Annular or subvalvular approach to chronic ischemic mitral regurgitation? Frederick A. Tibayan, MD, Filiberto Rodriguez, MD, Frank Langer, MD, Mary K.

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Annular or subvalvular approach to chronic ischemic mitral regurgitation? Frederick A. Tibayan, MD, Filiberto Rodriguez, MD, Frank Langer, MD, Mary K. Zasio, BA, Lynn Bailey, BS, David Liang, MD, PhD, George T. Daughters, MS, Neil B. Ingels, PhD, D. Craig Miller, MD The Journal of Thoracic and Cardiovascular Surgery Volume 129, Issue 6, Pages 1266-1275 (June 2005) DOI: 10.1016/j.jtcvs.2005.01.021 Copyright © 2005 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 A, Schematic of SLAC suture. A 2–0 polypropylene suture was anchored to the midseptal annulus and exteriorized through the lateral annulus to an adjustable tourniquet. S-L, Septal-lateral annular dimension. B, Schematic of PAP suture. A 2–0 polypropylene suture was anchored to the posterior papillary muscle, brought through the mitral annulus near the posterior commissure, and exteriorized to an adjustable tourniquet. The Journal of Thoracic and Cardiovascular Surgery 2005 129, 1266-1275DOI: (10.1016/j.jtcvs.2005.01.021) Copyright © 2005 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Displacements of valvular-ventricular complex between baseline (left) and 8 weeks after inferior myocardial infarction (CIMR, right). Arrows indicate significant changes (P < .05, CIMR vs baseline, repeated-measures analysis of variance with the Dunnett test) in end-systolic septal-lateral annular dimension, papillary muscle displacement, leaflet displacement, and septal-lateral interleaflet separation. CIMR resulted in increased interleaflet separation (type I leaflet motion) and apical restriction of the posterior leaflet (type IIIb leaflet motion) in association with both annular dilation and displacement of the posterior papillary muscle laterally, posteriorly, and toward the base. P, Positive posterior axis; L, positive lateral axis; A, positive apical axis; APM, anterior papillary muscle; PPM, posterior papillary muscle; AML, anterior mitral leaflet; PML, posterior mitral leaflet. The Journal of Thoracic and Cardiovascular Surgery 2005 129, 1266-1275DOI: (10.1016/j.jtcvs.2005.01.021) Copyright © 2005 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Displacements of valvular-ventricular complex after tightening SLAC suture. Arrows indicate significant changes (P < .05, CIMR [left] vs SLAC [right], repeated-measures analysis of variance with the Dunnett test) in end-systolic septal-lateral annular dimension, papillary muscle displacement, leaflet displacement, and septal-lateral interleaflet separation. SLAC undersized annular septal-lateral diameter, corrected lateral displacement of the posterior papillary muscle, and reduced septal-lateral interleaflet separation. P, Positive posterior axis; L, positive lateral axis; A, positive apical axis; APM, anterior papillary muscle; PPM, posterior papillary muscle; AML, anterior mitral leaflet; PML, posterior mitral leaflet. The Journal of Thoracic and Cardiovascular Surgery 2005 129, 1266-1275DOI: (10.1016/j.jtcvs.2005.01.021) Copyright © 2005 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 Displacements of valvular-ventricular complex after tightening PAP suture. Arrows indicate significant changes (P < .05, CIMR [left] vs PAP [right], repeated-measures analysis of variance with the Dunnett test) in end-systolic septal-lateral annular dimension, papillary muscle displacement, leaflet displacement, and septal-lateral interleaflet separation. PAP reduced septal-lateral annular diameter, moved the posterior papillary muscle closer to the annulus, and corrected apical restriction of the posterior leaflet (but did not affect the degree of MR). P, Positive posterior axis; L, positive lateral axis; A, positive apical axis; APM, anterior papillary muscle; PPM, posterior papillary muscle; AML, anterior mitral leaflet; PML, posterior mitral leaflet. The Journal of Thoracic and Cardiovascular Surgery 2005 129, 1266-1275DOI: (10.1016/j.jtcvs.2005.01.021) Copyright © 2005 The American Association for Thoracic Surgery Terms and Conditions

Figure E1 Schematic of marker array showing radiopaque markers and coordinate reference system. Note that for the purposes of illustration, the anterior papillary muscle and posterior papillary muscle are oriented perpendicular to the commissure-commissure axis rather than parallel to the commissure-commissure axis. P, Positive posterior axis; L, positive lateral axis; A, positive apical axis; APM, anterior papillary muscle; PPM, posterior papillary muscle. The Journal of Thoracic and Cardiovascular Surgery 2005 129, 1266-1275DOI: (10.1016/j.jtcvs.2005.01.021) Copyright © 2005 The American Association for Thoracic Surgery Terms and Conditions