Interact CardioVasc Thorac Surg 2008;7:325-327. doi:10.1510/icvts.2007.169557
© 2008 European Association of Cardio-Thoracic Surgery
Case report - Cardiac general |
Papillary muscle sling and overlapping cardiac volume reduction with aortic valve replacement for valvular cardiomyopathy
Kiyohito Yamamoto*,
Hisato Ito and
Takane Hiraiwa
Department of Cardiovascular Surgery, Hamamatsu Medical Center, 328, Tomitsuka, Naka, Hamamatsu, Shizuoka 432-8580, Japan
Received 2 October 2007;
received in revised form 15 November 2007;
accepted 19 November 2007
*Corresponding author. Tel.: +81-53-453-7111; fax: +81-53-452-9217.
E-mail address: k-yama{at}hmedc.or.jp (K. Yamamoto).
 |
Abstract
|
|---|
A 63-year-old male was admitted to our hospital because of severe aortic regurgitation. The left ventricle was extremely dilated and mild functional mitral regurgitation was detected because of outward displacement of papillary muscles. We used a papillary muscle sling with aortic valve replacement to correct the widened distance between the papillary muscles. A papillary muscle sling when used for reducing tethering at the mitral valve also reduces the posterior left ventricular volume. As well, a transmural longitudinal incision along the left anterior descending artery in the left ventricular free wall was sutured by an overlapping method to reduce the anterior left ventricular volume. The combination of papillary muscle sling and the overlapping method does not need any resection of the cardiac muscle and so would be beneficial for end-stage valvular cardiomyopathy.
Key Words: Papillary muscle sling; Overlapping cardiac volume reduction; Aortic regurgitation; Valvular cardiomyopathy
|
1. Introduction
|
|---|
Reports of clinical results of left ventriculoplasty for valvular cardiomyopathy are rare. Left ventricular dysfunction due to chronic aortic regurgitation (AR) is initially a reversible phenomenon and full recovery of left ventricular size and function is possible with aortic valve replacement (AVR). However, patients with a diastolic dimension  80 mm have been noted to have a poor postoperative outcome, raising concerns that extreme left ventricular dilation may be a marker of irreversible myocardial damage [1]. We believe that left ventriculoplasty could be an option for end-stage valvular cardiomyopathy of AR to improve postoperative left ventricular function and long-term survival.
|
2. Clinical summaries
|
|---|
A 63-year-old male was admitted to our hospital because of dyspnea. Transthoracic echocardiography (TTE) revealed severe AR and mild functional mitral regurgitation (Fig. 1). The left ventricular end diastolic diameter (LVDd) and left ventricular end systolic diameter (LVDs) were 83.9 mm and 70.7 mm, respectively (Fig. 2a). The left ventricular ejection fraction (LVEF) was 39%. The parameters of the mitral apparatus measured by TTE were as follows: coaptation depth 7.8 mm; tenting area 1.2 cm2; tethering distance 42.4 mm; and interpapillary muscle distance 48.0 mm. A catheter biopsy revealed interstitial fibrosis of the myocardium. New York Heart Association (NYHA) functional class was III. Body surface area was 1.84 m2, and electrocardiography showed normal sinus rhythm. We used a papillary muscle sling and performed overlapping cardiac volume reduction (OLCVR) with AVR. Cardiopulmonary bypass was conducted under mild hypothermia with antegrade and retrograde intermittent cold blood cardioplegia. To ensure retrograde cardioplegia, the catheter was directly intubated to the coronary sinus via a right atriotomy. First, the widened distance between the papillary muscles was corrected using a 5-mm Gore-Tex tube (WL Gore, Flagstaff, AZ, USA) encircling the trabecular base of the papillary muscles [2]. The tube was then tightened until the two papillary muscles were in close contact. Next, we performed OLCVR by a previously reported procedure [3]. A transmural longitudinal incision was made along the left anterior descending artery in the enlarged left ventricular free wall from below the first diagonal branch to the apex. Continuous sutures of the left incision marginal to the endocardium of the septal wall and interrupted sutures of the right incision marginal to the ventricular free wall were placed so that postoperative LVDd became about 70 mm. Finally, a mechanical valve (25-mm SJM Regent valve; St. Jude Medical, St. Paul, MN, USA) was implanted. After terminal warm blood cardioplegia, the aorta was declamped. Then cardiopulmonary bypass assisted the impaired myocardium for 60 min. Weaning from cardiopulmonary bypass was uneventful without mechanical support. Aortic cross-clamp time was 172 min, and cardiopulmonary bypass time 234 min. The postoperative course was uneventful, and the patient was discharged to home on postoperative day 26. Postoperative TTE at discharge showed no mitral regurgitation. The parameters of the mitral apparatus measured by TTE were improved as follows: coaptation depth 7.2 mm; tenting area 0.9 cm2; tethering distance 24.7 mm; and interpapillary muscle distance 42.0 mm. LVEF was 42%, and LVDd was reduced to 70.1 mm (Fig. 2b). NYHA functional class improved to I.
View larger version (131K):
[in this window]
[in a new window]
|
Fig. 1. Preoperative transthoracic echocardiography. Color Doppler echocardiography reveals severe aortic regurgitation.
|
|
View larger version (43K):
[in this window]
[in a new window]
|
Fig. 2. Transthoracic echocardiography (TTE). (a) Preoperative TTE shows an extremely dilated left ventricle. The LVDd is 83.9 mm. (b) TTE at discharge shows LVDd reduced to 70.1 mm. Ao, aorta; LA, left atrium; LV, left ventricle.
|
|
|
3. Discussion
|
|---|
Left ventricular dysfunction due to chronic aortic regurgitation is initially a reversible phenomenon after AVR. However, some patients with a markedly reduced preoperative LVEF have higher postoperative mortality rates than patients with normal LVEF [1]. At ten years postoperatively, 41% of low LVEF (LVEF <35%) patients survive compared with 70% of normal LVEF patients (LVEF 50%) [4]. In these cases, interstitial fibrosis of the myocardium develops and left ventricular dysfunction does not fully recover after AVR [5]. Taking these facts into consideration, we postulated that left ventriculoplasty concomitant with AVR was essential to improve postoperative left ventricular function and long-term survival for the patient reported here.
Recently, we used a papillary muscle sling [2] concomitant with mitral annuloplasty for functional mitral regurgitation of ischemic cardiomyopathy and idiopathic dilated cardiomyopathy [6]. The functional mitral regurgitation is attributed to left ventricular dilatation and outward displacement of the papillary muscles, resulting in mitral valve tethering. A papillary muscle sling would reduce tethering at the mitral valve and maintain the efficacy of mitral annuloplasty as well as shorten the posterior left ventricular wall between papillary muscles, also reducing left ventricular volume. On the other hand, Matsui et al. reported OLCVR for end-stage cardiomyopathy [3]. This method could reduce the anterior left ventricular volume without any resection of cardiac muscles and retain the elliptical shape of the left ventricle. The other merit compared with a Batista operation is the preservation of the circumflex coronary artery.
Differently from ischemic cardiomyopathy, all the cardiac muscles are potentially viable in valvular cardiomyopathy. Residual cardiac muscle after left ventriculoplasty has the potential ability to support left ventricular function. However, an extremely dilated left ventricle would not fully reverse after AVR, because interstitial fibrosis of the myocardium would develop [5]. Patients with AR and markedly depressed left ventricular function have a high postoperative mortality rate after AVR [4]. Taking the law of Laplace into consideration, we believe that surgical intervention for left ventriculoplasty decreases the load to cardiac muscles in which interstitial fibrosis has developed, and improves long-term survival. Furthermore, we think it also important not to resect cardiac muscle but, as well as this, there is a need to reduce left ventricular volume. The posterior left ventricular wall between the papillary muscles is shortened as a result of a papillary muscle sling, simultaneously improving functional mitral regurgitation. The anterior left ventricular wall and the septal wall are also shortened by OLCVR. We think that this combination procedure of a papillary muscle sling and OLCVR is beneficial for end-stage valvular cardiomyopathy to improve postoperative left ventricular function and long-term survival. However, the long-term efficacy of this procedure on end-stage valvular cardiomyopathy remains unclear. A clinical trial is expected in the future.
Last, when aortic cross-clamp time is prolonged for left ventriculoplasty, increased complications can occur, especially in cases with extremely depressed myocardium. Therefore, we also need to pay attention to perioperative management and myocardial protection. We successfully treated this case by our policy of myocardial protection. However, we would need to use continuous retrograde blood cardioplegia [7] in cases with severely depressed left ventricular function.
|
References
|
|---|
- Klodas E, Enriquez-Sarano M, Tajik AJ, Mullany CJ, Bailey KR, Seward JB. Aortic regurgitation complicated by extreme left ventricular dilation: long-term outcome after surgical correction. J Am Coll Cardiol 1996;27:670–677.[Abstract]
- Hvass U, Tapia M, Baron F, Pouzet B, Shafy A. Papillary muscle sling: a new functional approach to mitral repair in patients with ischemic left ventricular dysfunction and functional mitral regurgitation. Ann Thorac Surg 2003;75:809–811.[Abstract/Free Full Text]
- Matsui Y, Fukada Y, Suto Y, Yamauchi H, Luo B, Miyama M, Sasaki S, Tanabe T, Yasuda K. Overlapping cardiac volume reduction operation. J Thorac Cardiovasc Surg 2002;124:395–397.[Free Full Text]
- Chaliki HP, Mohty D, Avierinos JF, Scott CG, Schaff HV, Tajik AJ, Enriquez-Sarano M. Outcomes after aortic valve replacement in patients with severe aortic regurgitation and markedly reduced left ventricular function. Circulation 2002;106:2687–2693.[Abstract/Free Full Text]
- Taniguchi K, Kawamaoto T, Kuki S, Masai T, Mitsuno M, Nakano S, Kawashima Y, Matsuda H. Left ventricular myocardial remodeling and contractile state in chronic aortic regurgitation. Clin Cardiol 2000;23:608–614.[Medline]
- Ito H, Yamamoto K, Hiraiwa T. Mitral valve repair with papillary muscle sling for functional mitral regurgitation: application of double mitral ring concept in a case of ischemic cardiomyopathy and a case of idiopathic dilated cardiomyopathy. Gen Thorac Cardiovasc Surg 2007;55:297–301.[CrossRef][Medline]
- Bezon E, Choplain JN, Khalifa AA, Numa H, Salley N, Barra JA. Continuous retrograde cardioplegia ensures prolonged aortic cross-clamping time without increasing the operative risk. Interact Cardiovasc Thorac Surg 2006;5:403–407.[Abstract/Free Full Text]
|
|
Top
Abstract
1. Introduction