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Relocation of Papillary Muscles for Ischemic Mitral Valve Regurgitation: The Role of Three-Dimensional Transesophageal Echocardiography

Fattouch, Khalil MD, PhD*; Castrovinci, Sebastiano MD; Murana, Giacomo MD; Dioguardi, Pietro MD*; Guccione, Francesco MD*; Bianco, Giuseppe MD*; Nasso, Giuseppe MD; Speziale, Giuseppe MD

Innovations:Technology and Techniques in Cardiothoracic and Vascular Surgery: January/February 2014 - Volume 9 - Issue 1 - p 54–59
doi: 10.1097/IMI.0000000000000040
Original Articles

Objective The assessment of the mitral valve apparatus (MVA) and its modifications during ischemic mitral regurgitation (IMR) is better performed by three-dimensional (3D) transesophageal echocardiography (TEE). The aim of our study was to carry out nonrestrictive mitral annuloplasty in addition to relocation of papillary muscles (PPMs) oriented by preoperative real-time 3D TEE through the mitral valve quantification dedicated software.

Methods Since January 2008, a total of 70 patients with severe IMR were examined both before and after mitral valve repair. The mean (SD) coaptation depth and the mean (SD) tenting area were 1.4 (0.4) cm and 3.2 (0.5) cm2, respectively. Intraoperative 3D TEE was performed, followed by a 3D offline reconstruction of the MVA. A schematic MVA model was obtained, and a geometric model as a “truncated cone” was traced according to preoperative data. The expected truncated cone after annuloplasty was retraced. A conventional normal coaptation depth of approximately 6 mm was used to detect the new position of the PPMs tips.

Results Perioperative offline reconstruction of the MVA and the respective truncated cone was feasible in all patients. The expected position of the PPMs tips, desirable to reach a normal tenting area with a coaptation depth of 6 mm or more, was obtained in all patients. After surgery, all parameters were calculated, and no statistically significant difference was found compared with the expected data.

Conclusions Relocation of PPMs plus ring annuloplasty reduce mitral valve tenting and may improve mitral valve repair results in patients with severe IMR. This technique may be easily and precisely guided by preoperative offline 3D echocardiographic mitral valve reconstruction.

From the *Department of Cardiovascular Surgery, GVM Care and Research, Maria Eleonora Hospital, Palermo, Palermo, Italy; †Department of Cardiovascular Surgery, University of Bologna, Bologna, Italy; and ‡Department of Cardiovascular Surgery, GVM Care and Research, Anthea Hospital, Bari, Bari, Italy.

Accepted for publication December 4, 2013.

Presented at the Annual Scientific Meeting of the International Society for Minimally Invasive Cardiothoracic Surgery, June 12–15, 2013, Prague, Czech Republic.

Disclosure: The authors declare no conflicts of interest.

Address correspondence and reprint requests to Khalil Fattouch, MD, PhD, Department of Cardiovascular Surgery, GVM Care and Research, Maria Eleonora Hospital, Viale Regione Siciliana 1571, 90100, Palermo, Italy. E-mail:

©2014 by the International Society for Minimally Invasive Cardiothoracic Surgery