This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Salvatore Lentini Francesco Monaco Roberto Gaeta Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Lentini, S. Articles by Gaeta, R. Search for Related Content PubMed Articles by Lentini, S. Articles by Gaeta, R. Related Collections Related Article

Reducing the sphericity index in patients with ischemic mitral regurgitation and dilated heart

Cardiac Surgery Unit, Policlinic Hospital, University of Messina, Messina 98100, Italy

Papillary muscle realignment and mitral annuloplasty in patients with severe ischemic mitral regurgitation and dilated heart

We read with interest the paper by Fumimoto and coworkers. The authors report a technique of papillary muscle realignment in patients with severe ischemic mitral regurgitation (IMR) caused by leaflets tethering in dilated left ventricle [1].

IMR is a quite common complication after myocardial infarction. The definition was given by Borger et al. in his review article [2]. Several pathophysiologic mechanisms are involved in generating IMR [3]. However, the prerequisite to create regurgitation is a left ventricular focal or global dysfunction, with a geometric alteration in the shape of the ventricle, that will alter the relationship with the mitral valve apparatus. Some echocardiographic parameters, such as tethering pattern, coaptation depth, LV diameters, inter-papillary muscle distance or the quantitative analysis by the effective regurgitant orifice area (ero) and the grade of regurgitation, are all used in the decision made during the treatment of the IMR in those patients. The aim of surgical therapy is to ameliorate heart failure symptoms, and improve LV remodelling and function. The targets of surgical ischemic MV repair may involve annulus, leaflets, chordae and ventricles.

Fumimoto and coworkers presented this series of patients treated by approximation of the base of the papillary muscles using mattress 3-0 polypropylene sutures with PTFE pledgets. They associated to this technique also a downsizing annuloplasty of the mitral valve. They had good results in terms of coaptation depth, tenting area, grade of mitral regurgitation. We used a similar but slightly different technique in approximately the base of the papillary muscles. We think that IMR in dilated post-ischemic heart would benefit from a treatment on the ventricle, and in particular the reduction of the sphericity index [4]. In a series of 39 patients undergoing CABG, presenting with dilated post-ischemic LV, reduced EF, and associated IMR grade I to 3, we associated surgical ventricular remodelling in the aim to restore a more physiologic ventricular shape. The LV was opened in the area of scar. A series of concentric polypropylene purse string sutures of different diameters were used around the free wall of the ventricle up to the septum. Those sutures also encircled the base of the papillary muscles. More mattress sutures were passed when needed in the areas of bulging of dilated segmental areas. In this way we approximate the base of the papillary muscles, and we also reduce the diameter of the LV at the height of the insertion of the papillary muscles. At echocardiography, this reduces the tethering pattern on the mitral apparatus. We associate downsizing ring annuloplasty for advanced grade of IMR. This approach is done with the aim of reducing the sphericity index, that correlates with the degree of mitral regurgitation (MR) and with the distance of papillary muscles [4]. Infarct has been reported that when sphericity index is high as in global dilatation of ischemic cardiomyopathy, mitral function is more impaired.

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1. Fumimoto K, Fukui T, Shimokawa T, Takanashi S. Papillary muscle realignment and mitral annuloplasty in patients with severe ischemic mitral regurgitation and dilated heart. Interact CardioVasc Thorac Surg 2008;7:368–372.[Abstract/Free Full Text]
2. Borger MA, Alam A, Murphy PM, Doenst T, David TE. Chronic ischemic mitral regurgitation: repair, replace or rethink? Ann Thorac Surg 2006;81:1153–1161.[Abstract/Free Full Text]
3. Agricola E, Oppizzi M, Pisani M, Meris A, Maisano F, Margonato A. Ischemic mitral regurgitation: mechanisms and echocardiographic classification. Eur J Echocardiogr 2008;9:207–221.[Abstract/Free Full Text]
4. Di Donato M, Dabic P, Castelvecchio S, Santambrogio C, Brankovic J, Collarini L, Joussef T, Frigiola A, Buckberg G, Menicanti L, RESTORE Group. Left ventricular geometry in normal and post-anterior myocardial infarction patients: sphericity index and ‘new’ conicity index comparisons. Eur J Cardiothorac Surg 2006;29(Suppl_1):S225–230.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Salvatore Lentini Francesco Monaco Roberto Gaeta Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Lentini, S. Articles by Gaeta, R. Search for Related Content PubMed Articles by Lentini, S. Articles by Gaeta, R. Related Collections Related Article