Annular versus subvalvular approaches to acute ischemic mitral regurgitation

Tomasz A. Timek, David T. Lai, Frederick (Fred) Tibayan, David Liang, Filiberto Rodriguez, George T. Daughters, Paul Dagum, Neil B. Ingels, Craig Miller

Research output: Contribution to journalArticle

30 Citations (Scopus)

Abstract

Background - Ischemic mitral regurgitation (IMR) has been attributed to annular dilatation, papillary muscle (PM) displacement ("apical leaflet tenting"), or both. We compared the efficacy of reducing annular or subvalvular dimensions to gain more mechanistic insight into acute IMR. Methods - Eight adult sheep underwent implantation of radiopaque markers on the LV, mitral annulus (MA), each leaflet edge, and each PM tip. Trans-annular septal-lateral (SL) and inter-PM tip sutures were placed and externalized. Biplane videofluoroscopy and transesophageal echocardiography were performed before and continuously during LCx occlusion-induced IMR with SL annular (SLAC) or inter-PM (PAPS) suture tightening (4 to 5 mm of cinching for 5 seconds during ischemia). MA SL dimension, inter-papillary distance (APM-PPM), and the distances between the anterior (APM) and posterior (PPM) PM tips and the mid-septal annulus ("saddle horn") were calculated from 3-D marker coordinates at end-systole. Results - SLAC reduced IMR (grade= 2.1±0.6 versus 0.7±0.5, P.001), SL annular diameter (4.9±2.5 mm smaller versus pre-cinching; P.001), and PM-"saddle horn" distances (0.9±0.7 and 1.0±0.8 mm reduction for APM and PPM, respectively; P.005). PAPS reduced APM-PPM distance (3.7±1.8 mm reduction versus precinching; P.001), only slightly decreased the PPM-"saddle horn" distance (0.3±0.3 mm reduction; P.03), and had no effect on IMR. Conclusions - Acute IMR was abolished by annular SL reduction, which also repositioned both PM tips closer to the mid-septal annulus and paradoxically increased leaflet "apical tenting"; reducing inter-papillary dimension was not effective, even though it displaced the leaflets toward the annular plane (less "apical tenting").

Original languageEnglish (US)
JournalCirculation
Volume106
Issue number13 SUPPL.
StatePublished - Sep 24 2002
Externally publishedYes

Fingerprint

Papillary Muscles
Mitral Valve Insufficiency
Horns
Sutures
Systole
Transesophageal Echocardiography
Dilatation
Sheep
Ischemia

Keywords

  • Annular cinching
  • Coronary artery disease
  • Ischemic mitral regurgitation
  • Mitral annulus
  • Mitral regurgitation

ASJC Scopus subject areas

  • Physiology
  • Cardiology and Cardiovascular Medicine

Cite this

Timek, T. A., Lai, D. T., Tibayan, F. F., Liang, D., Rodriguez, F., Daughters, G. T., ... Miller, C. (2002). Annular versus subvalvular approaches to acute ischemic mitral regurgitation. Circulation, 106(13 SUPPL.).

Annular versus subvalvular approaches to acute ischemic mitral regurgitation. / Timek, Tomasz A.; Lai, David T.; Tibayan, Frederick (Fred); Liang, David; Rodriguez, Filiberto; Daughters, George T.; Dagum, Paul; Ingels, Neil B.; Miller, Craig.

In: Circulation, Vol. 106, No. 13 SUPPL., 24.09.2002.

Research output: Contribution to journalArticle

Timek, TA, Lai, DT, Tibayan, FF, Liang, D, Rodriguez, F, Daughters, GT, Dagum, P, Ingels, NB & Miller, C 2002, 'Annular versus subvalvular approaches to acute ischemic mitral regurgitation', Circulation, vol. 106, no. 13 SUPPL..
Timek TA, Lai DT, Tibayan FF, Liang D, Rodriguez F, Daughters GT et al. Annular versus subvalvular approaches to acute ischemic mitral regurgitation. Circulation. 2002 Sep 24;106(13 SUPPL.).
Timek, Tomasz A. ; Lai, David T. ; Tibayan, Frederick (Fred) ; Liang, David ; Rodriguez, Filiberto ; Daughters, George T. ; Dagum, Paul ; Ingels, Neil B. ; Miller, Craig. / Annular versus subvalvular approaches to acute ischemic mitral regurgitation. In: Circulation. 2002 ; Vol. 106, No. 13 SUPPL.
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abstract = "Background - Ischemic mitral regurgitation (IMR) has been attributed to annular dilatation, papillary muscle (PM) displacement ({"}apical leaflet tenting{"}), or both. We compared the efficacy of reducing annular or subvalvular dimensions to gain more mechanistic insight into acute IMR. Methods - Eight adult sheep underwent implantation of radiopaque markers on the LV, mitral annulus (MA), each leaflet edge, and each PM tip. Trans-annular septal-lateral (SL) and inter-PM tip sutures were placed and externalized. Biplane videofluoroscopy and transesophageal echocardiography were performed before and continuously during LCx occlusion-induced IMR with SL annular (SLAC) or inter-PM (PAPS) suture tightening (4 to 5 mm of cinching for 5 seconds during ischemia). MA SL dimension, inter-papillary distance (APM-PPM), and the distances between the anterior (APM) and posterior (PPM) PM tips and the mid-septal annulus ({"}saddle horn{"}) were calculated from 3-D marker coordinates at end-systole. Results - SLAC reduced IMR (grade= 2.1±0.6 versus 0.7±0.5, P.001), SL annular diameter (4.9±2.5 mm smaller versus pre-cinching; P.001), and PM-{"}saddle horn{"} distances (0.9±0.7 and 1.0±0.8 mm reduction for APM and PPM, respectively; P.005). PAPS reduced APM-PPM distance (3.7±1.8 mm reduction versus precinching; P.001), only slightly decreased the PPM-{"}saddle horn{"} distance (0.3±0.3 mm reduction; P.03), and had no effect on IMR. Conclusions - Acute IMR was abolished by annular SL reduction, which also repositioned both PM tips closer to the mid-septal annulus and paradoxically increased leaflet {"}apical tenting{"}; reducing inter-papillary dimension was not effective, even though it displaced the leaflets toward the annular plane (less {"}apical tenting{"}).",
keywords = "Annular cinching, Coronary artery disease, Ischemic mitral regurgitation, Mitral annulus, Mitral regurgitation",
author = "Timek, {Tomasz A.} and Lai, {David T.} and Tibayan, {Frederick (Fred)} and David Liang and Filiberto Rodriguez and Daughters, {George T.} and Paul Dagum and Ingels, {Neil B.} and Craig Miller",
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T1 - Annular versus subvalvular approaches to acute ischemic mitral regurgitation

AU - Timek, Tomasz A.

AU - Lai, David T.

AU - Tibayan, Frederick (Fred)

AU - Liang, David

AU - Rodriguez, Filiberto

AU - Daughters, George T.

AU - Dagum, Paul

AU - Ingels, Neil B.

AU - Miller, Craig

PY - 2002/9/24

Y1 - 2002/9/24

N2 - Background - Ischemic mitral regurgitation (IMR) has been attributed to annular dilatation, papillary muscle (PM) displacement ("apical leaflet tenting"), or both. We compared the efficacy of reducing annular or subvalvular dimensions to gain more mechanistic insight into acute IMR. Methods - Eight adult sheep underwent implantation of radiopaque markers on the LV, mitral annulus (MA), each leaflet edge, and each PM tip. Trans-annular septal-lateral (SL) and inter-PM tip sutures were placed and externalized. Biplane videofluoroscopy and transesophageal echocardiography were performed before and continuously during LCx occlusion-induced IMR with SL annular (SLAC) or inter-PM (PAPS) suture tightening (4 to 5 mm of cinching for 5 seconds during ischemia). MA SL dimension, inter-papillary distance (APM-PPM), and the distances between the anterior (APM) and posterior (PPM) PM tips and the mid-septal annulus ("saddle horn") were calculated from 3-D marker coordinates at end-systole. Results - SLAC reduced IMR (grade= 2.1±0.6 versus 0.7±0.5, P.001), SL annular diameter (4.9±2.5 mm smaller versus pre-cinching; P.001), and PM-"saddle horn" distances (0.9±0.7 and 1.0±0.8 mm reduction for APM and PPM, respectively; P.005). PAPS reduced APM-PPM distance (3.7±1.8 mm reduction versus precinching; P.001), only slightly decreased the PPM-"saddle horn" distance (0.3±0.3 mm reduction; P.03), and had no effect on IMR. Conclusions - Acute IMR was abolished by annular SL reduction, which also repositioned both PM tips closer to the mid-septal annulus and paradoxically increased leaflet "apical tenting"; reducing inter-papillary dimension was not effective, even though it displaced the leaflets toward the annular plane (less "apical tenting").

AB - Background - Ischemic mitral regurgitation (IMR) has been attributed to annular dilatation, papillary muscle (PM) displacement ("apical leaflet tenting"), or both. We compared the efficacy of reducing annular or subvalvular dimensions to gain more mechanistic insight into acute IMR. Methods - Eight adult sheep underwent implantation of radiopaque markers on the LV, mitral annulus (MA), each leaflet edge, and each PM tip. Trans-annular septal-lateral (SL) and inter-PM tip sutures were placed and externalized. Biplane videofluoroscopy and transesophageal echocardiography were performed before and continuously during LCx occlusion-induced IMR with SL annular (SLAC) or inter-PM (PAPS) suture tightening (4 to 5 mm of cinching for 5 seconds during ischemia). MA SL dimension, inter-papillary distance (APM-PPM), and the distances between the anterior (APM) and posterior (PPM) PM tips and the mid-septal annulus ("saddle horn") were calculated from 3-D marker coordinates at end-systole. Results - SLAC reduced IMR (grade= 2.1±0.6 versus 0.7±0.5, P.001), SL annular diameter (4.9±2.5 mm smaller versus pre-cinching; P.001), and PM-"saddle horn" distances (0.9±0.7 and 1.0±0.8 mm reduction for APM and PPM, respectively; P.005). PAPS reduced APM-PPM distance (3.7±1.8 mm reduction versus precinching; P.001), only slightly decreased the PPM-"saddle horn" distance (0.3±0.3 mm reduction; P.03), and had no effect on IMR. Conclusions - Acute IMR was abolished by annular SL reduction, which also repositioned both PM tips closer to the mid-septal annulus and paradoxically increased leaflet "apical tenting"; reducing inter-papillary dimension was not effective, even though it displaced the leaflets toward the annular plane (less "apical tenting").

KW - Annular cinching

KW - Coronary artery disease

KW - Ischemic mitral regurgitation

KW - Mitral annulus

KW - Mitral regurgitation

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