The role of papillary muscle approximation in mitral valve repair for the treatment of secondary mitral regurgitation

Abstract

Secondary mitral regurgitation (MR) is present in up to half of patients with dilated cardiomyopathy, and is associated with a poor prognosis. It primarily results from progressive left ventricular remodelling, papillary muscle displacement and tethering of the mitral valve leaflets. Mitral valve repair with an undersized ring annuloplasty is the reparative procedure of choice in the treatment of secondary MR. However, this technique is associated with a 30-60% incidence of recurrent moderate or greater MR at mid-term follow-up, which results in progressive deterioration of left ventricular function and increased morbidity. Combined mitral valve repair and papillary muscle approximation has been applied in order to address both the annular and subvalvular dysfunction that coexist in secondary MR, which include graft and suture-based techniques. Herein, we provide a systematic review of the published literature regarding the technical aspects, clinical application, and outcomes of mitral valve repair with combined ring annuloplasty and papillary muscle approximation for the treatment of secondary MR.

Mitral valve repair and subvalvular intervention for secondary mitral regurgitation: a systematic review and meta-analysis of randomized controlled and propensity matched studies

“…The benefits of a Ring + subvalvular MV repair for secondary MR are derived from the application of therapeutic strategies addressing the subvalvular dysfunction that restricts proper valvular mechanics (10)(11)(12)14). A concomitant ring annuloplasty is utilized to correct annular dilatation that often co-exists; however, the undersizing strategy often implemented contributes to persistent MV leaflet tethering, placing a greater emphasis on LV support from a subvalvular intervention (24,25).…”

“…However, in those with no MR recurrence, a durable MV repair was associated with greater LV reverse remodeling, as compared with replacement. Given these findings and the potential benefits of MV repair in terms of peri-operative morbidity and avoidance of prosthesisrelated complications, there is increasing interest in surgical techniques targeting the subvalvular dysfunction present in secondary MR, with the aim of improving MV repair durability (10)(11)(12)(13)(14).…”

Minimally invasive valve surgery in high-risk patients

“…In order to improve the durability of a MVrep for secondary mitral regurgitation, adjunctive subvalvular interventions have been increasingly utilized to correct papillary muscle displacement and relieve mitral leaflet tethering (24,25). Santana et al, analyzed the outcomes of 19 consecutive patients undergoing MIVS via a right thoracotomy for severe secondary mitral regurgitation in whom the MVrep was performed concomitantly with papillary muscle approximation utilizing a 4mm polytetrafluoroethylene graft (26,27).…”

Multimodality imaging assessment of mitral valve anatomy in planning for mitral valve repair in secondary mitral regurgitation

“…Moreover, and in order to enhance the results of surgical MV repair, additional interventions to the standard mitral valve annuloplasty have been developed in the last decade and provide promising results regarding outcomes in patients with secondary MR. The PM relocation procedures, such as sling procedure and PM approximation, chordae cutting or chordae "Cut-and-transfer" technique have been used with good results regarding recurrent rate of MR, positive LV remodeling, improvement of quality of life and symptomatic status (70)(71)(72)(73)(74)(75)(76)(77)(78)(79)(80)(81)(82). Other approaches directly addressing the ventricular problem and thus focused on LV wall remodeling have also been experimentally tested but without translation to patient care (83)(84)(85).…”