WJCS  Vol.5 No.7 , July 2015
A Surgical Perspective on Ischemic Mitral Regurgitation: Tethering or Prolapse? Going Back to Papillary Muscles Anatomy. What the Surgeons Really Need to Know
More than one third of patients with ischemic mitral regurgitation (IMR) present a valve prolapse whose mechanism is subtended by a papillary injury. The recent literature is pointing at a regional ventricular injury or wall motion abnormality rather than a global LV dysfunction as responsible for IMR and the presence of localized valve prolapse related to papillary dysfunction is additionally supporting this idea. Leaflet tethering or prolapse in these patients is subtended by lesion of the papillary muscle (PM) per se rather than its dysfunction secondary to regional and global ventricle enlargement. Identification of this type of lesion is difficult and can be overlooked. Morphological characteristics and anatomical variability of the papillary muscles determine their different susceptibility ischemic damage and dysfunction. Pioneering work in mitral anatomy shows a range of morphological diversity of PM anatomy and leads to an anatomical classification with important implications in IMR surgery. New methods of investigation, as multidetector computed tomography or magnetic resonance provide a very accurate and proper identification of the morphological pattern of the subvalvular apparatus, which is crucial for a long-lasting and successful surgical correction. The involvement of PM in the pathophysiology of IMR not only in terms of their functional anomaly, but also of their effective anatomical aspects and characteristics is increasingly emerging. The modern advancements of imaging techniques can guide the preoperative surgical planning and the surgeon needs to be aware of morphological features of the subvalvular apparatus and combine these findings with echographic functional parameters before embarking in complex mitral repairs.

Cite this paper
Nappi, F. , Spadaccio, C. and Acar, C. (2015) A Surgical Perspective on Ischemic Mitral Regurgitation: Tethering or Prolapse? Going Back to Papillary Muscles Anatomy. What the Surgeons Really Need to Know. World Journal of Cardiovascular Surgery, 5, 63-69. doi: 10.4236/wjcs.2015.57011.
[1]   Kron, I.L., Hung, J., Overbey, J.R., Bouchard, D., Gelijns, A.C., Moskowitz, A.J., Voisine, P., O’Gara, P.T., Argenziano, M., Michler, R.E., Gillinov, M., Puskas, J.D., Gammie, J.S., Mack, M.J., Smith, P.K., Sai-Sudhakar, C., Gardner, T.J., Ailawadi, G., Zeng, X., O’Sullivan, K., Parides, M.K., Swayze, R., Thourani, V., Rose, E.A., Perrault, L.P., Acker, M.A. and Investigators, C. (2015) Predicting Recurrent Mitral Regurgitation after Mitral Valve Repair for Severe Is- chemic Mitral Regurgitation. The Journal of Thoracic and Cardiovascular Surgery, 149, 752-761.

[2]   Acker, M.A., Parides, M.K., Perrault, L.P., Moskowitz, A.J., Gelijns, A.C., Voisine, P., Smith, P.K., Hung, J.W., Blackstone, E.H., Puskas, J.D., Argenziano, M., Gammie, J.S., Mack, M., Ascheim, D.D., Bagiella, E., Moquete, E.G., Ferguson, T.B., Horvath, K.A., Geller, N.L., Miller, M.A., Woo, Y.J., D’Alessandro, D.A., Ailawadi, G., Dagenais, F., Gardner, T.J., O’Gara, P.T., Michler, R.E., Kron, I.L. for the CTSN (2014) Mitral-Valve Repair versus Replacement for Severe Ischemic Mitral Regurgitation. The New England Journal of Medicine, 370, 23-32.

[3]   Nicolini, F., Agostinelli, A., Vezzani, A., Molardi, A., Benassi, F., Gallingani, A., Romano, G. and Gherli, T. (2015) Surgical Treatment for Functional Ischemic Mitral Regurgitation: Current Options and Future Trends. Acta Biomed, 86, 17-26.

[4]   Jensen, H. (2015) Surgical Treatment of Functional Ischemic Mitral Regurgitation. Danish Medical Bulletin, 61, 3.

[5]   Hajsadeghi, S., Samiee, N., Hosseini, S.S., Hassanzadeh, M. and Jafarian Kerman, S.R. (2015) Novel Echocardiographic Indices as Predictors of Immediate Recurrence after Undersized Ring Annuloplasty for Ischemic Mitral Regurgitation. Echocardiography.

[6]   Rama, A., Nappi, F., Praschker, B.G. and Gandjbakhch, I. (2008) Papillary Muscle Approximation for Ischemic Mitral Valve Regurgitation. Journal of Cardiac Surgery, 23, 733-735.

[7]   Jensen, H., Jensen, M.O., Smerup, M.H., Vind-Kezunovic, S., Ringgaard, S., Andersen, N.T., Vestergaard, R., Wierup, P., Hasenkam, J.M. and Nielsen, S.L. (2009) Impact of Papillary Muscle Relocation as Adjunct Procedure to Mitral Ring Annuloplasty in Functional Ischemic Mitral Regurgitation. Circulation, 120, S92-S98.

[8]   Watanabe, T., Arai, H., Nagaoka, E., Oi, K., Hachimaru, T., Kuroki, H., Fujiwara, T. and Mizuno, T. (2014) Influence of Procedural Differences on Mitral Valve Configuration after Surgical Repair for Functional Mitral Regurgitation: In Which Direction Should the Papillary Muscle Be Relocated? Journal of Cardiothoracic Surgery, 9, 185.

[9]   Shudo, Y., Matsumiya, G., Sakaguchi, T., Miyagawa, S., Yoshikawa, Y., Yamauchi, T., Takeda, K., Saito, S., Nakatani, S., Taniguchi, K., Izutani, H. and Sawa, Y. (2010) Assessment of Changes in Mitral Valve Configuration with Multidetector Computed Tomography: Impact of Papillary Muscle Imbrication and Ring Annuloplasty. Circulation, 122, S29-S36.

[10]   Kalra, K., Wang, Q., McIver, B.V., Shi, W., Guyton, R.A., Sun, W., Sarin, E.L., Thourani, V.H. and Padala, M. (2014) Temporal Changes in Interpapillary Muscle Dynamics as an Active Indicator of Mitral Valve and Left Ventricular Interaction in Ischemic Mitral Regurgitation. Journal of the American College of Cardiology, 64, 1867-1879.

[11]   Sanz, J. and Weinsaft, J.W. (2014) Ischemic Mitral Regurgitation: Is Mitral Valve Physiology Moving from Global to Local? Journal of the American College of Cardiology, 64, 1880-1882.

[12]   Jouan, J., Tapia, M., Cook, R.C., Lansac, E. and Acar, C. (2004) Ischemic Mitral Valve Prolapse: Mechanisms and Im- plications for Valve Repair. European Journal of Cardio-Thoracic Surgery, 26, 1112-1117.

[13]   Nishimura, R.A., Otto, C.M., Bonow, R.O., Carabello, B.A., Erwin 3rd, J.P., Guyton, R.A., O’Gara, P.T., Ruiz, C.E., Skubas, N.J., Sorajja, P., Sundt 3rd, T.M. and Thomas, J.D., American College of Cardiology/American Heart Association Task Force on Practice, G. (2014) 2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 63, e57-e185.

[14]   Argulian, E. (2015) Valvular Disease, Myocardial Mechanics, and Valve Guidelines. JACC: Cardiovascular Imaging, 8, 382.

[15]   Galli, E., Lancellotti, P., Sengupta, P.P. and Donal, E. (2014) LV Mechanics in Mitral and Aortic Valve Diseases: Value of Functional Assessment beyond Ejection Fraction. JACC: Cardiovascular Imaging, 7, 1151-1166.

[16]   Estes Jr., E.H., Dalton, F.M., Entman, M.L., Dixon 2nd, H.B. and Hackel, D.B. (1966) The Anatomy and Blood Supply of the Papillary Muscles of the Left Ventricle. American Heart Journal, 71, 356-362.

[17]   Kim, K., Kaji, S., An, Y., Nishino, T., Tani, T., Kitai, T. and Furukawa, Y. (2014) Interpapillary Muscle Distance Independently Affects Severity of Functional Mitral Regurgitation in Patients with Systolic Left Ventricular Dysfunction. The Journal of Thoracic and Cardiovascular Surgery, 148, 434-440.

[18]   Nieman, K., Achenbach, S., Pugliese, F., Cosyns, B., Lancellotti, P. and Kitsiou, A. (2015) Cardiac Computed Tomography Core Syllabus of the European Association of Cardiovascular Imaging (EACVI). European Heart Journal— Cardiovascular Imaging, 16, 351-352.

[19]   Zeng, X., Nunes, M.C., Dent, J., Gillam, L., Mathew, J.P., Gammie, J.S., Ascheim, D.D., Moquete, E. and Hung, J. (2014) Asymmetric versus Symmetric Tethering Patterns in Ischemic Mitral Regurgitation: Geometric Differences from Three-Dimensional Transesophageal Echocardiography. Journal of the American Society of Echocardiography, 27, 367-375.

[20]   Badiwala, M.V., Verma, S. and Rao, V. (2009) Surgical Management of Ischemic Mitral Regurgitation. Circulation, 120, 1287-1293.