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J Thorac Cardiovasc Surg 1998;116:36-40
© 1998 Mosby, Inc.

Surgery For Congenital Heart Disease

Development of the papillary muscles of the mitral valve: morphogenetic background of parachute-like asymmetric mitral valves and other mitral valve anomalies

Financial support of The Netherlands Heart Foundation, grant 93.057, is acknowledged.

This work was performed at the Department of Anatomy, Leiden University Medical Center, The Netherlands.

Received for publication Nov. 17, 1997. Revisions requested Feb. 4, 1998; revisions received March 2, 1998. Accepted for publication March 2, 1998. Address for reprints: P. W. Oosthoek, PhD, Department of Anatomy, Leiden University, P.O. Box 9602, 2300 RC Leiden, The Netherlands.

Objectives: To understand papillary muscle malformations, such as in parachute mitral valves or parachute-like asymmetric mitral valves, we studied the development of papillary muscles.
Methods: Normal human hearts at between 5 and 19 weeks of development were studied with immunohistochemistry, three-dimensional reconstructions, and gross inspection. Scanning electron microscopy was used to study human and rat hearts.
Results: In embryonic hearts a prominent horseshoe-shaped myocardial ridge runs from the anterior wall through the apex to the posterior wall of the left ventricle. In the atrioventricular region this ridge is continuous with atrial myocardium and covered with cushion tissue. The anterior and posterior parts of the trabecular ridge enlarge and loosen their connections with the atrial myocardium. Their lateral sides gradually delaminate from the left ventricular wall, and the continuity between the two parts is incorporated in the apical trabecular network. In this way the anterior and posterior parts of the ridge transform into the anterolateral and the posteromedial papillary muscles, respectively. Simultaneously, the cushions remodel into valve leaflets and chordae. Only the chordal part of the cushions remains attached to the developing papillary muscles.
Conclusions: Disturbed delamination of the anterior or posterior part of the trabecular ridge from the ventricular wall, combined with underdevelopment of chordae, seems to be the cause of asymmetric mitral valves. Parachute valves, however, develop when the connection between the posterior and anterior part of the ridge condenses to form one single papillary muscle. Thus parachute valves and parachute-like asymmetric mitral valves originate in different ways.

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