlapping Procedures,” European Journal Cardio-Thoracic Surgery, Vol. 32, No. 1, 2007, pp. 52-57. doi:10.1016/j.ejcts.2007.02.030

[9]   T. Ueno, R. Sakata, Y. Iguro, H. Yamamoto, M. Ueno, T. Ueno, et al., “Impact of Subvalvular Procedure for Ischemic Mitral Regurgitation on Leaflet Configuration, Mobility, and Recurrence,” Circulation Journal, Vol. 72, No. 11, 2008, pp. 1737-1743. doi:10.1253/circj.CJ-08-0449

[10]   C. L. Athanasuleas, G. D. Buckberg, A. W. Stanley, W. Siler, V. Dor, M. Di Donato, et al., “Surgical Ventricular Restoration in the Treatment of Congestive Heart Failure Due to Post-Infarction Ventricular Dilation,” Journal of the American College of Cardiology, Vol. 44, No. 7. pp. 1439-1445. doi:10.1016/j.jacc.2004.07.017

[11]   W. A. Zoghbi, M. Enriquez-Sarano, E. Foster, P. A. Grayburn, C. D. Kraft, R. A. Levine, et al., “Recommendations for Evaluation of the Severity of Native Valvular Regurgitation with Two-Dimensional and Doppler Echocardiography,” Journal of the American Society of Echocardiography, Vol. 16, No. 7, 2003, pp. 777-802. doi:10.1016/S0894-7317(03)00335-3

[12]   R. U. Nair, S. G. Williams, K. U. Nwafor, A. S. Hall and L. B. Tan, “Left Ventricular Volume Reduction without Ventriculectomy,” The Annals of Thoracic Surgery, Vol. 71, No. 6, 2001, pp. 2046-2049. doi:10.1016/S0003-4975(01)02460-2

[13]   F. Grigioni, M. Enriquez-Sarano, K. J. Zehr, K. R. Bailey and A. J. Tajik, “Ischemic Mitral Regurgitation: Long-Term Outcome and Prognostic Implications with Quantitative Doppler Assessment,” Circulation, Vol. 103, 2001, pp. 1759-1764. doi:10.1161/01.CIR.103.13.1759

[14]   S. F. Bolling, F. D. Pagani, G. M. Deeb and D. S. Bach, “Intermediate-Term Outcome of Mitral Reconstruction in Cardiomyopathy,” The Journal of Thoracic and Cardiovascular Surgery, Vol. 115, No. 2, 1998, pp. 381-386. doi:10.1016/S0022-5223(98)70282-X

[15]   E. C. McGee, A. M. Gillinov, E. H. Blackstone, J. Rajeswaran, G. Cohen, F. Najam, et al., “Recurrent Mitral Regurgitation after Annuloplasty for Functional Ischemic Mitral Regurgitation,” The Journal of Thoracic and Cardiovascular Surgery, Vol. 128, No. 6, 2004, pp. 916-924. doi:10.1016/j.jtcvs.2004.07.037

[16]   J. Braun, J. J. Bax, M. I. Versteegh, P. G. Voigt, E. R. Holman, R. J. Klautz, et al., “Preoperative Left Ventricular Dimensions Predict Reverse Remodeling Following Restrictive Mitral Annuloplasty in Ischemic Mitral Regurgitation,” European Journal of Cardiothoracic Surgery, Vol. 27, No. 5, 2005, pp. 847-853. doi:10.1016/j.ejcts.2004.12.031

[17]   A. M. Calafiore, S. Gallina, M. Di Mauro, F. Gaeta, A. L. Iacò, S. D’Alessandro, et al., “Mitral Valve Procedure in Dilated Cardiomyopathy: Repair or Replacement?” The Annals of Thoracic Surgery, Vol. 71, No. 4, 2001, pp. 1146-1152. doi:10.1016/S0003-4975(00)02650-3

[18]   N. Liel-Cohen, J. L. Guerrero, Y. Otsuji, M. D. Handschumacher, L. G. Rudski, P. R. Hunziker, et al., “Design of a New Surgical Approach for Ventricular Remodeling to Relieve Ischemic Mitral Regurgitation: Insights from 3-Dimensional Echocardiography,” Circulation, Vol. 101, 2000, pp. 2756-2763. doi:10.1161/01.CIR.101.23.2756

[19]   L. Menicanti, M. Di Donato, A. Frigiola, G. Buckberg, C. Santambrogio, M. Ranucci, et al., “Ischemic Mitral Regurgitation: Intraventricular Papillary Muscle Imbrication without Mitral Ring during Left Ventricular Restoration,” The Journal of Thoracic and Cardiovascular Surgery, Vol. 123, No. 6, 2002, pp. 1041-1050. doi:10.1067/mtc.2002.121677

[20]   P. M. McCarthy, R. C. Starling, J. Wong, G. M. Scalia, T. Buda, R. L. Vargo, et al., “Early Results with Partial Left Ventriculectomy,” The Journal of Thoracic and Cardiovascular Surgery, Vol. 114, No. 5, 1997, pp. 755-763. doi:10.1016/S0022-5223(97)70079-5

[21]   J. K. Kirklin, D. C. Naftel, R. L. Kormos, L. W. Stevenson, F. D. Pagani, M. A. Miller, et al., “Second INTERMACS Annual Report: More than 1000 Primary Left Ventricular Assist Device Implants,” J Heart Lung Transplant, Vol. 29, No. 1, 2010, pp. 1-10. doi:10.1016/j.healun.2009.10.009