title: Mitral valve annuloplasty and papillary muscle relocation oriented by 3-dimensional transesophageal echocardiography for severe functional mitral regurgitation.
abstract: OBJECTIVE
  The study of the mitral valve apparatus and its modifications during functional mitral regurgitation (FMR) is better revealed by 3-dimensional (3D) transesophageal echocardiography (TOE). To plan mitral valve repair by annuloplasty and papillary muscle (PPM) relocation, we proposed a valve repair procedure oriented by the new main features obtained by real-time 3D TOE reconstruction of the mitral valve apparatus.
  
  
  METHODS
  Since January 2008, 25 patients with severe FMR before mitral valve repair were examined. Mean coaptation depth and mean tenting area were 1.3 ± 0.2 cm and 3.2 ± 0.5 cm(2), respectively. Intraoperative 2D and 3D TOE were performed, followed by a 3D offline reconstruction of the mitral valve apparatus. A schematic mitral valve apparatus model was obtained. A geometric model like a truncated cone was traced in according to the preoperative measurements. The size of the prosthetic ring was selected preoperatively according to the anterior leaflet surface. The expected truncated cone after annuloplasty was retraced. A conventional normal coaptation depth about 0.6 cm was used to detect the new position of the PPM tips.
  
  
  RESULTS
  Offline reconstruction of the mitral valve apparatus and respective truncated cone were feasible in all patients. The expected position of the PPM tips desirable to reach a normal tenting area with a coaptation depth 0.6 cm or less was obtained in all patients. After surgery, all parameters were calculated and no statistically significant difference was found compared with the expected data.
  
  
  CONCLUSIONS
  PPM relocation plus ring annuloplasty reduce mitral valve tenting and may improve mitral valve repair results for patients with severe FMR. This technique may be easily and precisely guided by preoperative offline 3D echocardiographic mitral valve reconstruction.
authors.affiliation: Department of Cardiac Surgery, University of Palermo, Palermo, Italy. khalilfattouch@hotmail.com
authors.forename: Khalil
authors.initials: K
authors.lastname: Fattouch
authors.forename: Giacomo
authors.initials: G
authors.lastname: Murana
authors.forename: Sebastiano
authors.initials: S
authors.lastname: Castrovinci
authors.forename: Claudia
authors.initials: C
authors.lastname: Mossuto
authors.forename: Roberta
authors.initials: R
authors.lastname: Sampognaro
authors.forename: Maria Giuliana
authors.initials: MG
authors.lastname: Borruso
authors.forename: Emanuela Clara
authors.initials: EC
authors.lastname: Bertolino
authors.forename: Giuseppa
authors.initials: G
authors.lastname: Caccamo
authors.forename: Giovanni
authors.initials: G
authors.lastname: Ruvolo
authors.forename: Patrizio
authors.initials: P
authors.lastname: Lancellotti
mesh_terms: D000368:Aged; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects; D019560:Echocardiography, Three-Dimensional; D017548:Echocardiography, Transesophageal; D006801:Humans; D007090:Image Interpretation, Computer-Assisted; D007558:Italy; D008875:Middle Aged; D008943:Mitral Valve / Q000503:physiopathology / Q000601:surgery* / Q000648:ultrastructure*; D058386:Mitral Valve Annuloplasty / Q000009:adverse effects; D008944:Mitral Valve Insufficiency / Q000000981:diagnostic imaging* / Q000503:physiopathology / Q000601:surgery*; D010210:Papillary Muscles / Q000000981:diagnostic imaging* / Q000503:physiopathology / Q000601:surgery*; D011237:Predictive Value of Tests; D012720:Severity of Illness Index; D016896:Treatment Outcome