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Papillary Muscles Relocation for Ischemic Mitral Valve Regurgitation: the Role of 3-Dimensional Transesophageal Echocardiography
Khalil Fattouch1, Giuseppe Nasso2, Giuseppe Bianco1, Sebastiano Castrovinci3, Giacomo Murana3, Pietro Dioguardi1, Francesco Guccione1, Giuseppe Speziale2.
1Department of Cardiovascular Surgery, GVM Care and Research, Maria Eleonora Hospital, Palermo, Palermo, Italy, 2Department of Cardiovascular Surgery, GVM Care and Research, Anthea Hospital, Bari, Bari, Italy, 3Department of Cardiovascular Surgery, University of Bologna, Bologna, Italy.

Objective: The assessment of the mitral valve apparatus and its modifications during ischemic mitral regurgitation (IMR) is better revealed by 3-dimensional (3D) transesophageal echocardiography (TEE). To plan mitral valve repair using annuloplasty and papillary muscle (PPM) relocation, we proposed a valve repair procedure oriented by real-time 3D TEE reconstruction of the mitral valve apparatus.
Methods: Since January 2008, we examined 70 patients with severe IMR before mitral valve repair. Mean coaptation depth and mean tenting area were 1.4 ± 0.4 cm and 3.2 ± 0.5 cm2, respectively. Intraoperative 3D TEE were performed, followed by a 3D off-line reconstruction of the mitral valve apparatus. A schematic mitral valve apparatus model was obtained. A geometric model as a truncated cone was traced according to the preoperative data. The size of the prosthetic ring was selected preoperatively according to the anterior leaflet surface. The expected truncated cone after annuloplasty was retraced. A conventional normal coaptation depth about 6 mm was used to detect the new position of the PPM tips (Fig.1).
Results: Peri-operative off-line reconstruction of the mitral valve apparatus and respective truncated cone were feasible in all patients. The expected position of the PPM 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: PPM relocation plus ring annuloplasty reduce mitral valve tenting and may improve mitral valve repair results for patients with severe IMR. This technique may be easily and precisely guided by preoperative off-line 3D echocardiographic mitral valve reconstruction.


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