Posterior Leaflet Augmentation in Ischemic Mitral Regurgitation Increases Leaflet Coaptation and Mobility Arminder S. Jassar, MBBS, Masahito Minakawa,

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Posterior Leaflet Augmentation in Ischemic Mitral Regurgitation Increases Leaflet Coaptation and Mobility Arminder S. Jassar, MBBS, Masahito Minakawa, MD, Takashi Shuto, MD, J. Daniel Robb, MBBS, Kevin J. Koomalsingh, MD, Melissa M. Levack, MD, Mathieu Vergnat, MD, Thomas J. Eperjesi, BS, Benjamin M. Jackson, MD, Joseph H. Gorman, MD, Robert C. Gorman, MD The Annals of Thoracic Surgery Volume 94, Issue 5, Pages 1438-1445 (November 2012) DOI: 10.1016/j.athoracsur.2012.05.025 Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Leaflet augmentation: posterior infarct involving the posterior papillary muscle (PPM) was created by ligating branches of the circumflex artery. A pericardial patch was sewn across the three scallops of the posterior leaflet (P1, P2, P3). (AL = anterior leaflet; Ao = aorta; APM = anterior papillary muscle; Septum = interventricular septum [cut].) The Annals of Thoracic Surgery 2012 94, 1438-1445DOI: (10.1016/j.athoracsur.2012.05.025) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Leaflet segmentation technique. (A) Template of transverse cross-sections every 1 mm along intercommissural axis. (B) One of the two-dimensional cross-sections represented by the white dashed line in (A); the atrial surface of the mitral valve leaflets and the coaptation zone is interactively marked (green curves). The most atrial coaptation point is marked with the white dot and the most ventricular coaptation point is marked with an X. (C) Schematic demonstrating how the atrial and ventricular coaptation points are then projected onto a viewing plane orthogonal to the least squares annular plane passing through the commissures to construct a two-dimensional representation of the coaptation zone. The white and red dashed lines are both within least squares annular plane in all three panels. (AC = anterior commissure; AML = anterior mitral leaflet; AoV = aortic valve; Coapt = coaptation; LA = left atrium; LV = left ventricle; LVOT = left ventricle outflow tract; PC = posterior commissure; PML = posterior mitral leaflet.) The Annals of Thoracic Surgery 2012 94, 1438-1445DOI: (10.1016/j.athoracsur.2012.05.025) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Leaflet mobility and coaptation distance. (A) The mid (P2) portion of the mitral valve (after repair with ring annuloplasty and leaflet augmentation) during systole, “θ” marks the angle between the line joining the anterior (A) and the posterior (P) annulus (green line) and the tangent drawn along the leaflet hinge point and the leaflet surface adjacent to it (red dashes). (B) The same region of the valve during diastole and θ′ was the angle between the line joining the anterior and posterior annulus and the tangent drawn along the leaflet hinge point and adjacent leaflet surface. All values of θ and θ′ above the interannular line (ie, toward left atrium [LA]) were assigned a positive value, and all values below (ie, toward left ventricle [LV]) were assigned negative values. Leaflet excursion angle was calculated as (θ − θ′). (C) Coaptation distance (CD) was calculated as the two-dimensional projected distance of the anterior annulus to the plane of leaflet coaptation (black dashes). Coaptation distance was measured at 1-mm intervals along the intercommissural axis, from anterior commissure (AC) to posterior commissure (PC). To account for variability in valve size between animals, the coaptation distance and intercommissural distance were normalized, and depicted as percent. (D) Coaptation distance for all 15 sheep before creation of infarct (ie, normal mitral valve). Dashes represent standard error. (AL = anterior mitral leaflet; Ao = aorta; AoV = aortic valve; AP = anteroposterior; LVOT = left ventricle outflow tract; PL = posterior mitral leaflet.) The Annals of Thoracic Surgery 2012 94, 1438-1445DOI: (10.1016/j.athoracsur.2012.05.025) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Coaptation length and coaptation area. (A) The postrepair coaptation length (overlap length) across the span of the entire mitral valve in the three groups. For purpose of depiction, the intercommissural position has been depicted as percent. Dashes represent standard error. (B) The two-dimensional projected coaptation area (area of leaflet overlap) for the 30-mm ring annuloplasty group (30 mm), 24-mm annuloplasty group (24 mm), and the 30-mm ring annuloplasty plus posterior leaflet augmentation group (PLA) 8 weeks after creation of the infarct (prerepair). (C) The projected two-dimensional area of leaflet overlap for the three groups after respective repair. In both (B) and (C), arrow heads indicate the atrial coaptation edge, and arrows indicate the ventricular coaptation edge. (AC = anterior commissure; PC = posterior commissure.) The Annals of Thoracic Surgery 2012 94, 1438-1445DOI: (10.1016/j.athoracsur.2012.05.025) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Coaptation distance is depicted as percentage of the anteroposterior (AP) annular diameter across the entire mitral valve from anterior commissure (AC) to posterior commissure (PC): (A, B, C) before repair and (D, E, F) after repair in the 30-mm, 24-mm, and the leaflet augmentation (PLA) groups, respectively. (Anterior = anterior annulus; posterior = posterior annulus.) The Annals of Thoracic Surgery 2012 94, 1438-1445DOI: (10.1016/j.athoracsur.2012.05.025) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions