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J Thorac Cardiovasc Surg 1997;113:292-301
© 1997 Mosby, Inc.

SURGERY FOR ACQUIRED HEART DISEASE

PAPILLARY MUSCLE–LEFT VENTRICULAR WALL "COMPLEX"

Supported by grants HL-29589 and HL-48837 from the National Heart, Lung, and Blood Institute and the Veterans Administration Medical Research Service. Drs. Komeda and Glasson are Carl and Leah McConnell Cardiovascular Surgical Research Fellows. Dr. Glasson is also supported by The Thoracic Surgery Foundation Research Fellowship Award.

Received for publication May 6, 1996 revisions requested July 16, 1996; revisions received Oct. 4, 1996 accepted for publication Oct. 9, 1996. Address for reprints: D. Craig Miller, MD, Department of Cardiovascular and Thoracic Surgery, Falk Cardiovascular Research Center, Stanford University School of Medicine, Stanford, CA 94305-5247.

Abstract

Objectives. Mitral valve homografts, despite theoretical advantages, are not widely used, in part because of lack of basic information about the three-dimensional geometry of the mitral apparatus. Methods: Radiopaque markers were used in the study of eight closed-chest dogs under four conditions: (1) baseline, (2) caval occlusion, (3) tachycardia (atrial pacing), and (4) nitroprusside infusion. Using a cylindrical coordinate system, defined with the origin at the midpoint between the anterior and posterior commissures, and the left ventricular long axis (z-axis), defined by the origin and the left ventricular apex, D_TIP-MA (the z-coordinate [millimeters] of the papillary muscle tip), was measured at 10 time points throughout the entire cardiac cycle. D_BASE-MA (the z-coordinate of the papillary muscle base) and L_PM (the length of the papillary muscle [millimeters]) were also measured. Results: D_TIP-MA varied slightly with time (p < 0.001 by analysis of variance), but the magnitude of change was negligible (<0.9 mm) (e.g., D_TIP-MA of the anterior papillary muscle was 20.7 ± 2.7/20.8 ± 2.8 [end-diastolic/end-systolic, mean ± 1 standard deviation]; D_TIP-MA of the posterior papillary muscle was 25.8 ± 4.8/25.5 ± 4.5). D_TIP-MA was minimally influenced by the above perturbations. D_BASE-MA and L_PM of each papillary muscle, however, changed throughout the cardiac cycle (p < 0.001 by analysis of variance) by about 4 mm, and both parameters were dependent on loading conditions. Conclusions. Papillary muscle length changed to keep the D_TIP-MA distance constant such that the papillary muscle and left ventricular wall functioned together as a unit ("J-shaped complex"). These results provide a physiologic rationale for measuring D_TIP-MA, define its potential surgical usefulness, and imply that using the entire length of the donor's papillary muscle (i.e., maintaining the entire J-shaped complex) is important in operations in which homograft or stentless xenograft mitral valves are used.

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