Interpapillary muscle distance independently affects severity of functional mitral regurgitation in patients with systolic left ventricular dysfunction

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Interpapillary muscle distance independently affects severity of functional mitral regurgitation in patients with systolic left ventricular dysfunction Kitae Kim, MD, Shuichiro Kaji, MD, Yoshimori An, MD, Tomohiro Nishino, MD, Tomoko Tani, MD, Takeshi Kitai, MD, Yutaka Furukawa, MD The Journal of Thoracic and Cardiovascular Surgery Volume 148, Issue 2, Pages 434-440.e1 (August 2014) DOI: 10.1016/j.jtcvs.2013.09.029 Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Potential mechanism of IPMD affecting mitral leaflet tethering. Left panel: A cross-sectional image of the mitral valve in a commisure–commisure direction is shown. Middle panel: Mediolateral displacement of the anterior and posterior PM, which increases the IPMD, potentially lifts up the central portion of the leaflets and increases the tethering of whole leaflets. Right panel: In contrast, apical displacement of both PMs with shortening of the IPMD does not lift up the central portion of both leaflets and results in less leaflet tethering. APM, Anterior papillary muscle; PPM, posterior papillary muscle; LV, left ventricular. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 434-440.e1DOI: (10.1016/j.jtcvs.2013.09.029) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Severity of FMR and mitral tenting volume in tertiles of IPMD. Upper panel, MR severity (vena contracta width, mm) in tertiles of IPMD, adjusting for posterior PM tethering distance. Lower panel, Mitral tenting volume in tertiles of IPMD, adjusting for posterior PM tethering distance. *P = .005 versus the first tertile and P = .001 versus the second tertile. **P < .001 versus the first and the second tertiles. VC, Vena contracta; IPMD, interpapillary muscle distance. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 434-440.e1DOI: (10.1016/j.jtcvs.2013.09.029) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Anatomic and 3D images of leaflet tethering in patients (A-C) with FMR and (D-F) without FMR. A and D, Double oblique anatomic image passing through mitral leaflets and both PMs in a mediolateral direction. B and E, Vertical view of reconstructed 3D images of mitral apparatus from the left ventricle. C and F, Horizontal view from the anterior direction. In the FMR(+) patient, the posterior PM tethering distance, IPMD, and total tenting volume were 41 mm, 36 mm, and 5.3 mL, respectively. In the FMR(-) patient, the posterior PM tethering distance, IPMD, and total tenting volume were 41 mm, 24 mm, and 1.8 mL, respectively. Color bar in the image indicates tenting height, which is the same in each view. The closest point to the mitral annulus of each triangle indicates the tip of the PM. FMR, Functional mitral regurgitation; PM, papillary muscle. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 434-440.e1DOI: (10.1016/j.jtcvs.2013.09.029) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure E1 Flow chart of patient selection. During the study period, 684 patients with old myocardial infarction or dilated cardiomyopathy underwent MSCT coronary angiography. Of these, 108 patients were diagnosed as having regional or global LVD (EF <50%) by echocardiography. After excluding patients as shown in the figure, 83 patients were enrolled in this study. MSCT, Multislice computed tomography; LV, left ventricular. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 434-440.e1DOI: (10.1016/j.jtcvs.2013.09.029) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure E2 Schematic representation of anterior and posterior PM tethering distance and IPMD. Posterior PM tethering distances were measured as the distances between the posterior PM tip and the saddle horn (yellow line), and anterior PM tethering distances were measured as the distances between the anterior PM tip and the saddle horn (red line). IPMD was measured as the distance between the tips of the PMs (black dotted line). The posterior PM tethering distances were resolved into apical (green dotted line) and posteromedial (blue dotted line) components. Similarly, anterior PM tethering distances were resolved into apical and posterolateral components. PM, Papillary muscle. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 434-440.e1DOI: (10.1016/j.jtcvs.2013.09.029) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions