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Ann Thorac Surg 2001;71:1464-1470
© 2001 The Society of Thoracic Surgeons

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Original article: cardiovascular

Repair of anterior leaflet prolapse by papillary muscle repositioning: a new surgical option

^a Department of Cardiovascular Surgery, Foch Hospital, Suresnes, France

Address reprint requests to Dr Dreyfus, Foch Hospital, Department of Cardiovascular Surgery, 40 rue Worth, BP 36, 92151 Suresnes Paris University V, France
e-mail: g.dreyfus{at}hopital-foch.org

Presented at the Thirty-sixth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 31–Feb 2, 2000.

	Abstract

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Background. Although mitral valve repair is considered the gold standard for treating mitral regurgitation, anterior leaflet prolapse may still remain a challenging problem. This challenge is even greater for posterior commissural prolapse. We have used papillary muscle repositioning to treat anterior leaflet prolapse and suggest it as an alternative technique for all other methods previously described.

Methods. From 1989 to 1999 we performed 253 mitral valve repairs, among which 132 involved anterior leaflet prolapse. In this population there were two groups: group I (n = 92) treated with papillary muscle repositioning and group II (n = 40) treated with chordal shortening. There was no statistical difference between the two groups concerning age, functional class, and left ventricular function. Etiology was similar in both groups, a degenerative process being predominant. At echocardiography, regurgitation was graded 3.4/4 in both groups. There was no statistical difference concerning preoperative ejection fraction, end-systolic and end-diastolic left ventricular diameter.

Results. There were one in-hospital death in group I and two deaths in group II not related to mitral valve repair. Mean follow up is 36.4 ± 29.2 months in group I and 70.5 ± 9.5 months in group II. No patient was lost to follow-up. Mean regurgitation at follow-up was 0.75 ± 0.67 in group I and 0.8 ± 0.8 in group II (p = not significant). There was no statistical difference between the two groups concerning postoperative ejection fraction, end-systolic and end-diastolic left ventricular diameter. There was no late cardiac death in either group and there were no thromboembolic events. Actuarial survival rate is 98.9% and 96.3% in group I and 92.5% and 88.1% in group II at 3 and 8 years, respectively.

Conclusions. Therefore, we conclude that papillary muscle repositioning is a safe technique that provides excellent results at mid-term follow-up and facilitates treatment of anterior leaflet prolapse.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Although mitral valve repair is the gold standard to treat mitral regurgitation [1, 2], there may be some concerns about anterior leaflet prolapse. Whatever the lesions, Carpentier has well shown that mitral valve repair is durable and offers the best therapeutic option with regard to left ventricular recovery and quality of life [3–5]. In Western countries, rheumatic diseases have disappeared, and most of the patients have degenerative disease. In such instances, many patients show anterior leaflet prolapse, which can still be a surgical challenge, as opposed to posterior leaflet, for which there is a single surgical technique namely, quadrangular resection. Anterior leaflet prolapse can be treated by different techniques such as chordal shortening (CS), chordal transposition [6], or chordal substitution [7]. Most of those techniques require a learning curve and experience to achieve good results. As opposed to other techniques CS is not a direct shortening method, which can make it even more complex. Moreover, when anterior leaflet prolapse occurs, according to the prolapsed area, it may be more or less difficult. Special care has to be taken when dealing with posterior commissural prolapse for which none of the previous techniques achieve consistent results. Therefore, we have used papillary muscle repositioning (PMR) as a surgical alternative to all other methods to correct anterior leaflet prolapse. The aim of the study is to compare a reference technique such as CS to PMR, and to analyze its results in the long term with a complete follow-up reaching 10 years.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
From October 1989 to November 1999 we have performed 253 mitral valve repairs, among which 132 involved anterior leaflet prolapse. This cohort comprises 52% of all patients with mitral regurgitation treated in the same period with mitral repair. This series was divided into two groups: group I (n = 92) had PMR and group II (n = 40) had CS. Table 1 summarizes the clinical profile of these patients. There was no statistical difference between the two groups concerning age, sex, atrial fibrillation, and functional class (group I: 2.5 ± 0.7; group II: 2.5 ± 0.9). In group I 47.8% and in group II 45% were functionally asymptomatic or mildly symptomatic (New York Heart Association functional class I–II). Etiology was similar in both groups with the degenerative process (Barlow and dystrophic diseases) being predominant; 84.7% and 80% in groups I and II, respectively.

View larger version (54K): [in this window] [in a new window]   Fig 1. Posterior papillary muscle anatomy. The three heads can be identified: anterior, medial, and posterior.

View larger version (44K): [in this window] [in a new window]   Fig 2. Chordae arising from the anterior head are anchored to the anterior leaflet, chordae arising from the intermediate head are anchored to the commissural area, and those arising from the posterior head to the posterior leaflet. Elongation of chordae arising from the anterior head is usually the reason for anterior leaflet prolapses.

View larger version (57K): [in this window] [in a new window]   Fig 3. Surgical techniques of papillary muscle repositioning consists of separating the anterior head from the other heads and taking it down into the left ventricle. To achieve this we make a stitch in the fibrous segment of the anterior head and tie it to the fibrous segment of the posterior head.

Follow-up
Follow-up was complete and data were obtained through questionnaires and telephone contacts with patients, family physicians, and cardiologists. All patients underwent Doppler echocardiography assessment for this study. Follow-up was complete, as no patient was lost to follow-up.

Statistical analysis
All results were expressed as mean ± standard error of the mean. Postoperative events such as death, thromboembolic complications, infective endocarditis, and reoperations were characterized by actuarial statistics with the Kaplan–Meier method. The Student’s t test was used to compare mean parameters, and ² test to compare repartition. A p value of less than 0.05 was considered statistically significant.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
Operative mortality was 1.08% in group I (1 of 92 patients) and 5% in group II (2 of 40 patients). The only death in group I occurred in a patient who experienced postoperative bowel infarction and subsequently died on postoperative day 10. One of the two deaths in group II occurred in a woman aged 65 years, who had received coronary artery bypass grafting in conjunction to mitral valve repair. She suffered from persistent low cardiac output, and died on day 5 postoperatively from multiorgan failure. In the second death, postoperative septicemia leading to multiorgan failure led to death on the fourth postoperative day. Eight (8.6%) and nine (22.5%) patients experienced one or more perioperative complications in groups I and II, respectively. There was one myocardial infarction (1.08%) in group I, none in group II, one (1.08%) and two (5%) low cardiac output in groups I and II, respectively, and one reoperation for bleeding in each group (1.08%) and (2.5%), respectively. One patient in each group suffered from wound infection. Four patients (4.3%) in group I and 5 (12.5%) in group II had complete heart block; 4 patients (4.2%) in group I and 1 patient (2.5%) in group II required permanent pacemaker implantation. Only 1 patient in group II required early reoperation for severe residual mitral regurgitation (MR). He was reoperated on the first postoperative day, and was successfully treated by prosthetic ring insertion. No systolic anterior motion occurred among the 132 patients in who underwent mitral valve repair.

Late results
Follow-up was complete for all 129 survivors and ranged from 2 to 119 months and 18 to 121 months with a mean of 36.4 ± 29.2 and 70.5 ± 9.5 months in groups I and II, respectively.

Patient survival
There was one late death in group I and two in group II. The causes of death were noncardiac for all. The actuarial survival is 98.9% (94.1% to 99.8%) and 96.3% (86.4% to 99.1%) in group I and 92.5% (80.1% to 97.4%) and 88.1% (72.2% to 95.4%) in group II at 3 and 8 years, respectively (Fig 4) and does not reach statistical significance.

View larger version (11K): [in this window] [in a new window]   Fig 4. Actuarial survival curve (Kaplan-Meier) (p = 0.15). (CS = chordal shortening; PMR = papillary muscle repositioning.)

View larger version (10K): [in this window] [in a new window]   Fig 5. Freedom from reoperation (p = 0.62). (CS = chordal shortening; PMR = papillary muscle repositioning.)

Thromboembolic complications and infective endocarditis
No thromboembolic episode occurred during follow-up, and there were no cases of infective endocarditis among all survivors.

Event-free survival
Event-free survival, as assessed by the freedom from death, thromboembolism, reoperation, and anticoagulation-related hemorrhage at 3 and 8 years is 97.8% (92.4% to 99.4%) and 95.2% (85.8% to 98.5%) in group I and 90% (76.9% to 96%) and 85.7% (69.9% to 93.9%) in group II, respectively (Fig 6) and does not reach statistical significance.

View larger version (12K): [in this window] [in a new window]   Fig 6. Event-free survival p = 0.13). (CS = chordal shortening; PMR = papillary muscle repositioning.)

Doppler echocardiography
All patients but 1 in group I and 2 in group II were studied by Doppler echocardiography at the time of most recent follow-up for the purpose of this study. Residual MR was graded on a scale from 0 to 4+/4. Seventy-four patients in group I (83.1%) and 27 patients in group II (79.4%) had no or minimal MR (0 to 1+/4). Fourteen patients in group I (15.7%) and 6 patients in group II (17.6%) had mild MR (2+/4). One patient in each group had severe MR (3+/4). Mean regurgitation was 0.75 ± 0.67 and 0.8 ± 0.8 (p = not significant) in groups I and II, respectively. There was no statistical difference between the two groups concerning left ventricular end-systolic diameter (group I, 34.5 ± 6.8 mm; group II, 37.4 ± 9.7 mm), left ventricular end-diastolic diameter (group I, 53 ± 7.4 mm; group II, 54.8 ± 8.5 mm), left atrial size (group I, 42.5 ± 8.6 mm; group II, 42.6 ± 8.8 mm), pulmonary artery pressure (group I, 30.2 ± 8.7 mm Hg; group II, 29.6 ± 7.5 mm Hg), and left ventricular ejection fraction (group I, 64.3% ± 10.2%; group II, 62.9% ± 13.1%) (Table 5).

	Comment

Top Abstract Introduction Material and methods Results Comment References

However, most patients in this series had degenerative mitral valve disease, which often involves both leaflets; 84.7% of group I patients and 80% of group II patients had either Barlow’s disease or dystrophic disease. This extremely high incidence of degenerative disease might explain the need for anterior leaflet repair for all cases. It is extremely important to stress that billowing anterior leaflet is not the same as prolapsed anterior leaflet. If there are elongated or ruptured chordae of the free edge of the anterior leaflet, there is a prolapse. In such patients, isolated repair of the posterior leaflet cannot treat the mitral regurgitation. The recent report by Gillinov and colleagues [12] is very controversial, because one can believe that anterior leaflet prolapse can be neglected without further consequence. It has to be stressed that this series deals with posterior prolapse and anterior leaflet billowing valve. They clearly show that the free edge of the anterior leaflet is not prolapsed. We strongly recommend to treat separately the anterior leaflet prolapse and the posterior leaflet prolapse and we believe that ring insertion does not allow to treat anterior leaflet prolapse by itself.

In term of surgical techniques and in contrast to posterior leaflet repair, anterior leaflet prolapse cannot be treated with a single technique, but requires using combined techniques. Chordal shortening has been used most extensively and has the longest follow-up [13, 14]. Its indications were the need to shorten elongated chordae. When chordae are ruptured, chordal transposition from the posterior leaflet to the anterior leaflet seems to be very efficient [6]. Some investigators have proposed to correct leaflet prolapse due either to elongated or ruptured chordae with polytetrafluoroethylene substitute [7].

Each method has some advantages and drawbacks. Each method has its promoter: CS has been favored by Carpentier as well as chordal transposition [1, 6]. David and Zussa and their colleagues favor PTFE substitutes [7, 15]. To determine whether one technique is superior to another we have undergone a nonrandomized retrospective study, comparing a reference technique, such as CS, to a simple new method, namely PMR, and assess whether or not long-term results would be as good as those with classic techniques. Both were used at the same time, although CS were used more frequent initially, and PMR became progressively the method of choice.

The reasons for choosing such a technique are numerous. First, PMR is interesting only when chordae are elongated, that is why this study compares PMR with CS and not with other techniques. Technically, CS is not a direct method to shorten elongated chordae, because the effective shortening represents half of the length buried into the trench of the papillary muscle. Consequently, CS requires experience in the field of mitral valve repair. On the contrary, PMR is a direct shortening as the repositioning, deeper into the left ventricular cavity equals to the length of the prolapse. Therefore, we believe that this technique is easier and faster. Moreover, CS requires great care to avoid the burring sutures to be in contact with the shortened chordae, because it can induce rupturing with time. Probably because of this technical aspect some researchers, such as Gillinov and colleagues [16] reported a failure rate of 22% in their valve repair when using CS, which increased up to 36% in degenerative disease. Although we did not find this complication in our personal experience with more than 250 mitral valve repairs, such failure rate might explain the need to search for an alternative technique.

We favor PMR over CS for many technical reasons. This method can be mostly useful in case of paramedian and paracommissural posterior prolapse of the anterior leaflet. In many patients the chordae usually arise from the tip of the posterior papillary muscle. Therefore, chordal burring becomes impossible because rarely more than two chordae can be buried into a same trench. In those instances PMR offers a safe and elegant alternative option. The basic principle of this technique is to split the anterior head of the posterior papillary muscle to pull separately, deep down into the ventricle, a few chordae independently from the others. When paramedian anterior leaflet prolapse occurs, very often the posterior commissural area is not involved. In such cases the splitting of the anterior head corrects the localized prolapse without interfering with the adjacent structures of the leaflet. In most instances repositioning takes only one 4-0 monofilament suture tied into the fibrous area of the head of the papillary muscle. This is the simplest and fastest technique to correct anterior leaflet prolapse. We have always been able to perform it. Two specific pathologies should be emphasized. When anterior leaflet prolapse occurs at the level of the anterior papillary muscle, PMR is also feasible. In most instances, there are only two components, one anterior and one posterior, that can be easily split and then the same technique can be used. Therefore, any prolapsed area of the anterior can be successfully treated with this technique. More interestingly, posterior commissural prolapse may still remain the most challenging lesion to repair. In our series we have found 8.6% of patients in group I showing such lesions. By separating the anterior and the intermediate head, from the posterior one, it allows us to shorten, to a different extent, the commissural chordae from the paramedian chordae. In such cases sliding plasty of both anterior and posterior leaflet may be associated with chordal shortening ending with a new commissure. In such cases we never had to replace the valve, nor did we have to reoperate on the patients. Second, results shown by our study are not only good, but durable, as follow-up reaches 10 years (mean, 4.5 years). No patient has been reoperated for recurrent mitral regurgitation. Our freedom from reoperation is 100% and event-free survival is 95.2% (85.8% to 98.5%) at 8 years. We strongly believe that this method shows better results than others used previously. Gillinov and associates [16] reported a 10% reoperation rate at 5 years, and Smedira and colleagues [17] had a freedom from reoperation of 74% at 5 years for CS and 96% for chordal transposition. Although this series reports exclusively on anterior leaflet repair, close to 50% of the patients were asymptomatic or mildly symptomatic. It now well accepted that patients with severe mitral regurgitation, although not symptomatic, should receive mitral valve repair to restore or preserve their myocardial function [18]. According to such results it seems possible to propose mitral valve repair to any patient, even if they are asymptomatic, as long as the underlying pathology is degenerative and that mitral regurgitation is severe. Moreover, anterior leaflet prolapse in usually associated with a higher incidence of valve repair failure. In contrast with other reports, we have shown that anterior leaflet prolapse is not a risk factor for valve repair failure.

In conclusion, we believe that all methods can achieve good results. Interestingly complex mitral valve lesions may require a combination of techniques. We believe that PMR does not require an extensive learning curve, and because it is a fast technique it saves time for other maneuvers to treat completely anterior leaflet prolapse. David and colleagues [11] have stated that "prolapse of multiple segments of both leaflets may be better served by valve replacement than by valve repair until newer reconstruction approaches, such as shortening of the entire papillary muscle trunk are proved satisfactory." Although we do not propose to displace the entire papillary muscle, we believe that partial papillary muscle displacement can provide a safe durable and reproducible technique to correct the most complex lesions of the anterior leaflet such as in Barlow’s disease with or without posterior commissural prolapse and extensive valvular tissue.

With time, experience and follow-up, we have now extended this method to the anterior papillary muscle and PMR is our method of choice to treat anterior leaflet prolapse. Complete follow-up has shown that using such technique no patient has required reoperation and that event-free survival is excellent.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Gilles D. Dreyfus Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Dreyfus, G. D. Articles by De Lentdecker, P. Search for Related Content PubMed PubMed Citation Articles by Dreyfus, G. D. Articles by De Lentdecker, P. Related Collections Valve disease