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Calafiore AM, Prapas S, Totaro A, Guarracini S, Cargoni M, Katsavrias K, Fattouch K, Di Mauro M. Cutting the second order chords during mitral valve repair. J Card Surg 2022; 37:4072-4078. [PMID: 36378871 DOI: 10.1111/jocs.17194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/15/2022] [Accepted: 09/04/2022] [Indexed: 11/16/2022]
Abstract
The chordae tendinae connect the papillary muscles (PMs) to the mitral valve. While the first-order chordae serve to secure the leaflets to maintain valve closure and prevent mitral valve prolapse, the second-order chordae are believed to play a role in maintaining normal left ventricle size and geometry. The PMs, from where the chordae tendinae originate, function as shock absorbers that compensate for the geometric changes of the left ventricular wall. The second-order chordae connect the PMs to both trigons under tension. The tension distributed towards the second-order chordae has been demonstrate to be more than threefold that in their first-order counterpart. Cutting the second-order chordae puts all the tension on the first-order chordae, which are then closer to their rupture point. However, it has been experimentally demonstrated that the tension at which the first-order chordae break is 6.8 newtons (N), by far higher than the maximal tension reached, that is 0.4 N. Even if the clinical reports have been favorable, the importance of cutting the second-order chordae to recover curvature of the anterior leaflet and increase the coaptation length between the mitral valve leaflets has been slowly absorbed by the surgical world. Nevertheless, there are progressive demonstrations that chordal tethering affects the anterior leaflet not only in secondary, but also in primary mitral regurgitation, having a not negligible role in the long-term outcome of mitral repair.
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Affiliation(s)
| | - Sotirios Prapas
- Division of Cardiac Surgery A, Henry Dunant Hospital, Athens, Greece
| | - Antonio Totaro
- Department of Cardiovascular Diseases, Gemelli Molise, Campobasso, Italy
| | | | - Marco Cargoni
- Department of Surgical, Oncologic and Stomatological Disciplines, GVM Care & Research, Maria Eleonora Hospital, University of Palermo, Palermo, Italy
| | - Kostas Katsavrias
- Division of Cardiac Surgery A, Henry Dunant Hospital, Athens, Greece
| | - Khalil Fattouch
- Department of Cardiac Anesthesia, Mazzini Hospital, Teramo, Italy
| | - Michele Di Mauro
- Departmente of Cardio-Thoracic and Vascular Surgery, Heart and Vascular Center, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC), Maastricht, The Netherlands
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Shi W, McIver BV, Kalra K, Sarin EL, Schmarkey S, Duggan M, Thourani VH, Guyton RA, Padala M. A Swine Model of Percutaneous Intracoronary Ethanol Induced Acute Myocardial Infarction and Ischemic Mitral Regurgitation. J Cardiovasc Transl Res 2017; 10:391-400. [PMID: 28577038 DOI: 10.1007/s12265-017-9751-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 05/12/2017] [Indexed: 11/26/2022]
Abstract
Ischemic mitral regurgitation (IMR) is a frequent complication after a myocardial infarction (MI), which doubles mortality. Transcatheter mitral repairs are emerging as alternative treatment options to open heart surgery for IMR, but animal models to test them are lacking. We report a percutaneous swine model of IMR. Seventeen swine were randomized to (group 1, n = 12) MI causing IMR, and (group 2, n = 5) controls. In group 1, MI was induced via percutaneous ethanol injection into the obtuse marginal branches of the left circumflex artery, resulting in ST elevating myocardial infarction. Nine animals were survived to 8-10 weeks with weekly echocardiograms and three swine were survived to 16-20 weeks with MRI at termination. In group 1 animals, average IMR fraction at termination was 26.6 ± 2.3% in the echo group, and 24.51 ± 0.41% in the MRI group. None of the animals in group 2 had IMR. Left ventricular dysfunction and significant dilatation were evident in group 1 animals, compared to the controls. In conclusion, a reproducible model of IMR is reported for use in pre-clinical testing of new mitral technologies.
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Affiliation(s)
- Weiwei Shi
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Emory University, 380-B, Northyards Boulevard, Atlanta, GA, 30313, USA
| | - Bryant V McIver
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Emory University, 380-B, Northyards Boulevard, Atlanta, GA, 30313, USA
| | - Kanika Kalra
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Emory University, 380-B, Northyards Boulevard, Atlanta, GA, 30313, USA
| | - Eric L Sarin
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Emory University, 380-B, Northyards Boulevard, Atlanta, GA, 30313, USA
- INOVA Heart & Vascular Institute, Fairfax, VA, USA
| | - Susan Schmarkey
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Emory University, 380-B, Northyards Boulevard, Atlanta, GA, 30313, USA
| | - Michael Duggan
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Emory University, 380-B, Northyards Boulevard, Atlanta, GA, 30313, USA
- Division of Cardiac Anesthesiology, Emory University, Atlanta, USA
| | - Vinod H Thourani
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Emory University, 380-B, Northyards Boulevard, Atlanta, GA, 30313, USA
| | - Robert A Guyton
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Emory University, 380-B, Northyards Boulevard, Atlanta, GA, 30313, USA
| | - Muralidhar Padala
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Emory University, 380-B, Northyards Boulevard, Atlanta, GA, 30313, USA.
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3
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Halaney DL, Sanyal A, Nafissi NA, Escobedo D, Goros M, Michalek J, Acevedo PJ, Pérez W, Patricia Escobar G, Feldman MD, Han HC. The Effect of Trabeculae Carneae on Left Ventricular Diastolic Compliance: Improvement in Compliance With Trabecular Cutting. J Biomech Eng 2017; 139:2595441. [PMID: 28024161 PMCID: PMC7104769 DOI: 10.1115/1.4035585] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 12/13/2016] [Indexed: 12/25/2022]
Abstract
The role of trabeculae carneae in modulating left ventricular (LV) diastolic compliance remains unclear. The objective of this study was to determine the contribution of trabeculae carneae to the LV diastolic compliance. LV pressure-volume compliance curves were measured in six human heart explants from patients with LV hypertrophy at baseline and following trabecular cutting. The effect of trabecular cutting was also analyzed with finite-element model (FEM) simulations. Our results demonstrated that LV compliance improved after trabecular cutting (p < 0.001). Finite-element simulations further demonstrated that stiffer trabeculae reduce LV compliance further, and that the presence of trabeculae reduced the wall stress in the apex. In conclusion, we demonstrate that integrity of the LV and trabeculae is important to maintain LV stiffness and loss in trabeculae leads to more LV compliance.
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Affiliation(s)
- David L Halaney
- Department of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229;Department of Veterans Affairs, South Texas Veterans Health Care System, San Antonio, TX 78229
| | - Arnav Sanyal
- Department of Mechanical Engineering, University of Texas at San Antonio, San Antonio, TX 78249
| | - Navid A Nafissi
- Department of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229
| | - Daniel Escobedo
- Department of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229;Department of Veterans Affairs, South Texas Veterans Health Care System, San Antonio, TX 78229
| | - Martin Goros
- Department of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229
| | - Joel Michalek
- Department of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229
| | - Pedro J Acevedo
- Department of Anatomy, University of Environmental and Applied Sciences U.D.C.A., Bogotá, Cundinamarca, Colombia
| | - William Pérez
- Department of Anatomy, Faculty of Veterinary Medicine, University of the Republic, Montevideo 11200, Uruguay
| | - G Patricia Escobar
- Department of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229
| | - Marc D Feldman
- Department of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229;Department of Veterans Affairs, South Texas Veterans Health Care System, San Antonio, TX 78229 e-mail:
| | - Hai-Chao Han
- Fellow ASME Department of Mechanical Engineering, University of Texas at San Antonio, San Antonio, TX 78249
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Dal-Bianco JP, Bartko PE, Levine RA. The power of ultrasound: treating secondary MR with sound waves. Eur Heart J Cardiovasc Imaging 2016; 17:1108-9. [PMID: 27550662 DOI: 10.1093/ehjci/jew154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jacob P Dal-Bianco
- Harvard Medical School, Cardiac Ultrasound Laboratory, Massachusetts General Hospital, 55 Fruit Street, Yawkey 5B, Boston, MA 02114, USA
| | - Philipp E Bartko
- Harvard Medical School, Cardiac Ultrasound Laboratory, Massachusetts General Hospital, 55 Fruit Street, Yawkey 5B, Boston, MA 02114, USA
| | - Robert A Levine
- Harvard Medical School, Cardiac Ultrasound Laboratory, Massachusetts General Hospital, 55 Fruit Street, Yawkey 5B, Boston, MA 02114, USA
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Levine RA, Hagége AA, Judge DP, Padala M, Dal-Bianco JP, Aikawa E, Beaudoin J, Bischoff J, Bouatia-Naji N, Bruneval P, Butcher JT, Carpentier A, Chaput M, Chester AH, Clusel C, Delling FN, Dietz HC, Dina C, Durst R, Fernandez-Friera L, Handschumacher MD, Jensen MO, Jeunemaitre XP, Le Marec H, Le Tourneau T, Markwald RR, Mérot J, Messas E, Milan DP, Neri T, Norris RA, Peal D, Perrocheau M, Probst V, Pucéat M, Rosenthal N, Solis J, Schott JJ, Schwammenthal E, Slaugenhaupt SA, Song JK, Yacoub MH. Mitral valve disease--morphology and mechanisms. Nat Rev Cardiol 2015; 12:689-710. [PMID: 26483167 DOI: 10.1038/nrcardio.2015.161] [Citation(s) in RCA: 231] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Mitral valve disease is a frequent cause of heart failure and death. Emerging evidence indicates that the mitral valve is not a passive structure, but--even in adult life--remains dynamic and accessible for treatment. This concept motivates efforts to reduce the clinical progression of mitral valve disease through early detection and modification of underlying mechanisms. Discoveries of genetic mutations causing mitral valve elongation and prolapse have revealed that growth factor signalling and cell migration pathways are regulated by structural molecules in ways that can be modified to limit progression from developmental defects to valve degeneration with clinical complications. Mitral valve enlargement can determine left ventricular outflow tract obstruction in hypertrophic cardiomyopathy, and might be stimulated by potentially modifiable biological valvular-ventricular interactions. Mitral valve plasticity also allows adaptive growth in response to ventricular remodelling. However, adverse cellular and mechanobiological processes create relative leaflet deficiency in the ischaemic setting, leading to mitral regurgitation with increased heart failure and mortality. Our approach, which bridges clinicians and basic scientists, enables the correlation of observed disease with cellular and molecular mechanisms, leading to the discovery of new opportunities for improving the natural history of mitral valve disease.
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Affiliation(s)
- Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Yawkey 5E, Boston, MA 02114, USA
| | - Albert A Hagége
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | | | | | - Jacob P Dal-Bianco
- Massachusetts General Hospital, Cardiac Ultrasound Laboratory, Harvard Medical School, Boston, MA, USA
| | | | | | | | - Nabila Bouatia-Naji
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | - Patrick Bruneval
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | | | - Alain Carpentier
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | | | | | | | - Francesca N Delling
- Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | | | - Christian Dina
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | - Ronen Durst
- Hadassah-Hebrew University Medical Centre, Jerusalem, Israel
| | - Leticia Fernandez-Friera
- Hospital Universitario HM Monteprincipe and the Centro Nacional de Investigaciones Cardiovasculares, Carlos III (CNIC), Madrid, Spain
| | - Mark D Handschumacher
- Massachusetts General Hospital, Cardiac Ultrasound Laboratory, Harvard Medical School, Boston, MA, USA
| | | | - Xavier P Jeunemaitre
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | - Hervé Le Marec
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | - Thierry Le Tourneau
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | | | - Jean Mérot
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | - Emmanuel Messas
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | - David P Milan
- Cardiovascular Research Center, Harvard Medical School, Boston, MA, USA
| | - Tui Neri
- Aix-Marseille University, INSERM UMR 910, Marseille, France
| | | | - David Peal
- Cardiovascular Research Center, Harvard Medical School, Boston, MA, USA
| | - Maelle Perrocheau
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | - Vincent Probst
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | - Michael Pucéat
- Aix-Marseille University, INSERM UMR 910, Marseille, France
| | | | - Jorge Solis
- Hospital Universitario HM Monteprincipe and the Centro Nacional de Investigaciones Cardiovasculares, Carlos III (CNIC), Madrid, Spain
| | - Jean-Jacques Schott
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | | | - Susan A Slaugenhaupt
- Center for Human Genetic Research, MGH Research Institute, Harvard Medical School, Boston, MA, USA
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Jouan J. Mitral valve repair over five decades. Ann Cardiothorac Surg 2015; 4:322-34. [PMID: 26309841 DOI: 10.3978/j.issn.2225-319x.2015.01.07] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 11/27/2014] [Indexed: 01/13/2023]
Abstract
It has become evident that mitral valve (MV) repair is the preferable treatment for the majority of patients presenting with severe mitral regurgitation (MR). This success clearly testifies that the surgical procedure is accessible, reproducible and is carrying excellent long-lasting results. From the pre-extracorporeal circulation's era to the last percutaneous approaches, a large variety of techniques have been proposed to address the different features of MV diseases. This article aimed at reviewing chronologically the development of these dedicated techniques through their origins and the debates that they generated in the literature.
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Affiliation(s)
- Jerome Jouan
- Department of Cardiovascular Surgery, Georges Pompidou European Hospital, 75015 Paris, France
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7
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Da Col U, Di Lazzaro D, Affronti A, Perticoni S, Ragni T. Nine Years' Experience with the Chordal Cutting Technique in Ischemic Mitral Regurgitation. J Card Surg 2014; 29:605-8. [DOI: 10.1111/jocs.12392] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Uberto Da Col
- S.C. Cardiochirurgia; Ospedale S. Maria della Misericordia, Azienda Ospedaliera di Perugia; Perugia Italy
| | - Davide Di Lazzaro
- S.C. Cardiochirurgia; Ospedale S. Maria della Misericordia, Azienda Ospedaliera di Perugia; Perugia Italy
| | - Alessandro Affronti
- S.C. Cardiochirurgia; Ospedale S. Maria della Misericordia, Azienda Ospedaliera di Perugia; Perugia Italy
| | - Simone Perticoni
- S.C. Cardiochirurgia; Ospedale S. Maria della Misericordia, Azienda Ospedaliera di Perugia; Perugia Italy
| | - Temistocle Ragni
- S.C. Cardiochirurgia; Ospedale S. Maria della Misericordia, Azienda Ospedaliera di Perugia; Perugia Italy
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8
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Dal-Bianco JP, Beaudoin J, Handschumacher MD, Levine RA. Basic mechanisms of mitral regurgitation. Can J Cardiol 2014; 30:971-81. [PMID: 25151282 DOI: 10.1016/j.cjca.2014.06.022] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Revised: 06/16/2014] [Accepted: 06/22/2014] [Indexed: 12/17/2022] Open
Abstract
Any structural or functional impairment of the mitral valve (MV) apparatus that exhausts MV tissue redundancy available for leaflet coaptation will result in mitral regurgitation (MR). The mechanism responsible for MV malcoaptation and MR can be dysfunction or structural change of the left ventricle, the papillary muscles, the chordae tendineae, the mitral annulus, and the MV leaflets. The rationale for MV treatment depends on the MR mechanism and therefore it is essential to identify and understand normal and abnormal MV and MV apparatus function.
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Affiliation(s)
- Jacob P Dal-Bianco
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan Beaudoin
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Department of Cardiology, Québec City, Québec, Canada
| | - Mark D Handschumacher
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert A Levine
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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Murashita T, Okada Y, Kanemitsu H, Fukunaga N, Konishi Y, Nakamura K, Koyama T. Midterm outcomes of chordal cutting in combination with downsized ring annuloplasty for ischemic mitral regurgitation. Ann Thorac Cardiovasc Surg 2014; 20:1008-15. [PMID: 24492174 DOI: 10.5761/atcs.oa.13-00293] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE We describe midterm outcomes after division of secondary chords (chordal cutting) combined with downsized ring annuloplasty for ischemic mitral regurgitation (IMR). METHODS We compared the clinical outcomes in patients who underwent chordal cutting with downsized ring annuloplasty (CC-group, n = 15) and those who underwent conventional ring annuloplasty only (Conventional-group, n = 35) for IMR. Follow-up was complete in all patients. The median follow-up time was 4.1 years. RESULTS Thirty-day mortality was 0% in CC-group and 20% in Conventional-group. The overall survival rate at 5-year was 80.8% ± 12.6% in CC-group and 61.7% ± 8.4% in Conventional-group (Log-rank, p = 0.145). The freedom rate from valve-related events at 5 year was 84.6% ± 10.0% in CC-group and 65.3% ± 10.1% in Conventional-group (Log-rank, p = 0.213). Recurrence of severe mitral regurgitation was revealed in 3 patients of CC-group. Preoperative tenting height was the significant predictor of mitral regurgitation recurrence. In CC-group, the mean left ventricular ejection fraction was 38.0% ± 14.0%, which was similar to the preoperative value of 40.0% ± 13.2% (p = 0.349). CONCLUSIONS Chordal cutting with downsized ring annuloplasty for IMR is a simple method and provides satisfactory early outcomes. However, it carries with high recurrence of MR especially for patients with high tenting height.
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Affiliation(s)
- Takashi Murashita
- Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
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Abstract
The mitral valve apparatus is a complex 3-dimensional (3D) functional unit that is critical to unidirectional heart pump function. This review details the normal anatomy, histology, and function of the main mitral valve apparatus components: mitral annulus, mitral valve leaflets, chordae tendineae, and papillary muscles. Two-dimensional and 3D echocardiography is ideally suited to examine the mitral valve apparatus and has provided important insights into the mechanism of mitral valve disease. An overview of standardized echocardiography image acquisition and interpretation is provided. Understanding normal mitral valve apparatus function is essential to comprehend alterations in mitral valve disease and the rationale for repair strategies.
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Szymanski C, Bel A, Cohen I, Touchot B, Handschumacher MD, Desnos M, Carpentier A, Menasché P, Hagège AA, Levine RA, Messas E. Comprehensive annular and subvalvular repair of chronic ischemic mitral regurgitation improves long-term results with the least ventricular remodeling. Circulation 2012; 126:2720-7. [PMID: 23139296 DOI: 10.1161/circulationaha.111.033472] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Undersized ring annuloplasty for ischemic mitral regurgitation (MR) is associated with variable results and >30% MR recurrence. We tested whether subvalvular repair by severing second-order mitral chordae can improve annuloplasty by reducing papillary muscle tethering. METHODS AND RESULTS Posterolateral myocardial infarction known to produce chronic remodeling and MR was created in 28 sheep. At 3 months, sheep were randomized to sham surgery versus isolated undersized annuloplasty versus isolated bileaflet chordal cutting versus the combined therapy (n=7 each). At baseline, chronic myocardial infarction (3 months), and euthanasia (6.6 months), we measured left ventricular (LV) volumes and ejection fraction, wall motion score index, MR regurgitation fraction and vena contracta, mitral annulus area, and posterior leaflet restriction angle (posterior leaflet to mitral annulus area) by 2-dimensional and 3-dimensional echocardiography. All groups were comparable at baseline and chronic myocardial infarction, with mild to moderate MR (MR vena contracta, 4.6±0.1 mm; MR regurgitation fraction, 24.2±2.9%) and mitral annulus dilatation (P<0.01). At euthanasia, MR progressed to moderate to severe in controls but decreased to trace with ring plus chordal cutting versus trace to mild with chordal cutting alone versus mild to moderate with ring alone (MR vena contracta, 5.9±1.1 mm in controls, 0.5±0.08 with both, 1.0±0.3 with chordal cutting alone, 2.0±0.4 with ring alone; P<0.01). In addition, LV end-systolic volume increased by 108% in controls versus 28% with ring plus chordal cutting, less than with each intervention alone (P<0.01). In multivariate analysis, LV end-systolic volume and mitral annulus area most strongly predicted MR (r(2)=0.82, P<0.01). CONCLUSIONS Comprehensive annular and subvalvular repair improves long-term reduction of both chronic ischemic MR and LV remodeling without decreasing global or segmental LV function at follow-up.
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Affiliation(s)
- Catherine Szymanski
- Department of Cardio-Vascular Medicine, Hôpital Européen Georges Pompidou, INSERM U 633, PARCC, 20 Rue Leblanc, 75015 Paris, France
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12
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Padala M, Gyoneva L, Yoganathan AP. Effect of anterior strut chordal transection on the force distribution on the marginal chordae of the mitral valve. J Thorac Cardiovasc Surg 2011; 144:624-633.e2. [PMID: 22154223 DOI: 10.1016/j.jtcvs.2011.10.032] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2011] [Revised: 09/12/2011] [Accepted: 10/20/2011] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Transection of the secondary chordae on the anterior leaflet of the mitral valve to relieve leaflet tethering and reduce regurgitation is an experimentally proven procedure to correct functional mitral regurgitation. In the present study, we sought to investigate whether transecting the secondary chordae would have an effect on the marginal chordal force on the same leaflet. METHODS Adult porcine mitral valves (n = 8) were studied in a pulsatile heart simulator, in which the papillary muscle positions can be precisely positioned. Miniature transducers were inserted into the anterior marginal chordae to measure the chordal forces. Each valve was studied under baseline conditions, 3 different tethering conditions (apical, apical-lateral, and apical-lateral-posterior), and after chordal cutting in the 3 tethering conditions. The temporal changes and peak and average marginal chordal forces under each condition are reported. RESULTS Apical tethering increased the marginal chordal force by an average of 96% but remained unchanged after chordal cutting. With apical-lateral tethering, the marginal chordal force increased by 210% from baseline and increased further to 350% of baseline after chordal cutting. After apical-lateral-posterior tethering, the marginal chordal force increased to 335% of baseline before transection and by 548% after transection. CONCLUSIONS The increase in the marginal chordal force after secondary chordal cutting depends on the location of the papillary muscles and the extent of leaflet tethering. Although chordal cutting might not alter the valve mechanics under minimal leaflet tethering, it significantly affects the mechanics when the leaflet tethering is more pronounced, which is typically seen in patients with functional mitral regurgitation.
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Affiliation(s)
- Muralidhar Padala
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA
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13
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Mechanistic Insights into Ischemic Mitral Regurgitation: Echocardiographic and Surgical Implications. J Am Soc Echocardiogr 2011; 24:707-19. [DOI: 10.1016/j.echo.2011.04.001] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Indexed: 11/24/2022]
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14
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Messas E, Bel A, Szymanski C, Cohen I, Touchot B, Handschumacher MD, Desnos M, Carpentier A, Menasché P, Hagège AA, Levine RA. Relief of mitral leaflet tethering following chronic myocardial infarction by chordal cutting diminishes left ventricular remodeling. Circ Cardiovasc Imaging 2010; 3:679-86. [PMID: 20826595 DOI: 10.1161/circimaging.109.931840] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND one of the key targets in treating mitral regurgitation (MR) is reducing the otherwise progressive left ventricular (LV) remodeling that exacerbates MR and conveys adverse prognosis. We have previously demonstrated that severing 2 second-order chordae to the anterior mitral leaflet relieves tethering and ischemic MR acutely. The purpose of this study was to test whether this technique reduces the progression of LV remodeling in the chronic ischemic MR setting. METHODS AND RESULTS a posterolateral MI was created in 18 sheep by obtuse marginal branch ligation. After chronic remodeling and MR development at 3 months, 6 sheep were randomized to sham surgery (control group) and 12 to second-order chordal cutting (6 each to anterior leaflet [AntL] and bileaflet [BiL] chordal cutting, techniques that are in clinical application). At baseline, chronic infarction (3 months), and follow-up at a mean of 6.6 months post-myocardial infarction (MI) (euthanasia), we measured LV end-diastolic (EDV) and end-systolic volume (ESV), ejection fraction, wall motion score index, and posterior leaflet (PL) restriction angle relative to the annulus by 2D and 3D echocardiography. All measurements were comparable among groups at baseline and chronic MI. At euthanasia, AntL and BiL chordal cutting limited the progressive remodeling seen in controls. LVESV increased relative to chronic MI by 109±8.7% in controls versus 30.5±6.1% with chordal cutting (P<0.01) (LVESV in controls, 82.5±2.6 mL; in AntL, 60.6±5.1 mL; in BiL, 61.8±4.1 mL). LVEDV increased by 63±2.0% in controls versus 26±5.5% and 22±3.4% with chordal cutting (P<0.01). LV ejection fraction and wall motion score index were not significantly different at follow-up among the chordal cutting and control groups. MR progressively increased to moderate in controls but decreased to trace-mild with AntL and BiL chordal cutting (MR vena contracta in controls, 5.9±1.1 mm; in AntL, 2.6±0.1 mm; in BiL, 1.7±0.1 mm; P<0.01). BiL chordal cutting provided greater PL mobility (decreased PL restriction angle to 54.2±5.0° versus 83±3.2° with AntL chordal cutting; P<0.01). CONCLUSIONS reduced leaflet tethering by chordal cutting in the chronic post-MI setting substantially decreases the progression of LV remodeling with sustained reduction of MR over a chronic follow-up. These benefits have the potential to improve clinical outcomes.
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Affiliation(s)
- Emmanuel Messas
- Hôpital Européen Georges Pompidou, Department of Cardiology, University Paris Descartes, Paris.
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AL-ATABI M, ESPINO DM, HUKINS DWL. Computer and Experimental Modelling of Blood Flow through the Mitral Valve of the Heart. ACTA ACUST UNITED AC 2010. [DOI: 10.1299/jbse.5.78] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Silbiger JJ, Bazaz R. Contemporary insights into the functional anatomy of the mitral valve. Am Heart J 2009; 158:887-95. [PMID: 19958853 DOI: 10.1016/j.ahj.2009.10.014] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2009] [Accepted: 10/13/2009] [Indexed: 11/29/2022]
Abstract
The mitral valve is a highly complex structure the normal functioning of which requires the coordinated interaction of the leaflets, annulus, chordae tendineae, and papillary muscles. Perturbations of any of these components can interfere with normal valve function. The integrity of the mitral valve is also essential to maintaining normal left ventricular geometry and function through closely coupled ventricular-valvular interactions. This review summarizes recent developments in our understanding of the anatomy and physiology of the mitral valve.
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Affiliation(s)
- Jeffrey J Silbiger
- Department of Cardiology, Mount Sinai Services at Elmhurst Hospital Center, Mount Sinai School of Medicine, New York, NY, USA.
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Continued Global Left Ventricular Remodeling Is Not the Sole Mechanism Responsible for the Late Recurrence of Ischemic Mitral Regurgitation after Restrictive Annuloplasty. J Am Soc Echocardiogr 2009; 22:1256-64. [DOI: 10.1016/j.echo.2009.07.029] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2008] [Indexed: 11/23/2022]
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Slocum AH, Bosworth WR, Mazumdar A, Saez1 MA, Culpepper ML, Levine RA. Design of a Catheter-Based Device for Performing Percutaneous Chordal-Cutting Procedures. J Med Device 2009; 3:25001. [PMID: 20352058 DOI: 10.1115/1.3139835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
This paper focuses on the design and implementation of a percutaneous catheter-based device to provide physicians with an externally controlled tool capable of manipulating and cutting specific chordae tendinae within the hear to alleviate problems associated with some forms of mitral valve regurgitationt. In the United States alone, approximately 500,000 people develop ischemic or functional MR per year, and the chordae tendinae cutting procedure and device are needed because many patients do not have the required level of health necessary to survive open-heart surgery. A deterministic design process was used to generate several design concepts and then evaluate and compare each concept based on a set of functional requirements. A final concept to be alpha prototyped was then chosen, further developed, and fabricated. Experiments showed that the design was capable of locating and grabbing a chord and that ultrasound imaging is a viable method for navigating the device inside of the human body. Once contact between the chord and an RF ablator tip was confirmed, the chord was successfully ablated.
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Affiliation(s)
- Alexander H Slocum
- Massachusetts Institute of Technology, Department of Mechanical Engineering, Cambridge, MA 02139
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Solis J, Sitges M, Levine RA, Hung J. Ecocardiografía tridimensional. Nuevas perspectivas sobre la caracterización de la válvula mitral. Rev Esp Cardiol 2009. [DOI: 10.1016/s0300-8932(09)70161-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Komeda M, Kitamura H, Fukaya S, Okawa Y. Surgical Treatment for Functional Mitral Regurgitation. Circ J 2009; 73 Suppl A:A23-8. [DOI: 10.1253/circj.cj-09-0203] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Salgo IS. 3D echocardiographic visualization for intracardiac beating heart surgery and intervention. Semin Thorac Cardiovasc Surg 2008; 19:325-9. [PMID: 18395632 DOI: 10.1053/j.semtcvs.2007.12.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2007] [Indexed: 11/11/2022]
Abstract
Three-dimensional echocardiography has emerged as an essential tool for visualizing cardiac anatomy and for making more accurate measurements of cardiac structure and function. Recently, improvements in 3D beam-forming and transducer technologies have allowed higher resolution imaging from a transesophageal echocardiographic probe. This is creating new avenues for real-time visualization of intracardiac procedures without the need for cardiopulmonary bypass or opening the beating heart. Evolutions in visualization will allow a wider array of reparative procedures to be performed minimally invasively within a beating heart.
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Affiliation(s)
- Ivan S Salgo
- Cardiovascular Investigations, Ultrasound Research and Development, Philips Healthcare, Andover, MA 01810, USA.
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Borger MA, Murphy PM, Alam A, Fazel S, Maganti M, Armstrong S, Rao V, David TE. Initial results of the chordal-cutting operation for ischemic mitral regurgitation. J Thorac Cardiovasc Surg 2007; 133:1483-92. [PMID: 17532944 DOI: 10.1016/j.jtcvs.2007.01.064] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2006] [Revised: 01/07/2007] [Accepted: 01/29/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Division of secondary chords (chordal cutting) has been proposed as a method for decreasing mitral valve leaflet tethering and mitral regurgitation in patients with ischemic mitral regurgitation. However, very little clinical data exist to date for this procedure. METHODS We compared echocardiographic and clinical data in patients who underwent chordal-cutting mitral valve repair (n = 43) and those undergoing conventional mitral valve repair (control, n = 49) for ischemic mitral regurgitation. RESULTS Patients who underwent chordal cutting had a higher prevalence of recent myocardial infarction, left main disease, diabetes, and peripheral vascular disease (all P < .05). Left ventricular ejection fraction was lower in the chordal-cutting group (33 +/- 2% vs 44 +/- 2%) (mean +/- SE) and preoperative tent height was greater (11.7 +/- 0.5 vs 9.7 +/- 0.6 mm; both P < .01). In-hospital mortality was 10% in control patients and 9% in the chordal-cutting group (P = .9). Other complication rates were similar for the two groups. The reduction in tent height before-to-after repair was similar in the two groups of patients, but those undergoing chordal cutting had a greater reductions in tent area (53 +/- 3% vs 41 +/- 3%; P = .01). The chordal-cutting group also had greater mobility of the anterior leaflet, as measured by a reduction in the distance between the free edge of the anterior mitral valve leaflet and the posterior left ventricular wall (24 +/- 3% vs 11 +/- 4%; P = .01). Control patients had more recurrent mitral regurgitation during 2 years of follow-up by univariate (37% vs 15%; P = .03) and multivariate analysis (P = .03). Chordal cutting did not adversely affect postoperative left ventricular ejection fraction (10% +/- 5% relative increase in left ventricular ejection fraction vs 11% +/- 6% in the control group; P = .9). CONCLUSION Chordal cutting improves mitral valve leaflet mobility and reduces mitral regurgitation recurrence in patients with ischemic mitral regurgitation, without any obvious deleterious effects on left ventricular function.
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Affiliation(s)
- Michael A Borger
- Division of Cardiovascular Surgery and Department of Anesthesia, Toronto General Hospital, University Health Network, and University of Toronto, Toronto, Ontario, Canada.
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