BACKGROUND: Ischemic Mitral Regurgitation (IMR) is primarily due to left ventricular remodelling leading to annular dilatation and poor leaflet coaptation of the mitral valve (MV). Despite ring annuloplasty (RA) being commonly used for IMR, recent studies have raised concerns about the long-term durability of this approach, especially in the absence of any intervention on the sub-valvular apparatus. As such, papillary muscle relocation (PMR) has been introduced as an adjunct for the treatment of IMR, we present an innovative modification of the original technique for PMR using a multi-loop technique.
METHODS AND RESULTS: Six patients underwent PMR and RA for the treatment of IMR (Table 1). Figure 1 is a representative video of the surgical technique performed. A loop of Gore-Tex CV4 was created by passing each end through a pledget and two additional sutures were secured to the loop, thus creating the multi loop (Fig. 2A). The multi-loop was passed through the fibrous tip of the posteromedial papillary muscle (PM), whereby each side was buttressed with a pledget (Fig. 2B). Each pair of neo-chords attached to the loop was anchored to the posterior annulus at the level of P2 and P3. RA was performed with a complete rigid ring (Fig. 2C). The neo-chords were adjusted based on adequate leaflet coaptation, which was evaluated with a water test. The procedure was considered successful, if TEE revealed mild or no mitral regurgitation. All patients underwent concomitant CABG procedures. All operations were successful, as all patients exhibited none or mild mitral regurgitation immediately after the procedure. The mean post-operative length of hospital stay was 9 ± 2 days. The post-operative course was uneventful in all cases. Hospital mortality was 0%. Post-operative echo before discharged confirmed the intra-operative findings with excellent result of the repair. At a mean follow-up of 108 ± 8 days, all patients were free from recurrent mitral regurgitation and none has required re-intervention.
CONCLUSION: Here, we present a PMR technique using a multi-loop suture technique. This technique is innovative, as the use of pledgets alleviates the tension imbued by the neo-chord on the papillary muscle. Additionally, the multi-loop reduces the number of sutures and pledgets that are passed through the papillary muscle. This approach can simplify the papillary muscle relocation technique while ensuring an extensive stabilization of the posterior mitral valve annulus. Further studies are warranted to confirm the long term outcomes of this preliminary findings and long-term outcomes.