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J Thorac Cardiovasc Surg 1999;117:472-480
© 1999 Mosby, Inc.

SURGERY FOR ADULT CARDIOVASCULAR DISEASE

POTENTIAL MECHANISM OF LEFT VENTRICULAR OUTFLOW TRACT OBSTRUCTION AFTER MITRAL RING ANNULOPLASTY

From the Department of Cardiovascular and Thoracic Surgery,^a the Division of Cardiovascular Medicine,^c and the Department of Anesthesia,^e Stanford University School of Medicine, Stanford, Calif; Cardiac Surgery^f and Cardiology Sections,^d Department of Veterans Affairs Medical Center, Palo Alto, Calif; and the Department of Cardiovascular Physiology and Biophysics,^b Research Institute of the Palo Alto Medical Foundation, Palo Alto, Calif.

Supported in part by grants HL-29589 and HL-48837 from the National Heart, Lung, and Blood Institute. P.D and G.R.G. were supported by NHLBI Individual Research Service Awards HL10000-01 and HL-09569, respectively.

Read at the Twenty-fourth Annual Meeting of The Western Thoracic Surgical Association, Whistler, British Columbia, June 24-27, 1998.

Received for publication July 15, 1998. Revisions requested Sept 18, 1998. Revisions received Nov 24, 1998. Accepted for publication Nov 24, 1998. 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.

Objectives: The purpose of this study was to explore whether geometric changes that predispose to left ventricular outflow tract obstruction after mitral ring annuloplasty are coupled to subvalvular apparatus disturbances.
Methods: Radiopaque markers were implanted in sheep: 9 in the ventricle, 1 in the high interventricular septum, 1 on each papillary muscle tip, 8 around the mitral anulus, 4 on the anterior mitral leaflet, and 2 on the posterior leaflet. One group served as control (n = 5); the others were randomized to undergo annuloplasty with the Duran ring (n = 6; Medtronic, Inc, Minneapolis, Minn) or Carpentier-Edwards Physio ring (n = 6; Baxter Healthcare Corp, Irvine, Calif). After a 7- to 10-day recovery period, 3-dimensional marker coordinates were measured with biplane videofluoroscopy.
Results: At the beginning of ejection, (1) the anterior leaflet was displaced toward the left ventricular outflow tract; (2) the normal atrially flexed anterior anulus was flattened into the left ventricular outflow tract; (3) the posterior anulus was displaced toward the left ventricular outflow tract; (4) the anterior papillary muscle was displaced septally; and (5) the posterior papillary muscle was dislocated inwardly toward the anterior papillary muscle in the Physio ring group compared with the control group. During ejection, all these structures moved septally, encroaching further on the left ventricular outflow tract. In the Duran ring group, only the posterior anulus was displaced toward the left ventricular outflow tract; the anterior leaflet was not displaced toward the left ventricular outflow tract, and it did not move septally during ejection.
Conclusions: The semirigid Physio ring was associated with perturbations in annular dynamics that caused changes in papillary muscle geometry. We propose an integrated valvular–subvalvular mechanism to explain displacement of the anterior leaflet into the left ventricular outflow tract after mitral ring annuloplasty.

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