Early Echocardiographic Outcomes of Mitral Valve Annuloplasty versus Annuloplasty Combined with a Papillary Muscle Sling for Moderate to Severe Functional Mitral Regurgitation
Christos G. Mihos1, Andres M. Pineda2, Romain Capoulade1, Maiteder C. Larrauri-Reyes2, Serguei Melnitchouk1, Judy Hung1, Orlando Santana2.
1Massachusetts General Hospital, Boston, MA, USA, 2Coulmbia University, Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA.
BACKGROUND: Recurrent mitral regurgitation (MR) occurs in approximately 20-30% of patients with cardiomyopathy after mitral valve annuloplasty (Ring). A concomitant papillary muscle sling (Ring+Sling) may improve valve repair by promoting a more physiologic geometry of the mitral apparatus.
METHODS: Using 2:1 propensity-score matching, the echocardiographic outcomes of 26 patients with moderate to severe functional MR and cardiomyopathy who underwent Ring+Sling (4-mm polytetrafluoroethylene graft placed around the base of the papillary muscles) were compared with 13 patients who underwent Ring only, between March 2008 and May 2015. Functional MR was defined as restricted systolic leaflet closure, with normal leaflet anatomy and pliability. The MR was graded semi-quantitatively as 0 (trace/none), 1+ (mild), 2+ (moderate), and 3-4+ (moderate to severe).
RESULTS: The baseline demographics were similar, except for a higher incidence of hypertension in the Ring+Sling group (100% vs. 69%, p<0.001). There was no operative mortality in the Ring+Sling group, and 1 in patients undergoing Ring only (p=0.15). The mean time to follow-up echocardiogram was 10.9 months (range 0.1-42 months). At follow-up, a Ring+Sling repair was associated with a lower mitral valve tenting height (9mm vs. 12mm, p=0.04) and interpapillary muscle distance (14mm vs. 22mm, p<0.001), a smaller anterior leaflet tethering angle (30 degrees vs. 36 degrees, p=0.05) and posterior leaflet tethering angle (75 degrees vs. 94 degrees, p=0.02), and a greater leaflet coaptation length (10mm vs. 8mm, p=0.009), when compared with Ring only. The mean MR grade (0.7 vs. 0.9), and recurrence of moderate or greater MR (15% vs. 31%), did not reach a statistical difference between the groups at follow-up. Finally, actuarial survival at 3 years was 93% for Ring+Sling, and 85% for Ring only (p=0.28).
CONCLUSIONS: In patients with cardiomyopathy and moderate to severe functional MR, a Ring+Sling repair can be safely performed, and it improves the geometry of the mitral valve apparatus in the early post-operative period. Longer-term follow-up is needed to assess Ring+Sling durability and effects on left ventricular reverse remodeling. 
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