Surgical Options of Ischemic Mitral Regurgitation · PDF fileREVIEW ARTICLE Surgical Options of Ischemic Mitral Regurgitation Orlando Santana, MD,* and Joseph Lamelas, MD† Abstract:

REVIEW ARTICLE

Surgical Options of Ischemic Mitral RegurgitationOrlando Santana, MD,* and Joseph Lamelas, MD†

Abstract: Mitral regurgitation after a myocardial infarction is common. Itcan occur acutely or chronically, and its presence portends a poor prognosis.The focus of this article will be on chronic ischemic mitral regurgitation. Wewill discuss the current concepts of its pathophysiology, the benefits ofrevascularization, along with the surgical, and percutaneous therapeuticoptions.

Key Words: ischemic mitral regurgitation, mitral valve repair, mitralleaflet tethering

(Cardiology in Review 2010;18: 163–170)

Approximately 50% to 60% of patients with congestive heartfailure have some degree of mitral regurgitation (MR), and in

30% of these, the MR is moderate or severe.1 The majority of theseindividuals have a structurally normal mitral valve (MV), but thevalve is incompetent because of left ventricular remodeling that hasdisturbed the relationship between the subvalvular apparatus and theMV leaflets. This type of MR is referred to as functional MR. Func-tional MR in the subgroup of patients in which the underlying ventric-ular remodeling is due to a myocardial infarction (MI), is referred to asischemic MR. The presence of MR after an MI is associated with aworse prognosis.2 In those with 3� to 4� MR, the 5-year survival isapproximately 50%, even with surgical intervention.3

DEFINITION, CLASSIFICATION, ANDPATHOPHYSIOLOGY OF CHRONIC ISCHEMIC

MITRAL REGURGITATIONIschemic MR is defined as MR complicating the manifesta-

tions of coronary artery disease in the absence of primary leaflet, orchordal pathology.4 Any disruption of the proper function of themitral annulus, the valve leaflets, the chordae tendineae, the papil-lary muscles, or the supporting left ventricular walls may lead toMR. Carpentier developed a functional classification to describe thelesions responsible for MR5 based on the motion of the MV leaflets(Fig. 1).6 In this classification, type I dysfunction is characterized bynormal leaflet motion, with the MR being caused by annular dila-tation or leaflet perforation; type II dysfunction is caused by anincreased leaflet motion such as with leaflet prolapse, chordalrupture, or papillary muscle rupture; type IIIa has restricted leafletmotion during both diastole and systole, caused by subvalvularfibrosis, and commissural fusion, as seen in patients with rheumaticheart disease; type IIIb dysfunction has restricted leaflet motionduring systole, and is due to left ventricular enlargement andpapillary muscle displacement. This is the most common lesionassociated with chronic ischemic MR.

The cause of MR in ischemic MR is due to (1) mitral annulardilatation, and/or (2) papillary muscle displacement. This processcauses (1) leaflet malcoaptation, which is the failure of the leaflets tomeet, and (2) malapposition, which is the failure of the leaflets toclose at the same plane. Although mitral annular dilatation has beendescribed as a cause of MR, it has been shown that isolated annulardilatation, per se, does not cause significant regurgitation.7 In only5% of the cases of ischemic MR does annular dilatation play asignificant role.6 This means that the predominant cause of ischemicMR is the apical and lateral displacement of the papillary muscles,leading to tethering of the MV leaflets, with subsequent decreasedcoaptation.8 This tethering of the leaflets is more commonly seenafter a posteroinferior than an anterolateral wall MI.9 Therefore, it ismore common for the posteromedial papillary muscle to be theculprit associated with ischemic MR, and it affects mainly the P3/P2segment of the posterior leaflet6 (Fig. 2).

CORONARY ARTERY REVASCULARIZATIONSince the underlying cause of ischemic MR is coronary artery

disease, it would seem intuitive that coronary artery revasculariza-tion would ameliorate the severity of the MR. However, the datashow that in most patients coronary artery revascularization does notcorrect the MR. A study of 136 patients10 with ischemic MR whounderwent isolated coronary artery bypass graft surgery (CABG)showed on postoperative transthoracic echocardiogram that 40% ofpatients were left with 3 to 4� MR, and 51% were left with 2� MR.Only 9% of patients had significant improvement, with no more thantrace (0 to 1�) MR. Another report of 92 patients with 3� to 4�ischemic MR undergoing isolated CABG showed that in postoper-ative echocardiographic follow-up, nearly half the patients still had3� to 4� MR.11

CABG VERSUS CABG AND MV REPAIRTo date, no randomized trial has been done to evaluate the

efficacy of MV repair when performed at the time of CABG. Thepublished data have all been retrospective analyses. Wu et al12

evaluated 682 patients with moderate to severe MR and ejectionfraction �30% who underwent CABG; 419 patients underwentCABG alone, and 126 underwent CABG with MV repair. When theCABG MV repair group was compared with the CABG group, therewas no demonstrable mortality benefit conferred by the MV repair.Another study from the Cleveland Clinic13 evaluated 390 patientswith 3�/4� MR, with varying degrees of left ventricular systolicdysfunction. Of these, 290 patients underwent CABG with MVrepair and were compared with 100 patients who underwent CABGalone. Their conclusions were that the addition of MV annuloplastyto CABG did not improve long-term functional status or survival.Similar studies have come to the same conclusions.3

MITRAL VALVE REPLACEMENTAlthough no randomized trial has been performed comparing

the benefits of MV replacement versus MV repair, it appears thatMV repair has a lower operative mortality and a better long-termsurvival when compared with MV replacement.14 However, MVreplacement is still a reasonable option for patients with acute MR,and for those with chronic ischemic MR and multiple comorbidities,complex regurgitant jets (noncentral jet or more than one jet), or

From the *Echocardiography Laboratory, and †Cardiovascular Surgery, Mt. SinaiMedical Center, Miami Beach, FL.

Correspondence: Orlando Santana, MD, Echocardiography Laboratory, Mt. SinaiMedical Center, 4300 Alton Road, Miami Beach, Florida 33140. E-mail:[email protected].

Copyright © 2010 by Lippincott Williams & WilkinsISSN: 1061-5377/10/1804-0163DOI: 10.1097/CRD.0b013e3181d35613

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severe tethering of both MV leaflets.15 When considering whichtype of valve to implant, it is important to take into account that themajority of patients do not survive much longer than 5 years. Abioprosthetic valve in the mitral position starts to deteriorate ap-proximately 6 years postimplant.16 As a result, some surgeonsrecommend the use of a bioprosthetic valve over a mechanical one,

irrespective of the patient’s age, to avoid chronic anticoagulation.17

Also, chordal preservation is less technically demanding, and thereare fewer potential postoperative valve-related complications if abioprosthetic valve is used.

To evaluate the safety and efficacy of MV repair and MVreplacement for patients with severe ischemic MR, a multicenterrandomized trial titled “Evaluation of Outcomes Following MitralValve Repair/Replacement in Severe Chronic Ischemic Mitral Re-gurgitation”18 is now taking place. Patients will be randomized toMV repair with annuloplasty and a subvalvular procedure for severetethering, or to MV replacement with complete preservation of thesubvalvular apparatus. The primary end point of the study is thedegree of left ventricular remodeling at 12 months.

MITRAL VALVE REPAIRThe most common type of surgery performed for ischemic

MR is an undersized mitral annuloplasty. In this technique, a small(size 24 to 26 mm) mitral annuloplasty ring is used19 which causesa reduction in the anteroposterior (septolateral) diameter of the MVincreasing the surface of coaptation. The procedure is fairly easy toperform and reproducible. Over the past few years, many differenttypes of prosthetic rings have been developed, some are flexible,others rigid, some are complete, others incomplete. However, thereare no definite data that show that one ring is superior to another.

The drawback with the undersized annuloplasty technique isthe high rate of failure. In an article from Cleveland Clinic, 585patients who had undersized annuloplasty surgery over a 17-yearperiod were examined.20 In 28% of the patients, moderate or moreMR developed 6 months postoperatively. It is felt that the reason forthe recurrent MR is that the underlying process of left ventriculardilatation from left ventricular remodeling continues despite having“fixed” the valve. This remodeling causes further tethering of thepapillary muscles, especially the posteromedial papillary muscle,and causes the recurrence of MR.21 One needs to bear in mind thatischemic MR is more a ventricular problem than a valvular one.

To address the issue of remodeling, the Carpentier-McCarthy-Adams IMR ETlogix annuloplasty ring (CMA IMR ETlogix ring;Edwards Lifescience, Irvine, CA), was developed. This ring wasdesigned with a reduced middle to medial (P2-P3) curvature, and aslight dip at the P3-P2 segments to increase coaptation of thesetethered segments. Evaluation of this ring in 59 patients showed thatafter surgery 57 of 59 (97%) patients had grade 0 to 1� MR,

FIGURE 1. Carpentier’s functional classification of mitral regurgitation. Type I is characterized by normal leaflet motion, withthe mitral regurgitation being caused by annular dilatation or leaflet perforation; type II is caused by an increased leaflet mo-tion such as leaflet prolapse, chordal rupture, or papillary muscle rupture; type IIIa has restricted leaflet motion caused by sub-valvular fibrosis, and commissural fusion, as seen in patients with rheumatic heart disease; type IIIb dysfunction has restrictedleaflet motion during systole, and is due to left ventricular enlargement and papillary muscle displacement. Reprinted withpermission from Am Heart Hosp J. 2006;4:261–268.6

FIGURE 2. Restricted leaflet motion. It is noticed in the crosssectional view of the mitral valve that segments P3/P2 donot coapt due to restricted motion of the leaflet. Type IIIbdysfunction of Carpentier’s classification. Reprinted with per-mission from Am Heart Hosp J. 2006;4:261–268.6

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whereas 2 patients had 2� MR.22 This new prosthetic ring mayimprove the durability of MV repair. However, long-term results arenot yet available.

EDGE-TO-EDGE REPAIRThis technique, also known as the Alfieri stitch, involves

placing a suture at the center (A2-P2 portion) of the margins of bothleaflets, creating a double orifice MV.23 An annuloplasty ring needsto be placed with this procedure, because of poor long-term resultswithout it.24 Even with an annuloplasty ring, the failure rate for thisprocedure is high. Bhudia et al performed the edge-to-edge repairwith a flexible posterior annuloplasty band in 143 patients withischemic cardiomyopathy.25 At 2 years postoperatively, the propor-tion of patients with moderate MR (2�) was 23%, and the moder-ately severe MR (3�) was 24%. They concluded that other tech-niques were needed to correct the MR. Overall, the edge-to-edgerepair has fallen out of favor, and is not frequently used.

ANTERIOR LEAFLET AUGMENTATIONA simple approach to the tethering of the MV leaflets was

reported by Kincaid et al.26 The anterior leaflet was augmented insize by creating a defect in it, in the shape of an ellipse. The defectwas then filled with a piece of bovine pericardium, and a flexible 27-to 31-mm posterior annuloplasty band was placed. This methodallowed the level of leaflet coaptation to fall more posteriorly, andtowards the level of the displaced papillary muscles (Fig. 3). Thiswas performed in 25 patients with significant ischemic MR; post-operative transesophageal echocardiogram revealed trace or no MRin 80% of the patients and mild MR in 20%. At 2 years, the actuarialfreedom from moderate or greater MR was 81%.

SECOND ORDER CHORDAL CUTTINGAnother approach to reduce the tethering of the papillary

muscles and chordae tendineae on the MV leaflets is by cutting thesecondary cords. A study by Borger et al27 compared 43 patientswho underwent chordal-cutting MV repair to 49 patients havingconventional MV repair. The procedure consisted of cutting allthe secondary chords to the anterior leaflet, posterior leaflet, and thecommissure that arose from the affected papillary muscle. The

secondary chords arising from the normal papillary muscle were notdivided. They also placed a moderately undersized (size 26 to 32mm) flexible, incomplete annuloplasty band. The in-hospital mor-tality was 10% for the conventional annuloplasty group and 9%in the chordal cutting group. Their results showed that chordalcutting was associated with an improvement in the MV leafletmobility, a reduction in MR recurrence, without reducing leftventricular function.

POSTERIOR MITRAL VALVE RESTORATIONFundaro et al28 developed a technique to reduce tethering of

the MV leaflets and reduce the anteroposterior mitral annulusdimension after an inferior wall MI. Approaching the MV through astandard left atriotomy, an incision was made to detach the tetheredsegment of the posterior leaflet from the mitral annulus. Throughthis incision, the secondary chordae were transected to increase themobility of the posterior leaflet. The detached portion of the mitralannulus was then plicated, and the resulting defect in the posteriorleaflet was closed with a running suture. The plicated annulus wasthen reinforced with a Gore-Tex strip or posterior annuloplasty band(Fig. 4). This technique was performed in 9 patients, and postoper-ative transesophageal echocardiogram showed mild or no MR in allpatients.

PAPILLARY MUSCLE SLINGThis procedure devised by Hvass et al involves placing a 4

mm Gore-tex tube through the left atrium and encircling the base ofboth papillary muscles.29 The sling is tightened to decrease thedistance between both papillary muscles, and a moderately under-sized (30 mm) annuloplasty ring is placed (Fig. 5). In their study of10 patients, the tenting distance decreased from 14 to 4 mm, and theMR resolved in all the patients.

SURGICAL VENTRICULAR RESTORATION WITHPAPILLARY MUSCLE IMBRICATION

The term “surgical ventricular restoration” includes operativemethods that reduce left ventricular volume and restore the ventric-ular elliptical shape. Its use is limited to anterior wall MIs. In this

FIGURE 3. Anterior leaflet augmentation. A, The mitral valve as viewed from the surgeon’s perspective with sutures in theposterior annulus. An incision is made in the anterior leaflet from commissure to commissure, with a resultant elliptical defect.B, Anterior leaflet augmented with bovine pericardium. C, Completed repair with partial, flexible annuloplasty ring. Reprintedwith permission from Ann Thorac Surg. 2004;78:564–568.26

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technique, the anteroseptal, apical, and anterolateral left ventricularscarred segments are excluded from the rest of the left ventricle withan intracardiac patch or by direct closure.30 By altering the shape ofthe left ventricle and reducing wall stress, this procedure can reducepapillary muscle displacement and subsequent MR.31

The RESTORE (Reconstructive Endoventricular Surgery re-turning Torsion Original Radius Elliptical shape to the left ventricle)study was an observational study of 1198 patients, with an anteriorwall MI that underwent revascularization and surgical ventricularrestoration.32 A subgroup of 46 patients from this study also had anendoventricular MV repair without a prosthetic ring.33 This wasdone through the left ventricle via the opening that was made for thesurgical ventricular restoration procedure. A purse-string suture wasplaced that caused the papillary muscles to be brought closertogether, or imbricated. Postoperatively, 84% of the patients hadmild or less MR. The global operative mortality rate was 15.2%, andthe cumulative survival at 30 months was 63%.

SURGICAL RELOCATION OF THE POSTERIORPAPILLARY MUSCLE

Kron et al used a technique to reposition the displacedpapillary muscles in 18 patients who had suffered a transmuralinferior wall MI.34 In patients whose LV end-systolic dimension was�6 cm, a 3–0 Prolene suture was passed twice through the fibrousportion of the posterior papillary muscle tip. The suture was thenpassed up through the adjacent mitral annulus just posterior to theright fibrous trigone. MV annuloplasty was then performed byplacing a 26 to 28 mm annuloplasty ring (Fig. 6). In patients whoseleft ventricular end-systolic dimension was �6 cm, a surgicalventricular restoration procedure was added. In these, surgical relo-cation of the posterior papillary muscle tip was performed throughthe left ventricle. At 8 weeks postoperative, 3 patients had trace MR,and the rest had no MR.

INFARCT PLICATIONThis procedure is used exclusively in individuals with an

inferolateral wall MI. It involves plicating the infarcted regionwithout excision or cardiopulmonary bypass. This shortens theinfarcted area, and brings the displaced papillary muscle back

FIGURE 4. Posterior mitral valve restoration. Toameliorate posterior leaflet tethering and restorenormal distensibility an incision at the base of theposterior leaflet is performed and the basal chor-dae are cut. Then a plication of posterior mitralannulus is performed. The leaflet is sutured reduc-ing its size, and reinforced with Gore Tex strip ora posterior annuloplasty band. Reprinted withpermission from Ann Thorac Surg. 2004;77:729–730.28

FIGURE 5. Papillary muscle sling. A 4-mm Gore-tex tube isplaced encircling the papillary muscles. The Gore-tex istightened to reduce the distance between the papillary mus-cles. Reprinted with permission from Ann Thorac Surg. 2003;75:809–811.29




towards the mitral annulus, increasing the zone of coaptation, thusreducing the MR. Ramadan et al35 used this approach in 3 patients.They placed mattressed sutures over the infarcted region with aTeflon patch. No annuloplasty ring was placed and no bypass wasperformed to the affected region (Fig. 7). At 7 months, 2 had no MR,and the third had trivial MR.

INTEGRATED OVERLAPPING VENTRICULOPLASTYCOMBINED WITH PAPILLARY MUSCLE PLICATION

In an attempt to reduce left ventricular wall stress and MR,Matsui et al combined an overlapping cardiac volume reductionoperation with papillary muscle plication.36 They took 8 patientswith 3 to 4� MR, in New York Heart Association functional

class III–IV, and ejection fraction of 22%. MV annuloplasty withan undersized ring was performed. A 10-cm long incision wasthen made along the left anterior descending coronary artery.Through the incision, 3 pericardium-pledgeted mattress sutureswere placed around the bases of the anterior and posteriorpapillary muscles, and were brought together. The left ventriclewas then reduced in size by having the left marginal incisionoverlap the right marginal incision (Fig. 8).

Of the 8 patients, 1 patient died 2 months after the operationdue to irreversible cerebral damage. The other 7 were followed for102 � 26 days. The New York Heart Association functional classwas class I in 6 of the patients and class II in 1 patient. No MR wasnoted in the latest echocardiogram performed postoperatively.

FIGURE 6. Surgical relocation ofposterior papillary muscle. Two 3–0Prolene sutures placed between thedisplaced PPM (posterior papillarymuscle) and the posterior base ofthe mitral ring. The ascension of thePPM produces better coaptation ofP2/P3 with the anterior valve. Re-printed with permission from AnnThorac Surg. 2002;122:600–601.34

FIGURE 7. Infarct Plication. A, Sche-matic representation of the akineticinferobasal segment with tetheringof the posterior leaflet. The suturesare shown before tightening. B, Pli-cation of the dyskinetic segmentwith relocation of the posterior pap-illary muscle. LA indicates Left atri-um; LV, left ventricle; Ao, aorta;IMR, ischemic mitral regurgitation;PPM, posterior papillary muscle. Re-printed with permission from J Tho-rac Cardiovasc Surg. 2005;129:440–442.35




MITRAL COMPLEX REMODELINGThis operation takes a slightly more comprehensive approach

to the problems with ischemic MR, in that it addresses the valvularissues as well as the subvalvular ones. The procedure consists ofdivision and reconstruction of secondary chords, undersized MVannuloplasty, and bilateral papillary muscle relocation.37

In this technique, the secondary chords to the anterior leafletfrom both papillary muscles are separated. Two pairs of 5–0 and4–0 Gore-Tex sutures are then placed through both fibrous portionsof the anterior and posterior papillary muscle tips. Two pairs ofthe 5– 0 sutures are passed through the middle portion of theanterior leaflet. The suture length is adjusted to be the samelength as the marginal chords. This relieves the tethering of theanterior leaflet, and increases leaflet mobility. Each pair of the4 – 0 Gore-Tex sutures are then passed through the posteriorannulus at sites around the border of the lateral and middleportions and middle and medial portion of the annulus, and arealso passed through corresponding sites of a 26-mm semirigidannuloplasty ring. These annulopapillary sutures are then pulledto bring the papillary muscle tips closer to the annulus, so that thepoint of leaflet coaptation occurs in the plane of the mitralannulus during systole (Fig. 9). This surgery was performed in 3patients with severely reduced ejection fraction, and at mean 6months follow-up, no or trivial MR was noted.

EXTERNAL COMPRESSION DEVICESAn innovative strategy to reverse remodeling has been the

development of constraint devices. These devices are intended toimprove left ventricular function by reducing wall stress, and pro-vide passive diastolic support. The Acorn Corcap cardiac supportdevice is a biocompatible mesh-like jacket that slips around the heartduring surgery. It was evaluated in the ACORN trial, which was anunblinded trial that randomized 300 patients to 2 treatment armsdepending on a need for MV surgery or only medical treatment, withor without use of the support device. In the subgroup of 193 patientswho were enrolled in the MV repair/replacement stratum, 102

patients were randomized to the MV surgery alone group (control),and 91 were randomized to the MV surgery with implantation of thesupport device.38 At 23 months median follow-up, the addition ofthe support device led to greater decreases in left ventricular vol-umes, a more elliptical left ventricle shape, a trend for reduction inmajor cardiac procedures, and improvement in quality of life com-pared with MV surgery alone.

PERCUTANEOUS PROCEDURESThe percutaneous approach for the treatment of MR is in its

early stages of development. One approach to reduce the mitralannulus septal-lateral distance is to place a nitinol device in thecoronary sinus. The CARILLON Mitral Annuloplasty Device Eu-ropean Union Study (AMADEUS) study showed that at 6 months,the device reduced MR by 23% and improved quality of life andexercise tolerance.39

Another technique uses a trans-septal approach to perform anedge-to-edge mitral valve repair by placing a clip in the center of themitral orifice. This was evaluated in the Endovascular Valve Edge-to-Edge Repair Studies (EVEREST I and II).40 A total of 107patients with 3� to 4� MR were treated. Acute procedural successwas achieved in 79 of 107 (74%) patients, and 51 (64%) weredischarged with MR of �1�. Thirty-two patients (30%) had mitralvalve surgery during the 3.2 years after the clip procedure. A total of50 of 76 (66%) successfully-treated patients were free from death,mitral valve surgery, or MR �2� at 12 months. Kaplan-Meierfreedom from death was 95.9%, 94.0%, and 90.1%, and Kaplan-Meier freedom from surgery was 88.5%, 83.2%, and 76.3% at 1, 2,and 3 years, respectively. The 23 patients with functional MR hadsimilar acute results and durability.

Percutaneous devices do not reduce the amount of MR to theextent that a surgical procedure would, however, because of theirless invasive nature, these devices will most likely be reserved forpatients deemed too high risk for surgery.

FIGURE 8. Integrated overlappingventriculoplasty combined withpapillary muscle plication. The ex-cluded septum can be overlappedin cases of idiopathic dilated cardio-myopathy because it might assist incardiac function, whereas in ischemiccardiomyopathy the right marginalincision is attached close to the sutureline to achieve its reinforcement andhemostasis because the scarred sep-tum might restrict the motion of theleft anterior wall if overlapped exten-sively. Reprinted with permission fromJ Thorac Cardiovasc Surg. 2004;127:1221–1223.36




RECOMMENDATIONS/OUR EXPERIENCEThe American College of Cardiology/American Heart Asso-

ciation state in their latest valvular heart disease guidelines that “Thebest operation for ischemic MR is controversial, but MV repair withan annuloplasty ring is the procedure of choice in most instances.”41

At our institution, MV repair for ischemic MR usually involvesimplanting a complete rigid saddle-shaped ring sized to the inter-trigonal space and anterior leaflet. In patients who do not needcoronary revascularization, we perform all the MV repairs via aminimally invasive approach, regardless of the left ventricular func-tion. In patients with coronary artery disease amenable to percuta-neous intervention, we perform a hybrid procedure which entails anangioplasty with stenting of the coronary artery lesions, followed bythe minimally invasive valve surgery.

SUMMARYIschemic mitral regurgitation has a poor prognosis. Coronary

revascularization does little to improve the severity of the regurgi-tation. Although MR can be resolved acutely with mitral valverepair, there is a high rate of recurrence. Newer surgical techniquesare focusing on the subvalvular apparatus in an attempt to achievebetter results. The data with these techniques are limited, and thelong-term results are not known. The constraint devices, along withthe percutaneous approaches, show promise, but more data areneeded before their widespread use.

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FIGURE 9. A, Mitral complex remod-eling (APM indicates anterior papillarymuscle; PPM, posterior papillary mus-cle). B, Mitral complex remodelingconcept. (I) Functional mitral regurgi-tation due to leaflet tethering(MR�mitral regurgitation. (II) Divisionof secondary chords (*) restores con-vexo-concave curvature of the ante-rior leaflet. (III) Undersized annulo-plasty approximates theanteroposterior distance but increasesposterior leaflet tethering. (IV) Artifi-cial chords of 5–0 Gore-Tex (W. L.Gore & Associates, Flagstaff, AZ) su-ture (x) to the anterior leaflet marginreplace divided secondary chords.The 4–0 Gore-Tex relocation sutures(y) between both papillary musclesand posterior mitral annulus relocateboth papillary muscles in relation tothe mitral annulus, relieving anteriorand posterior leaflet tethering. Re-printed with permission from AnnThorac Surg. 2008;85:1820–1822.37




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Surgical Options of Ischemic Mitral Regurgitation · PDF fileREVIEW ARTICLE Surgical Options of Ischemic Mitral Regurgitation Orlando Santana, MD,* and Joseph Lamelas, MD† Abstract: