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Papillary Muscle Approximation Versus Restrictive Annuloplasty Alone for Severe Ischemic Mitral Regurgitation
Francesco Nappi1, Mario Lusini2, Cristiano Spadaccio3
1Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France.
Background:
Guidelines recommend surgery for patients with severe ischemic mitral regurgitation (MR). Nonrandomized studies suggest that subvalvular repair is associated with longer survival, but randomized studies are lacking.
Objectives:
This study sought to investigate the benefit of papillary muscle surgery on long-term clinical outcomes of patients with ischemic MR.
Methods:
Ninety-six patients with severe ischemic MR were randomized to either undersizing restrictive mitral annuloplasty (RA) or papillary muscle approximation with undersizing restrictive mitral annuloplasty (PMA) associated with complete surgical myocardial revascularization. The primary endpoint was change in left ventricular end-diastolic diameter (LVEDD) after 5 years, measured as the absolute difference from baseline, which was evaluated by paired Student t tests. Secondary endpoints included changes in echocardiographic parameters, overall mortality, the composite cardiac endpoint (major adverse cardiac and cerebrovascular events [MACCE]), and quality of life (QOL) during the 5-year follow-up.
Results:
At 5 years, mean LVEDD was 56.5 ± 5.7 mm with PMA versus 60.6 ± 4.6 mm with RA (mean change from baseline -5.8 ± 4.1 mm and -0.2 ± 2.3 mm, respectively; p < 0.001). Ejection fraction was 44.1 ± 6% in the PMA group versus 39.9 ± 3.9% in the RA group (mean change from baseline 8.8 ± 5.9% and 2.5 ± 4.3%, respectively; p < 0.001). There was no statistically significant difference in mortality at 5 years, but freedom from MACCE favored PMA in the last year of follow-up. PMA significantly reduced tenting height, tenting area, and interpapillary distance soon after surgery and for the long-term, and significantly lowered moderate-to-severe MR recurrence. No differences were found in QOL measures.
Conclusions:
Compared with RA only, PMA exerted a long-term beneficial effect on left ventricular remodeling and more effectively restored the mitral valve geometric configuration in ischemic MR, which improved long-term cardiac outcomes, but did not produce differences in overall mortality and QOL.
Insights
Papillary muscle approximation (PMA) surgery improves left ventricular remodeling and mitral valve geometry in patients with severe ischemic mitral regurgitation (MR) compared to restrictive mitral annuloplasty (RA) alone. While not impacting overall mortality or quality of life, PMA enhances long-term cardiac outcomes.
Area of Science:
- Cardiovascular Surgery
- Cardiac Mechanics
- Mitral Valve Disease
Background:
- Current guidelines recommend surgery for severe ischemic mitral regurgitation (MR).
- Previous studies suggest subvalvular repair improves survival, but lack randomized evidence.
- Randomized trials are needed to confirm benefits of specific surgical techniques.
Purpose of the Study:
- To evaluate the long-term clinical outcomes of papillary muscle surgery in patients with ischemic MR.
- To compare papillary muscle approximation (PMA) with restrictive mitral annuloplasty (RA) in severe ischemic MR.
- To assess the impact of surgical techniques on left ventricular remodeling and cardiac function.
Main Methods:
- Ninety-six patients with severe ischemic MR were randomized to PMA + RA or RA alone.
- Complete surgical myocardial revascularization was performed in all patients.
- Primary endpoint: change in left ventricular end-diastolic diameter (LVEDD) at 5 years. Secondary endpoints: echocardiographic parameters, mortality, MACCE, and QOL.
Main Results:
- PMA significantly reduced LVEDD and improved ejection fraction compared to RA at 5 years (p < 0.001).
- PMA demonstrated better freedom from major adverse cardiac and cerebrovascular events (MACCE).
- PMA effectively reduced MR recurrence and improved mitral valve geometry long-term, with no significant difference in mortality or quality of life.
Conclusions:
- Papillary muscle approximation (PMA) offers long-term benefits in left ventricular remodeling and mitral valve geometry for ischemic MR.
- PMA improves long-term cardiac outcomes compared to restrictive annuloplasty (RA) alone.
- While PMA did not affect overall mortality or quality of life, it enhances structural and functional recovery.
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