Effects of Targeted Papillary Muscle Relocation on Mitral Leaflet Tenting and Coaptation Jean-Pierre Rabbah, BS, Benjamin Chism, BS, Andrew Siefert,

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Effects of Targeted Papillary Muscle Relocation on Mitral Leaflet Tenting and Coaptation Jean-Pierre Rabbah, BS, Benjamin Chism, BS, Andrew Siefert, MS, Neelakantan Saikrishnan, PhD, Emir Veledar, PhD, Vinod H. Thourani, MD, Ajit P. Yoganathan, PhD The Annals of Thoracic Surgery Volume 95, Issue 2, Pages 621-628 (February 2013) DOI: 10.1016/j.athoracsur.2012.09.007 Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Papillary muscle relocation. Papillary muscles are displaced from their control position 5 mm apically (black), 8 mm laterally (purple), and 8 mm posteriorly (green). Basal relocation is performed to either the trigone (blue arrow) or the commissure (red arrow) in 2-mm increments. The Annals of Thoracic Surgery 2013 95, 621-628DOI: (10.1016/j.athoracsur.2012.09.007) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Disease progression. (A) Coaptation length and tenting area are plotted for the control and disease progression conditions. (B) Scatter plots of normalized coaptation length and tenting area to corresponding papillary muscle distance are plotted. Change in leaflet geometry was linearly proportional to papillary muscle distance. (MA = mitral annuloplasty; MI = myocardial infarction.) The Annals of Thoracic Surgery 2013 95, 621-628DOI: (10.1016/j.athoracsur.2012.09.007) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Papillary muscle relocation. (A) Coaptation length and tenting area are plotted for the 4- and 6-mm repair relocations. Control and chronic myocardial infarction (MI) with mitral annuloplasty (MA) are shown for reference. (B) Changes in normalized coaptation length and tenting area were linearly proportional to papillary muscle (PM) distance. (Comm = commissure; Trig = trigone.) The Annals of Thoracic Surgery 2013 95, 621-628DOI: (10.1016/j.athoracsur.2012.09.007) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Off-center coaptation lines. (A) Isolated posteromedial repair did not alleviate leaflet tenting compared with the control group for the contralateral coaptation line (A1–P1). The resulting tenting area was statistically larger compared with the control condition. (B) Normalized tenting height did not show an improvement with papillary muscle relocation at the contralateral coaptation line. Changes in leaflet geometry were linearly proportional to papillary muscle distance at the ipsilateral coaptation line. The Annals of Thoracic Surgery 2013 95, 621-628DOI: (10.1016/j.athoracsur.2012.09.007) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions