Epicardial Posterior Papillary Muscle Repositioning with Mitral Annular Reduction for FIMR Treatment: Initial Ex Vivo Heart Model Study

  • Krishaporn Kradangnga Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado, USA
  • Eric Monnet Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado, USA
Keywords: functional mitral regurgitation, heart model, posterior papillary muscle repositioning


Background: High recurrent functional ischemic mitral regurgitation (FIMR) has been observed after annuloplasty. Since annuloplasty alone could not prevent late recurrent FIMR or improve the survival rate after CABG, adjunctive subvalvular opt for better treatment tailored for each individual patient.

Methods: Ex vivo ovine heart models with annular dilatation and PPM displacement were used for analysis of mitral regurgitation (MR) flow, left ventricular and annular geometry after treatment by mitral annular reduction alone (MA, nMA = 12) or combined with epicardial PPM repositioning (MA+PPM, nMA+PPM=13).

Results: MR significantly was reduced from baseline in both the MA (P = .03) and MA+PPM (P = .02) groups, but was not significantly different between the groups. The septo-lateral mitral annular distance decreased after applying both methods (MA group P = .005; MA+PPM group P = .05). The tethering α angle of the APM in the frontal plane significantly increased from baseline in the MA+PPM group (P = .027). Furthermore, the MA+PPM group had a larger APM and PPM α angle in the frontal plane compared with the MA group after reducing the MR (P = .04). There were no statistically significant changes in tethering angles found in the MA group compared with baseline. MR reduction correlated with percentage decrease of septo-lateral mitral annular distance (rs = 0.51, P = .01), the percentage decrease of fibrosa-PPM distance (rs = 0.43, P = .03), and the percentage increase of the PPM anterior displacement (rs = -0.41, P = .04).

Conclusion: The decreased tethered angle of the PPM referred to the annulus, and the decreased interpapillary muscles distance suggested the PPM was repositioned inward and toward the septal annulus by the epicardial pushing pad.
Epicardial repositioning of the PPM adjunct with mitral annular reduction facilitated leaflet coaptation without the risk of overlying restriction of the mitral annular orifice.


Acker MA, Bolling S, Shemin R, et al. 2006. Mitral valve surgery in heart failure: Insights from the Acorn Clinical Trial. J Thorac Cardiovasc Surg 132:568–577.e4.

Acker MA, Jessup M, Bolling SF, et al. 2011. Mitral valve repair in heart failure: Five-year follow-up from the mitral valve replacement stratum of the Acorn randomized trial. J Thorac Cardiovasc Surg 142:569–574.e1.

Badiwala MV, Verma S, Rao V. 2009. Surgical Management of Ischemic Mitral Regurgitation. Circulation 120:1287–1293.

Bolling SF. 2001. Mitral valve reconstruction in the patient with heart failure. Heart Fail Rev 6:177–85.

Bursi F, Enriquez-Sarano M, Nkomo VT, et al. 2005. Heart Failure and Death After Myocardial Infarction in the Community The Emerging Role of Mitral Regurgitation. Circulation 111:295–301.

Calafiore AM, Gallina S, Di Mauro M, et al. 2001. Mitral valve procedure in dilated cardiomyopathy: repair or replacement? Ann Thorac Surg 71:1146–1152.

Daneshmand MA, Milano CA, Rankin JS, et al. 2009. Mitral Valve Repair for Degenerative Disease: A 20-Year Experience. Ann Thorac Surg 88:1828–1837.

Fattouch K, Sampognaro, R, Speziale G, et al. 2010. Impact of Moderate Ischemic Mitral Regurgitation After Isolated Coronary Artery Bypass Grafting. Ann Thorac Surg 90, 1187–1194.

Gillinov AM, Wierup PN, Blackstone EH, et al. 2001. Is repair preferable to replacement for ischemic mitral regurgitation? J Thorac Cardiovasc Surg 122:1125–1141.

Gorman III JH, Gupta KB, Streicher JT, et al. 1996. Dynamic three-dimensional imaging of the mitral valve and left ventricle by rapid sonomicrometry array localization. J Thorac Cardiovasc Surg 112, 712–724.

Gorman III JH, Jackson BM, Enomoto Y, Gorman RC. 2004. The effect of regional ischemia on mitral valve annular saddle shape. Ann Thorac Surg 77:544–548.

Green GR, Dagum P, Glasson JR, et al. 1999. Mitral Annular Dilatation and Papillary Muscle Dislocation Without Mitral Regurgitation in Sheep. Circulation 100:II95–II102.

Green GR, Dagum P, Glasson JR, et al. 1999. Restricted posterior leaflet motion after mitral ring annuloplasty. Ann Thorac Surg 68:2100–2106.

Hung J, Papakostas L, Tahta SA, et al. 2004. Mechanism of Recurrent Ischemic Mitral Regurgitation After Annuloplasty Continued LV Remodeling as a Moving Target. Circulation 110:II85–II90.

Inoue M, McCarthy PM, Popović ZB, et al. 2004. The Coapsys device to treat functional mitral regurgitation: in vivo long-term canine study. J Thorac Cardiovasc Surg 127:1068–1077.

Jensen H, Jensen MO, Ringgaard S, et al. 2008. Geometric determinants of chronic functional ischemic mitral regurgitation: insights from three-dimensional cardiac magnetic resonance imaging. J Heart Valve Dis 17:16–22.

Jensen H, Jensen MO, Smerup MH, et al. 2010. Three-dimensional assessment of papillary muscle displacement in a porcine model of ischemic mitral regurgitation. J Thorac Cardiovasc Surg 140:1312–1318.

Jensen H, Jensen MO, Nielsen SL. 2015. Surgical Treatment of Functional Ischemic Mitral Regurgitation. J Heart Valve Dis 24:30–42.

Kashem A, Hassan S, Crabbe DL, Melvin DB, Santamore WP, Left ventricular reshaping: Effects on the pressure-volume relationship. 2013. J Thorac Cardiovasc Surg 125:391-9.

Khabbaz KR, Mahmood F, Shakil O. 2013. Dynamic 3-Dimensional Echo-cardiographic Assessment of Mitral Annular Geometry in Patients With Functional Mitral Regurgitation. Ann Thorac Surg 95:105–110.

Kradangnga K. and Monnet E. 2018. Left ventricular dilatation and posterior papillary muscle displacement in an ex vivo pulsatile model of functional mitral regurgitation. Heart Surg Forum 21(4):275-280.

Kumanohoso T, Otsuji Y, Yoshifuku S, et al. 2003. Mechanism of higher incidence of ischemic mitral regurgitation in patients with inferior myocardial infarction: Quantitative analysis of left ventricular and mitral valve geometry in 103 patients with prior myocardial infarction. J Thorac Cardiovasc Surg 125:135–143.

McGee Jr EC, Gillinov AM, Blackstone EH, et al. 2004. Recurrent mitral regurgitation after annuloplasty for functional ischemic mitral regurgitation. J Thorac Cardiovasc Surg 128:916–924.

Members, 2006 Writing Committee, Bonow RO, Carabello BA, Chatterjee K, et al. 2008. 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 118:e523–e661.

Members AF, Vahanian A, Alfieri O, et al. 2012. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 33:2451–2496.

Members WC, Hillis LD, et al. 2011. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 124:e652–e735.

Monnet E, Pouching K. 2013. An Ex Vivo Model of Left Ventricular Dilation and Functional Mitral Regurgitation to Facilitate the Development of Surgical Techniques. Heart Surg Forum 16:329–335.

Nishimura RA, Otto CM, Bonow RO, et al. 2017. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation.

Otsuji Y, Levine RA, Takeuchi M, Sakata R, Tei C. 2008. Mechanism of ischemic mitral regurgitation. J Cardiol 51:145–156.

Raman J, Jagannathan R, Chandrashekar P, Sugeng L. 2011. Can We Repair the Mitral Valve from Outside the Heart? A Novel Extra-Cardiac Approach to Functional Mitral Regurgitation. Heart Lung Circ 20:157–162.

Richards AL, Cook RC, Bolotin G, Buckner GD. 2009. A Dynamic Heart System to Facilitate the Development of Mitral Valve Repair Techniques. Ann Biomed Eng 37:651–660.

Siefert AW, Jimenez JH, Koomalsingh KJ, et al. 2012. Dynamic Assessment of Mitral Annular Force Profile in an Ovine Model. Ann Thorac Surg 94:59–65.

Siefert AW, Rabbah JPM, Koomalsingh KJ, et al. 2013. In Vitro Mitral Valve Simulator Mimics Systolic Valvular Function of Chronic Ischemic Mitral Regurgitation Ovine Model. Ann Thorac Surg 95:825–830.

Tibayan FA, Rodriguez F, Zasio MK, et al. 2003. Geometric Distortions of the Mitral Valvular-Ventricular Complex in Chronic Ischemic Mitral Regurgitation. Circulation 108:II116–II121.

van Garsse L, Gelsomino S, Luca F, et al. 2012. Importance of anterior leaflet tethering in predicting recurrence of ischemic mitral regurgitation after restrictive annuloplasty. J Thorac Cardiovasc Surg 143(4):S54-9.

Zoghbi WA, Enriquez-Sarano M, Foster E, et al. 2003. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and doppler echocardiography. J Am Soc Echocardiogr 16:777–802

How to Cite
Kradangnga, K., & Monnet, E. (2020). Epicardial Posterior Papillary Muscle Repositioning with Mitral Annular Reduction for FIMR Treatment: Initial Ex Vivo Heart Model Study. The Heart Surgery Forum, 23(1), E010-E017. https://doi.org/10.1532/hsf.2725