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Asher SR, Ong CS, Malapero RJ, Heydarpour M, Malzberg GW, Shahram JT, Nguyen TB, Shook DC, Shernan SK, Shekar P, Kaneko T, Citro R, Muehlschlegel JD, Body SC. Effect of concurrent mitral valve surgery for secondary mitral regurgitation upon mortality after aortic valve replacement or coronary artery bypass surgery. Front Cardiovasc Med 2023; 10:1202174. [PMID: 37840960 PMCID: PMC10570832 DOI: 10.3389/fcvm.2023.1202174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 09/08/2023] [Indexed: 10/17/2023] Open
Abstract
Objectives It is uncertain whether concurrent mitral valve repair or replacement for moderate or greater secondary mitral regurgitation at the time of coronary artery bypass graft or aortic valve replacement surgery improves long-term survival. Methods Patients undergoing coronary artery bypass graft and/or aortic valve replacement surgery with moderate or greater secondary mitral regurgitation were reviewed. The effect of concurrent mitral valve repair or replacement upon long-term mortality was assessed while accounting for patient and operative characteristics and mitral regurgitation severity. Results Of 1,515 patients, 938 underwent coronary artery bypass graft or aortic valve replacement surgery alone and 577 underwent concurrent mitral valve repair or replacement. Concurrent mitral valve repair or replacement did not alter the risk of postoperative mortality for patients with moderate mitral regurgitation (hazard ratio = 0.93; 0.75-1.17) or more-than-moderate mitral regurgitation (hazard ratio = 1.09; 0.74-1.60) in multivariable regression. Patients with more-than-moderate mitral regurgitation undergoing coronary artery bypass graft-only surgery had a survival advantage from concurrent mitral valve repair or replacement in the first two postoperative years (P = 0.028) that did not persist beyond that time. Patients who underwent concurrent mitral valve repair or replacement had a higher rate of later mitral valve operation or reoperation over the five subsequent years (1.9% vs. 0.2%; P = 0.0014) than those who did not. Conclusions These observations suggest that mitral valve repair or replacement for more-than-moderate mitral regurgitation at the time of coronary artery bypass grafting may be reasonable in a suitably selected coronary artery bypass graft population but not for aortic valve replacement, with or without coronary artery bypass grafting. Our findings are supportive of 2021 European guidelines that severe secondary mitral regurgitation "should" or be "reasonabl[y]" intervened upon at the time of coronary artery bypass grafting but do not support 2020 American guidelines for performing mitral valve repair or replacement concurrent with aortic valve replacement, with or without coronary artery bypass grafting.
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Affiliation(s)
- Shyamal R. Asher
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI, United States
| | - Chin Siang Ong
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, United States
| | - Raymond J. Malapero
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, United States
| | - Mahyar Heydarpour
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA, United States
| | - Gregory W. Malzberg
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, United States
| | - Jasmine T. Shahram
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Thy B. Nguyen
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Douglas C. Shook
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, United States
| | - Stanton K. Shernan
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, United States
| | - Prem Shekar
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, MA, United States
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, MA, United States
| | - Rodolfo Citro
- Cardio-Thoracic-Vascular Department, University Hospital—San Giovanni di Dio e Ruggi d’Aragona, Salerno, Italy
| | - Jochen D. Muehlschlegel
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, United States
| | - Simon C. Body
- Department of Anesthesiology, Boston University School of Medicine, Boston, MA, United States
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2
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Salsano A, Nenna A, Molinari N, Avtaar Singh SS, Spadaccio C, Santini F, Chello M, Fiore A, Nappi F. Impact of Mitral Regurgitation Recurrence on Mitral Valve Repair for Secondary Ischemic Mitral Regurgitation. J Cardiovasc Dev Dis 2023; 10:124. [PMID: 36975888 PMCID: PMC10053850 DOI: 10.3390/jcdd10030124] [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: 02/26/2023] [Revised: 03/08/2023] [Accepted: 03/09/2023] [Indexed: 03/18/2023] Open
Abstract
OBJECTIVES The current guidelines still do not include specific recommendations on the use of subvalvular repair (SV-r) for treatment of ischemic mitral regurgitation (IMR). Therefore, the objective of our study was to evaluate the clinical impact of mitral regurgitation (MR) recurrence and ventricular remodeling on long-term outcomes after SV-r combined with restrictive annuloplasty (RA-r). METHODS We performed a subanalysis of the papillary muscle approximation trial, studying 96 patients with severe IMR and coronary artery disease undergoing restrictive annuloplasty alongside subvalvular repair (SV-r + RA-r group) or restrictive annuloplasty alone (RA-r group). We analyzed treatment failure differences, the influence of residual MR, left ventricular remodeling, and clinical outcomes. The primary endpoint was treatment failure (composite of death; reoperation; or recurrence of moderate, moderate-to-severe, or severe MR) within 5 years of follow-up after the procedure. RESULTS A total of 45 patients showed failure of the treatment within 5 years, of which 16 patients underwent SV-r + RA-r (35.6%) and 29 underwent RA-r (64.4%, p = 0.006). Patients with significant residual MR presented with a higher rate of all-cause mortality at 5 years compared with trivial MR (HR 9.09, 95% CI 2.08-33.33, p = 0.003). MR progression occurred earlier in the RA-r group, as 20 patients in the RA-r group vs. 6 in SV-r + RA-r group had a significant MR 2 years after surgery (p = 0.002). CONCLUSIONS RA-r remains a surgical mitral repair technique with an increased risk of failure and mortality at 5 years compared with SV-r. The rates of recurrent MR are higher, and recurrence occurs earlier, with RA-r alone compared to SV-r. The addition of the subvalvular repair increases the durability of the repair, thus extending all of the benefits of preventing MR recurrence.
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Affiliation(s)
| | - Antonio Nenna
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, 00128 Rome, Italy
| | - Nicolas Molinari
- IDESP, INSERM, PreMEdical INRIA, University of Montpellier, CHU Montpellier, 34295 Montpellier, France
| | | | | | | | - Massimo Chello
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, 00128 Rome, Italy
| | - Antonio Fiore
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor APHP, 94000 Creteil, France
- Advanced Surgical Technologies, Sapienza University of Rome, 00128 Roma, Italy
| | - Francesco Nappi
- Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, 93200 Paris, France
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Wang X, Xia X, Huang W, Li X, Liu Y. Anomalous origin of the left coronary artery from the pulmonary artery as a rare cause of mitral valve prolapse: a case report. BMC Cardiovasc Disord 2022; 22:304. [PMID: 35788178 PMCID: PMC9254612 DOI: 10.1186/s12872-022-02729-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mitral valve prolapse (MVP) is an etiologically heterogeneous disorder. Early diagnosis and prompt treatment of the underlying disease are of great significance. Herein, we present a rare case of MVP caused by anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). CASE PRESENTATION A 22-year-old female presented with a 16-year history of anterior mitral leaflet prolapse. However, she had never experienced any discomfort before. At a routine follow-up, a transthoracic echocardiogram showed anterior mitral leaflet prolapse (A2) with moderate mitral regurgitation, and a retrograde blood flow from an extremely dilated left coronary artery (LCA). Further coronary angiography and coronary computed tomography angiography confirmed the diagnosis of ALCAPA. She subsequently underwent successful LCA reimplantation and concomitant mitral valve replacement. Intraoperatively, her mitral annulus was mildly dilated, anterior mitral valve leaflet appeared markedly thickened with rolled edges, and a chordae tendineae connecting the anterior leaflet (A2) was ruptured and markedly shortened. CONCLUSIONS ALCAPA is a rare and potentially life-threatening congenital coronary artery anomaly that may cause mitral valve prolapse. Echocardiogram is an important screening tool for this disorder.
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Affiliation(s)
- Xuefeng Wang
- Department of Cardiology, The Affiliated Hospital of Southwest Medical University, NO. 25 Taiping Street, Luzhou, 646000, Sichuan, China
| | - Xiaorong Xia
- Ultrasound Department, The Affiliated Hospital of Southwest Medical University, NO. 25 Taiping Street, Luzhou, 646000, Sichuan, China
| | - Weiyi Huang
- Department of Cardiology, The Affiliated Hospital of Southwest Medical University, NO. 25 Taiping Street, Luzhou, 646000, Sichuan, China
| | - Xin Li
- Department of Cardiovascular Surgery, The Affiliated Hospital of Southwest Medical University, NO. 25 Taiping Street, Luzhou, 646000, Sichuan, China.
| | - Yingcai Liu
- Department of Cardiology, The Affiliated Hospital of Southwest Medical University, NO. 25 Taiping Street, Luzhou, 646000, Sichuan, China.
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4
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Asher SR, Malzberg GW, Ong CS, Malapero RJ, Wang H, Shekar P, Kaneko T, Pelletier MP, Mallidi H, Heydarpour M, Shook DC, Shernan SK, Fox JA, Muehlschlegel JD, Xu X, Nguyen TB, Sundt TM, Body SC. Joint preoperative transthoracic and intraoperative transoesophageal echocardiographic assessment of functional mitral regurgitation severity provides better association with long-term mortality. Interact Cardiovasc Thorac Surg 2021; 32:9-19. [PMID: 33313764 DOI: 10.1093/icvts/ivaa230] [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: 02/23/2020] [Revised: 08/10/2020] [Accepted: 09/03/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Functional mitral regurgitation (MR) is observed with ischaemic heart disease or aortic valve disease. Assessing the value of mitral valve repair or replacement (MVR/P) is complicated by frequent discordance between preoperative transthoracic echocardiographic (pTTE) and intraoperative transoesophageal echocardiographic (iTOE) assessment of MR severity. We examined the association of pTTE and iTOE with postoperative mortality in patients with or without MR, at the time of coronary artery bypass grafting (CABG) and/or aortic valve replacement without MVR/P. METHODS Medical records of 6629 patients undergoing CABG and/or aortic valve replacement surgery with or without functional MR and who did not undergo MVR/P were reviewed. MR severity assessed by pTTE and iTOE were examined for association with postoperative mortality using proportional hazards regression while accounting for patient and operative characteristics. RESULTS In 72% of 709 patients with clinically significant (moderate or greater) functional MR detected by pTTE, iTOE performed after induction of anaesthesia demonstrated a reduction in MR severity, while 2% of patients had increased severity of MR by iTOE. iTOE assessment of MR was better associated with long-term postoperative mortality than pTTE in patients with moderate MR [hazard ratio (HR) 1.31 (1.11-1.55) vs 1.02 (0.89-1.17), P-value for comparison of HR 0.025] but was not different for more than moderate MR [1.43 (0.96-2.14) vs 1.27 (0.80-2.02)]. CONCLUSIONS In patients undergoing CABG and/or aortic valve replacement without MVR/P, these findings support intraoperative reassessment of MR severity by iTOE as an adjunct to pTTE in the prediction of mortality. Alone, these findings do not yet provide evidence for an operative strategy.
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Affiliation(s)
- Shyamal R Asher
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI, USA
| | - Gregory W Malzberg
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Chin Siang Ong
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Raymond J Malapero
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Huan Wang
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Prem Shekar
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Marc P Pelletier
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Hari Mallidi
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Mahyar Heydarpour
- Division of Endocrinology, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Douglas C Shook
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Stanton K Shernan
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - John A Fox
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - J Daniel Muehlschlegel
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Xinling Xu
- Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Thy B Nguyen
- Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Simon C Body
- Department of Anesthesiology, Boston University School of Medicine, Boston, MA, USA
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5
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Colombino E, Biasato I, Vezzaro G, Amante E, Biagini D, Cavallarin L, Guerra N, Guil-Alcalà P, Mioletti S, Perona G, Tarantola M, Vincenti M, Guarda F, Mendéz-Sanchez A, Capucchio MT. Evaluation of stress-related parameters and intramural coronary arteriosclerosis in Lidia bulls and Piemontese oxen. ITALIAN JOURNAL OF ANIMAL SCIENCE 2021. [DOI: 10.1080/1828051x.2021.1993756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Elena Colombino
- Dipartimento di Scienze Veterinarie, Università degli Studi di Torino, Grugliasco (To), Italia
| | - Ilaria Biasato
- Dipartimento di Scienze Agrarie, Forestali e Alimentari, Università degli Studi di Torino, Grugliasco (To), Italy
| | - Giorgia Vezzaro
- Dipartimento di Scienze Veterinarie, Università degli Studi di Torino, Grugliasco (To), Italia
| | - Eleonora Amante
- Centro Regionale antidoping e di Tossicologia "A. Bertinaria", Orbassano (To), Italy
- Dipartimento di Chimica, Università degli Studi di Torino, Torino, Italy
| | - Davide Biagini
- Dipartimento di Scienze Agrarie, Forestali e Alimentari, Università degli Studi di Torino, Grugliasco (To), Italy
| | - Laura Cavallarin
- Istituto di Scienze delle Produzioni Alimentari (CNR), Grugliasco (To), Italy
| | | | - Pilar Guil-Alcalà
- Departamento de Anatomía y Anatomía Patológica Comparadas, Universidad de Córdoba, Córdoba, Spain
| | - Silvia Mioletti
- Dipartimento di Scienze Veterinarie, Università degli Studi di Torino, Grugliasco (To), Italia
| | - Giovanni Perona
- Dipartimento di Scienze Veterinarie, Università degli Studi di Torino, Grugliasco (To), Italia
| | - Martina Tarantola
- Dipartimento di Scienze Veterinarie, Università degli Studi di Torino, Grugliasco (To), Italia
| | - Marco Vincenti
- Centro Regionale antidoping e di Tossicologia "A. Bertinaria", Orbassano (To), Italy
- Dipartimento di Chimica, Università degli Studi di Torino, Torino, Italy
| | - Franco Guarda
- Dipartimento di Scienze Veterinarie, Università degli Studi di Torino, Grugliasco (To), Italia
| | - Aniceto Mendéz-Sanchez
- Departamento de Anatomía y Anatomía Patológica Comparadas, Universidad de Córdoba, Córdoba, Spain
| | - Maria Teresa Capucchio
- Dipartimento di Scienze Veterinarie, Università degli Studi di Torino, Grugliasco (To), Italia
- Istituto di Scienze delle Produzioni Alimentari (CNR), Grugliasco (To), Italy
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6
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Oyama MA, Elliott C, Loughran KA, Kossar AP, Castillero E, Levy RJ, Ferrari G. Comparative pathology of human and canine myxomatous mitral valve degeneration: 5HT and TGF-β mechanisms. Cardiovasc Pathol 2020; 46:107196. [PMID: 32006823 DOI: 10.1016/j.carpath.2019.107196] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 12/16/2019] [Accepted: 12/28/2019] [Indexed: 12/25/2022] Open
Abstract
Myxomatous mitral valve degeneration (MMVD) is a leading cause of valve repair or replacement secondary to the production of mitral regurgitation, cardiac enlargement, systolic dysfunction, and heart failure. The pathophysiology of myxomatous mitral valve degeneration is complex and incompletely understood, but key features include activation and transformation of mitral valve (MV) valvular interstitial cells (VICs) into an active phenotype leading to remodeling of the extracellular matrix and compromise of the structural components of the mitral valve leaflets. Uncovering the mechanisms behind these events offers the potential for therapies to prevent, delay, or reverse myxomatous mitral valve degeneration. One such mechanism involves the neurotransmitter serotonin (5HT), which has been linked to development of valvulopathy in a variety of settings, including valvulopathy induced by serotonergic drugs, Serotonin-producing carcinoid tumors, and development of valvulopathy in laboratory animals exposed to high levels of serotonin. Similar to humans, the domestic dog also experiences naturally occurring myxomatous mitral valve degeneration, and in some breeds of dogs, the lifetime prevalence of myxomatous mitral valve degeneration reaches 100%. In dogs, myxomatous mitral valve degeneration has been associated with high serum serotonin, increased expression of serotonin-receptors, autocrine production of serotonin within the mitral valve leaflets, and downregulation of serotonin clearance mechanisms. One pathway closely associated with serotonin involves transforming growth factor beta (TGF-β) and the two pathways share a common ability to activate mitral valve valvular interstitial cells in both humans and dogs. Understanding the role of serotonin and transforming growth factor beta in myxomatous mitral valve degeneration gives rise to potential therapies, such as 5HT receptor (5HT-R) antagonists. The main purposes of this review are to highlight the commonalities between myxomatous mitral valve degeneration in humans and dogs, with specific regards to serotonin and transforming growth factor beta, and to champion the dog as a relevant and particularly valuable model of human disease that can accelerate development of novel therapies.
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Affiliation(s)
- Mark A Oyama
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, USA; Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Chad Elliott
- Department of Surgery, Columbia Cardiovascular Institute and College of Physicians and Surgeons at Columbia University, New York, NY, USA
| | - Kerry A Loughran
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Alexander P Kossar
- Department of Surgery, Columbia Cardiovascular Institute and College of Physicians and Surgeons at Columbia University, New York, NY, USA
| | - Estibaliz Castillero
- Department of Surgery, Columbia Cardiovascular Institute and College of Physicians and Surgeons at Columbia University, New York, NY, USA
| | - Robert J Levy
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Giovanni Ferrari
- Department of Surgery, Columbia Cardiovascular Institute and College of Physicians and Surgeons at Columbia University, New York, NY, USA.
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7
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Nappi F, Spadaccio C. Obstructive Cardiomyopathy and Tethering in Ischemic Mitral Regurgitation: Two Sides of the Coin. Ann Thorac Surg 2018; 107:1911-1912. [PMID: 30557542 DOI: 10.1016/j.athoracsur.2018.11.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 11/15/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, 36 Rue des Moulins Gémeaux, 93200 Saint-Denis, France.
| | - Cristiano Spadaccio
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, United Kingdom
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9
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Papillary muscles of left ventricle-Morphological variations and it's clinical relevance. Indian Heart J 2017; 70:894-900. [PMID: 30580862 PMCID: PMC6306352 DOI: 10.1016/j.ihj.2017.12.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 11/21/2017] [Accepted: 12/09/2017] [Indexed: 11/20/2022] Open
Abstract
Introduction The two left ventricular papillary muscles are small structures at sternocostal and inferior wall but are vital to mitral valve competence. Extra papillary muscles could be found. Partial or complete rupture, complicating acute myocardial infarction, causes severe or even catastrophic mitral regurgitation, potentially correctable by surgery. Detailed knowledge of normal anatomy and variations is vital for accurate interpretation of information by echocardiography and for surgical repair. Materials and methods The material for present study consisted of 52 formalin fixed adult apparently normal cadaveric hearts belonging to either sex obtained from the Department of Anatomy. These hearts were dissected carefully to open the left ventricle and to expose the papillary muscles. According to their attitudinal position they were described as supero-lateral (S-L) and inferoseptal muscle (I-S) instead of conventional anterolateral and posteromedial. Different morphological features of papillary muscles were noted and measurements were taken. Results Classical picture of left ventricular papillary muscle was found only in 25% cases. Additionally extra muscles were found 34.61% and 71.15% in S-L and I-S group, respectively. Different shapes and pattern of papillary muscles were also been identified. An additional attribute of this study was measurement of length and breadth of papillary muscles which thus provides a base line data for further detailed studies in a large scale. Conclusion Oriental nomenclature is necessary not only for anatomist but also for electrocardiographers. Breadth of papillay muscle should be taken into morphometric account as for screening of hypertrophic cardiomyopathy. Proper anatomical knowledge is crucial for clinicians, surgeons and radiologists.
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10
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Nappi F, Spadaccio C, Chello M, Mihos CG. Papillary muscle approximation in mitral valve repair for secondary MR. J Thorac Dis 2017; 9:S635-S639. [PMID: 28740718 DOI: 10.21037/jtd.2017.06.98] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Ischemic mitral regurgitation (IMR) is a complex disorder occurring after a myocardial infarction and affecting both the mitral valvular and subvalvular apparati. Several abnormalities can be detected in IMR as annular dilatation, leaflet tethering with impaired coaptation and papillary muscle (PM) displacement along a posterior, apical or lateral vectors. Treatments available include, beside myocardial revascularization, mitral-valve repair or chordal-sparing replacement. Repair is normally achieved downsizing the mitral valve annulus with a rigid or semirigid ring. However, considering the involvement of the subvalvular apparatus, techniques addressing the PM have been developed. The rationale at the basis of this strategy relies in the possibility to reduce the interpapillary muscle distance restoring the geometry of the left ventricle (LV) and ultimately resolving the leaflet tethering at the basis of IMR. Subvalvular apparatus surgical approaches include the papillary muscle approximation (PMA), surgical relocation and PM sling. Improved outcomes in terms of postoperative positive left ventricular remodeling and recurrence of mitral regurgitation have been reported, but more investigations are required to confirm the efficacy of subvalvular apparatus surgery. Application of finite element analysis to improve preoperative and intraoperative planning and achieve a correct and durable repair by means of subvalvular surgery is an exciting new avenue in IMR research.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France
| | - Cristiano Spadaccio
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, UK.,University of Glasgow Institute of Cardiovascular and Medical Sciences, Glasgow, UK
| | - Massimo Chello
- Department of Cardiovascular Surgery, University Campus Bio-Medico, Rome, Italy
| | - Christos G Mihos
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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11
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Nappi F, Spadaccio C, Mihos CG, Fraldi M. Biomechanics raises solution to avoid geometric mitral valve configuration abnormalities in ischemic mitral regurgitation. J Thorac Dis 2017; 9:S624-S628. [PMID: 28740716 PMCID: PMC5505935 DOI: 10.21037/jtd.2017.05.63] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 05/09/2017] [Indexed: 11/06/2022]
Abstract
Ischemic mitral regurgitation (IMR) is a form of mitral insufficiency that is characterized by papillary muscle (PM) displacement, leaflet tethering, reduced closing forces, and different degree of annular dilatation. Treatment of this condition includes mitral valve replacement or mitral valve repair with restrictive annuloplasty. Recent evidences in mitral valve repair showed that addressing only the annulus and neglecting the subvalvular apparatus provides a suboptimal operation with poor long-term results. However, the complexity of the geometrical aberrances occurring in IMR demands for more accurate analysis also involving the biomechanics underlying the failing mitral valve and subvalvular apparatus. Finite element analysis (FEA) is a powerful tool in this context and we developed a biomechanical model of mitral valve and subvalvular unit using 3D geometry of the leaflets, annulus, chordae and PM. After the application of structural properties of materials to these elements and simulation of systemic pressure loading, FEA could be used to directly determine biomechanical changes and geometry variations. We believe this approach can provide valuable information to better address the surgical treatment of IMR and answer some of the questions still pending in IMR management.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France
| | - Cristiano Spadaccio
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, UK
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Christos G. Mihos
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Massimiliano Fraldi
- Department of Structures for Engineering and Architecture and Interdisciplinary Research Center for Biomaterials, Università di Napoli “Federico II”, Naples, Italy
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