Annular or subvalvular approach to chronic ischemic mitral regurgitation?

Objective: We sought to investigate whether annular or subvalvular interventions corrected chronic ischemic mitral regurgitation differently. Methods: Sheep underwent placement of markers on the left ventricle, mitral annulus, papillary muscles (anterior and posterior), and both leaflet edges. A transannular suture (septal-lateral annular cinching) was anchored to the midseptal mitral annulus and externalized through the midlateral mitral annulus. Another suture (papillary muscle repositioning) from the posterior papillary muscle was passed through the mitral annulus near the posterior commissure and externalized. After 7 days, 3-dimensional marker data were obtained before inducing posterolateral myocardial infarction. After 7 weeks, animals in whom chronic ischemic mitral regurgitation developed (n = 10) were restudied before and after pulling septal-lateral annular cinching or papillary muscle repositioning sutures. End-systolic septal-lateral annular diameter and 3-dimensional displacement of the papillary muscles and leaflet edges were computed. Results: Infarction increased mitral regurgitation (0.6 ± 0.5 to 2.3 ± 1.1); mitral annular septal-lateral dilation (4 ± 1 mm); posterior papillary muscle displacement laterally (4 ± 2 mm), posteriorly (9 ± 3 mm), and toward the annulus (2 ± 1 mm); posterior mitral leaflet apical tethering (3 ± 1 mm); and interleaflet separation (+3 ± 1 mm, P < .05 baseline vs chronic ischemic mitral regurgitation). Septal-lateral annular cinching reduced septal-lateral dimension (-9 ± 3 mm), corrected lateral posterior papillary muscle displacement (4 ± 1 mm) and septal-lateral interleaflet separation (-4 ± 2 mm), and decreased mitral regurgitation (0.6 ± 0.6, P < .05 septal-lateral annular cinching vs chronic ischemic mitral regurgitation) without affecting posterior leaflet restriction. Papillary muscle repositioning reduced septal-lateral diameter (-4 ± 1 mm), moved the anterior papillary muscle closer to the annulus (2 ± 1 mm), and relieved posterior leaflet apical restriction (2 ± 1 mm, P < .05 papillary muscle repositioning vs chronic ischemic mitral regurgitation) but did not change lateral posterior papillary muscle displacement or decrease mitral regurgitation (1.9 ± 1.2). Conclusions: Septal-lateral annular cinching moved the lateral annulus and the posterior papillary muscle closer to the septum and reduced mitral regurgitation unlike posterior papillary muscle repositioning, and thus the key mitral subvalvular repair component must correct posterior papillary muscle lateral displacement.