title: Papillary Muscle Approximation Versus Restrictive Annuloplasty Alone for Severe Ischemic Mitral Regurgitation.
abstract: 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.
  
  
  OBJECTIVE
  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.
authors.affiliation: Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France. Electronic address: francesconappi2@gmail.com.
authors.forename: Francesco
authors.initials: F
authors.lastname: Nappi
authors.affiliation: Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy.
authors.forename: Mario
authors.initials: M
authors.lastname: Lusini
authors.affiliation: Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, United Kingdom.
authors.forename: Cristiano
authors.initials: C
authors.lastname: Spadaccio
authors.affiliation: Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Nenna
authors.affiliation: Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy.
authors.forename: Elvio
authors.initials: E
authors.lastname: Covino
authors.affiliation: Department of Cardiothoracic Surgery, Hôpital Pitié-Salpétrière, Paris, France.
authors.forename: Christophe
authors.initials: C
authors.lastname: Acar
authors.affiliation: Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy.
authors.forename: Massimo
authors.initials: M
authors.lastname: Chello
mesh_terms: D001026:Coronary Artery Bypass; D004452:Echocardiography; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000209:etiology; D006352:Heart Ventricles / Q000000981:diagnostic imaging; D006801:Humans; D007558:Italy / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D058386:Mitral Valve Annuloplasty / Q000295:instrumentation / Q000379:methods*; D008944:Mitral Valve Insufficiency / Q000401:mortality / Q000601:surgery*; D017202:Myocardial Ischemia / Q000209:etiology* / Q000601:surgery; D010210:Papillary Muscles / Q000601:surgery*; D010359:Patient Readmission / Q000706:statistics & numerical data; D011446:Prospective Studies; D011788:Quality of Life; D012008:Recurrence; D012086:Reoperation / Q000706:statistics & numerical data; D013318:Stroke Volume; D020257:Ventricular Remodeling
keywords: mitral valve annuloplasty; mitral valve insufficiency; myocardial infarction; myocardial revascularization; undersizing annuloplasty; ventricular remodeling