title: Papillary muscle misalignment causes multiple mitral regurgitant jets: an ambiguous mechanism for functional mitral regurgitation.
abstract: OBJECTIVE
  The study aim was to test the hypothesis that asymmetric alignment (misalignment) of the papillary muscles is sufficient to cause incomplete mitral leaflet coaptation and functional mitral regurgitation (MR).
  
  
  METHODS
  Different spatial relationships between the papillary muscles and the mitral annulus were investigated in isolated porcine mitral valves in vitro to assess the impact on mitral valve competence. The systolic occlusional leaflet area (OLA) needed to cover the mitral orifice and the anterolateral (ACOM) and posteromedial (PCOM) commissural portion (OLA(ACOM), OLA(PCOM)) were assessed by 2D echocardiography to quantitate incomplete mitral leaflet coaptation. The regurgitant fraction (RF) and MR jet location were assessed by a flow meter and color Doppler ultrasound.
  
  
  RESULTS
  Posterolateral dislocation of the posteromedial papillary muscle impaired mitral leaflet coaptation at the corresponding half-portion of the mitral orifice (OLA(PCOM): 351-397 mm2 versus 296 mm2 (normal); p < 0.001) and modified the contralateral part (OLA(ACOM): 354-387 mm2 versus 304 mm2 (normal); p <0.001). The mitral leaflet coaptation line moved in apical and posterior directions, creating a commissural MR orifice at the PCOM side. At the ACOM side, anterior leaflet prolapse and restricted posterior leaflet mobility created an additional commissural regurgitant jet (RF = 0.11-0.13). Symmetrical papillary muscle misalignment restricted mitral leaflet mobility on both sides of the orifice in a synergistic manner (OLA(PCOM): 416-459 mm2 and OLA(ACOM): 427-489 mm2; both p <0.001 versus normal). The central MR jet orifice, which extended towards both commissures, caused more significant MR (RF = 0.15-0.26).
  
  
  CONCLUSIONS
  Papillary muscle misalignment caused mitral regurgitant jet ambiguity with an anterior MR jet location following posteromedial papillary muscle displacement. These findings may improve understanding of the relation between myocardial lesion and mitral regurgitant jet location and thereby facilitate rational strategies for valvular interventions.
authors.affiliation: Department of Cardiothoracic and Vascular Surgery and Institute of Experimental Clinical Research, Skejby Sygehus, Aarhus University Hospital, Denmark.
authors.forename: S L
authors.initials: SL
authors.lastname: Nielsen
authors.forename: H
authors.initials: H
authors.lastname: Nygaard
authors.forename: A A
authors.initials: AA
authors.lastname: Fontaine
authors.forename: A A
authors.initials: AA
authors.lastname: Fontaine
authors.forename: J M
authors.initials: JM
authors.lastname: Hasenkam
authors.forename: S
authors.initials: S
authors.lastname: He
authors.forename: A P
authors.initials: AP
authors.lastname: Yoganathan
mesh_terms: D000818:Animals; D015150:Echocardiography, Doppler; D006439:Hemodynamics; D066298:In Vitro Techniques; D008943:Mitral Valve / Q000000981:diagnostic imaging / Q000503:physiopathology*; D008944:Mitral Valve Insufficiency / Q000000981:diagnostic imaging / Q000473:pathology / Q000503:physiopathology*; D008955:Models, Cardiovascular; D008961:Models, Structural; D010210:Papillary Muscles / Q000473:pathology / Q000503:physiopathology*; D013552:Swine; D017725:Ventricular Pressure