-
Journal of the American College of... Oct 2018Mitral annulus disjunction (MAD) is an abnormal atrial displacement of the mitral valve leaflet hinge point. MAD has been associated with mitral valve prolapse (MVP) and...
BACKGROUND
Mitral annulus disjunction (MAD) is an abnormal atrial displacement of the mitral valve leaflet hinge point. MAD has been associated with mitral valve prolapse (MVP) and sudden cardiac death.
OBJECTIVES
The purpose of this study was to describe the clinical presentation, MAD morphology, association with MVP, and ventricular arrhythmias in patients with MAD.
METHODS
The authors clinically examined patients with MAD. By echocardiography, the authors assessed the presence of MVP and measured MAD distance in parasternal long axis. Using cardiac magnetic resonance (CMR), the authors assessed circumferential MAD in the annular plane, longitudinal MAD distance, and myocardial fibrosis. Aborted cardiac arrest and sustained ventricular tachycardia were defined as severe arrhythmic events.
RESULTS
The authors included 116 patients with MAD (age 49 ± 15 years; 60% female). Palpitations were the most common symptom (71%). Severe arrhythmic events occurred in 14 (12%) patients. Longitudinal MAD distance measured by CMR was 3.0 mm (interquartile range [IQR]: 0 to 7.0 mm) and circumferential MAD was 150° (IQR: 90° to 210°). Patients with severe arrhythmic events were younger (age 37 ± 13 years vs. 51 ± 14 years; p = 0.001), had lower ejection fraction (51 ± 5% vs. 57 ± 7%; p = 0.002) and had more frequently papillary muscle fibrosis (4 [36%] vs. 6 [9%]; p = 0.03). MVP was evident in 90 (78%) patients and was not associated with ventricular arrhythmia.
CONCLUSIONS
Ventricular arrhythmias were frequent in patients with MAD. A total of 26 (22%) patients with MAD did not have MVP, and MVP was not associated with arrhythmic events, indicating MAD itself as an arrhythmogenic entity. MAD was detected around a large part of the mitral annulus circumference and was interspersed with normal tissue.
Topics: Adult; Arrhythmias, Cardiac; Cross-Sectional Studies; Death, Sudden, Cardiac; Echocardiography; Female; Fibrosis; Heart Arrest; Humans; Magnetic Resonance Imaging, Cine; Male; Middle Aged; Mitral Valve; Mitral Valve Insufficiency; Mitral Valve Prolapse; Papillary Muscles; Syndrome; Ventricular Premature Complexes
PubMed: 30261961
DOI: 10.1016/j.jacc.2018.07.070 -
Cardiovascular Journal of AfricaWe aimed to evaluate and compare papillary muscle free strain in hypertrophic cardiomyopathy (HCMP) and hypertensive (HT) patients.
OBJECTIVES
We aimed to evaluate and compare papillary muscle free strain in hypertrophic cardiomyopathy (HCMP) and hypertensive (HT) patients.
METHODS
Global longitudinal strain (GLS), and longitudinal myocardial strain of the anterolateral (ALPM) and posteromedial papillary muscles (PMPM) were obtained in 46 HCMP and 50 HT patients.
RESULTS
Interventricular septum (IVS)/posterior wall (PW) thickness ratio, left ventricular mass index (LVMI), left atrial anteroposterior diameter (LAAP) and mitral E/E' were found to be increased in patients with HCMP compared to HT patients. Left ventricular cavity dimensions were smaller in HCMP patients. GLS of HCMP and HT patients were - 14.52 ± 3.01 and -16.85 ± 1.36%, respectively ( < 0.001). Likewise, ALPM and PMPM free strain values were significantly reduced in HCMP patients over HT patients [-14.00% (-22 to -11%) and -15.5% (-24.02 to -10.16%) vs -23.00% (-24.99 to -19.01%) and -22.30% (-26.48 to -15.95%) ( = 0.016 and = 0.010)], respectively. ALPM free strain showed a statistically significant correlation with GLS, maximal wall thickness, IVS thickness and LVMI. PMPM free strain showed a significant correlation with GLS, IVS thickness and LAAP. The GLS value of - 13.05 had a sensitivity of 61.9% and a specificity of 97.4% for predicting HCMP. ALPM and PMPM free strain values of -15.31 and -17.17% had 63 and 76.9% sensitivity and 85.7 and 76.9% specificity for prediction of HCMP.
CONCLUSIONS
Besides other echocardiographic variables, which were investigated in earlier studies, papillary muscle free strain also could be used in HCMP to distinguish HCMP- from HT-associated hypertrophy.
Topics: Humans; Hypertrophy, Left Ventricular; Papillary Muscles; Myocardial Contraction; Cardiomyopathy, Hypertrophic; Hypertension; Ventricular Function, Left
PubMed: 36947167
DOI: 10.5830/CVJA-2022-070 -
Arquivos Brasileiros de Cardiologia Apr 2017The role of papillary muscle function in severe mitral regurgitation with preserved and reduced left ventricular ejection fraction and the method of choice to evaluate...
FUNDAMENTO:
The role of papillary muscle function in severe mitral regurgitation with preserved and reduced left ventricular ejection fraction and the method of choice to evaluate PM have still been the subjects of controversy.
OBJECTIVES:
To evaluate and compare papillary muscle function in and between patients with severe degenerative and functional mitral regurgitation by using the free strain method.
METHODS:
64 patients with severe mitral regurgitation - 39 patients with degenerative mitral regurgitation (DMR group) and 25 patients with severe functional mitral regurgitation (FMR group) - and 30 control subjects (control group) were included in the study. Papillary muscle function was evaluated through the free strain method from apical four chamber images of the anterolateral papillary muscle (APM) and from apical three chamber images of the posteromedial papillary muscle (PPM). Global left ventricular longitudinal and circumferential strains were evaluated by applying 2D speckle tracking imaging.
RESULTS:
Global left ventricular longitudinal strain (DMR group, -17 [-14.2/-20]; FMR group, -9 [-7/-10.7]; control group, -20 [-18/-21] p < 0.001), global left ventricular circumferential strain (DMR group, -20 [-14.5/-22.7]; FMR group, -10 [-7/-12]; control group, -23 [-21/-27.5] p < 0.001) and papillary musle strains (PPMS; DMR group, -30.5 [-24/-46.7]; FMR group, -18 [-12/-30]; control group; -43 [-34.5/-39.5] p < 0.001; APMS; DMR group, (-35 [-23.5/-43]; FMR group, -20 [-13.5/-26]; control group, -40 [-32.5/-48] p < 0.001) were significantly different among all groups. APMS and PPMS were highly correlated with LVEF (p < 0.001, p < 0.001; respectively), GLS (p < 0.001, p < 0.001; respectively) and GCS (p < 0.001, p < 0.00; respectively) of LV among all groups. No correlation was found between papillary muscle strains and effective orifice area (EOA) in both groups of severe mitral regurgitation.
CONCLUSIONS:
Measuring papillary muscle longitudinal strain by the free strain method is practical and applicable. Papillary muscle dysfunction plays a small role in severe MR due to degenerative or functional causes and papillary muscle functions in general seems to follow left ventricular function. PPM is the most affected PM in severe mitral regurgitation in both groups of DMR and FMR.
FUNDAMENTO:
O papel da função do músculo papilar na regurgitação mitral grave com fração de ejeção do ventrículo esquerdo preservada e reduzida e o método de escolha para avaliar PM ainda são objetos de controvérsia.
OBJETIVOS:
Avaliar e comparar a função dos músculos papilares entre pacientes com insuficiência mitral funcional e degenerativa pelo método free strain.
MÉTODOS:
64 pacientes com insuficiência mitral grave - 39 pacientes com insuficiência mitral degenerativa grave (grupo IMD) e 25 com insuficiência mitral funcional grave (grupo IMF) - e 30 indivíduos controle (grupo controle) foram incluídos no estudo. A função dos músculos papilares foi avaliada pelo método free strain a partir de imagens apicais quatro-câmaras do músculo papilar anterolateral (MPA) e imagens apicais três-câmaras do músculo papilar posteromedial (MPP). Strains circunferenciais e longitudinais globais do ventrículo esquerdo foram avaliados por meio de imagens bidimensionais a partir do rastreamento de conjunto de pontos de cinza (speckle tracking).
RESULTADOS:
O strain longitudinal global do ventrículo esquerdo (grupo IMD, -17 [-14,2/-20]; grupo IMF, -9 [-7/-10,7]; grupo controle, -20 [-18/-21] p < 0,001); strain circunferencial global do ventrículo esquerdo (grupo IMD, -20 [-14,5/-22,7]; grupo IMF, -10 [-7/-12]; grupo controle, -23 [-21/-27,5] p < 0,001) e strains de músculos papilares (MPP; grupo IMD, -30,5 [-24/-46,7]; grupo IMF, -18 [-12/-30]; grupo controle; -43 [-34,5/-39,5] p < 0,001; MPA; grupo IMD, (-35 [-23,5/-43]; grupo IMF, -20 [-13,5/-26]; grupo controle, -40 [-32,5/-48] p < 0,001) mostraram-se significativamente diferentes nos grupos. MPA e MPP mostraram-se altamente correlacionados com a FEVE (p < 0,001, p < 0,00; respectivamente), SLG (p < 0,001, p < 0,001; respectivamente) e SCG (p < 0,001, p < 0,001; respectivamente) do VE entre todos os grupos. Não foi encontrada correlação entre os strains de músculos papilares e área eficaz do orifício (AEO) nos grupos de insuficiência mitral grave.
CONCLUSÕES:
A medição do strain longitudinal de músculos papilares pelo método free strain é prática e aplicável. A disfunção dos músculos papilares tem um papel pequeno em IM grave devido a causas degenerativas e funcionais, e a função dos músculos papilares, em general, parece seguir a função ventricular esquerda. O MPP é o MP mais afetado na insuficiência mitral em ambos os grupos, IMD e IMF.
Topics: Adult; Aged; Echocardiography; Female; Humans; Male; Middle Aged; Mitral Valve Insufficiency; Papillary Muscles; Prospective Studies; Stroke Volume; Ventricular Function, Left
PubMed: 28538762
DOI: 10.5935/abc.20170035 -
JACC. Clinical Electrophysiology Dec 2022
Topics: Humans; Papillary Muscles; Heart Ventricles; Mitral Valve Insufficiency
PubMed: 36543497
DOI: 10.1016/j.jacep.2022.08.030 -
Annals of Cardiac Anaesthesia 2021An asymptomatic 30-year-old male was referred for a transthoracic echocardiogram because of a systolic murmur that was noted on a pre-employment physical exam....
An asymptomatic 30-year-old male was referred for a transthoracic echocardiogram because of a systolic murmur that was noted on a pre-employment physical exam. Transthoracic imaging demonstrated a single papillary muscle from which the chordae of both mitral valve leaflets were attached. The mitral valve was seen to have a parachute-like configuration. Given the benign nature of the presentation, the patient did not seek further investigation.
Topics: Adult; Diagnostic Tests, Routine; Echocardiography; Humans; Male; Mitral Valve; Mitral Valve Insufficiency; Papillary Muscles; Referral and Consultation
PubMed: 33938836
DOI: 10.4103/aca.ACA_82_19 -
Romanian Journal of Internal Medicine =... Dec 2022We studied by means of echocardiography and cardiac MRI (CMR) the occurrence of an accessory papillary muscle that unites mostly the left ventricle (LV) apex with the...
We studied by means of echocardiography and cardiac MRI (CMR) the occurrence of an accessory papillary muscle that unites mostly the left ventricle (LV) apex with the basal antero-septum in the immediate vicinity of left ventricle outflow tract (LVOT) in patients with and without hypertrophic cardiomyopathy (HOCM). . We included all good quality echocardiography and CMR studies as reviewed by two cardiologists and assessed the occurrence of a contractile papillary muscle situated between the LV apex and antero-septum. A contractile accessory papillary muscle situated between the LV apex and the anteroseptum was seen in 100% of HOCM patients and 62% of control patients (p=0.05) in the CMR images acquired from a total of 9 HOCM and 13 control patients. The same structure was observed in 241 patients representing 69.5% of all-comers echocardiography studies. The age was 69 ± 17 years on average in the echocardiography arm, patients harboring the antero-septal accessory muscle being older (71.6 + 15.7 years old vs 63.5 ± 18.1 for those without, p=0.0005). We exemplify this structure by parasternal long axis still echocardiography images and clips from 24 patients and CMR SSFP still images and a clip from two HOCM patients and one control. . A contractile accessory papillary muscle was observed in more than half of the all-comer echocardiography studies, and in all HOCM patients in the CMR arm. Further research is needed to fully characterize the anatomical and physiological significance as well as the possible structural interventional consequences of this structure attaching in the immediate vicinity of the LVOT in HOCM and control patients.
Topics: Humans; Middle Aged; Aged; Aged, 80 and over; Papillary Muscles; Heart Ventricles; Ventricular Outflow Obstruction; Echocardiography; Cardiomyopathy, Hypertrophic; Magnetic Resonance Imaging
PubMed: 36178793
DOI: 10.2478/rjim-2022-0017 -
The Journal of Thoracic and... Oct 2022New transapical minimally invasive artificial chordae implantation devices are a promising alternative to traditional open-heart repair, with the potential for decreased...
OBJECTIVE
New transapical minimally invasive artificial chordae implantation devices are a promising alternative to traditional open-heart repair, with the potential for decreased postoperative morbidity and reduced recovery time. However, these devices can place increased stress on the artificial chordae. We designed an artificial papillary muscle to alleviate artificial chordae stresses and thus increase repair durability.
METHODS
The artificial papillary muscle device is a narrow elastic column with an inner core that can be implanted during the minimally invasive transapical procedure via the same ventricular incision site. The device was 3-dimensionally printed in biocompatible silicone for this study. To test efficacy, porcine mitral valves (n = 6) were mounted in a heart simulator, and isolated regurgitation was induced. Each valve was repaired with a polytetrafluoroethylene suture with apical anchoring followed by artificial papillary muscle anchoring. In each case, a high-resolution Fiber Bragg Grating sensor recorded forces on the suture.
RESULTS
Hemodynamic data confirmed that both repairs-with and without the artificial papillary muscle device-were successful in eliminating mitral regurgitation. Both the peak artificial chordae force and the rate of change of force at the onset of systole were significantly lower with the device compared with apical anchoring without the device (P < .001 and P < .001, respectively).
CONCLUSIONS
Our novel artificial papillary muscle could integrate with minimally invasive repairs to shorten the artificial chordae and behave as an elastic damper, thus reducing sharp increases in force. With our device, we have the potential to improve the durability of off-pump transapical mitral valve repair procedures.
Topics: Animals; Chordae Tendineae; Heart Valve Prosthesis Implantation; Mitral Valve; Mitral Valve Insufficiency; Papillary Muscles; Polytetrafluoroethylene; Silicones; Swine
PubMed: 33451843
DOI: 10.1016/j.jtcvs.2020.11.105 -
Journal of Cardiac Surgery Mar 2020The main pathophysiological factor of chronic ischemic mitral regurgitation (MR) is the outward displacement of the papillary muscles (PMs) leading to leaflet tethering.... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND AND AIMS
The main pathophysiological factor of chronic ischemic mitral regurgitation (MR) is the outward displacement of the papillary muscles (PMs) leading to leaflet tethering. For this reason, papillary muscle intervention (PMI) in combination with mitral ring annuloplasty (MRA) has recently been introduced into clinical practice to correct this displacement, and to reduce the recurrence of regurgitation.
METHODS
A meta-analysis was conducted comparing the outcomes of PMI and MRA performed in combination vs MRA performed alone, in terms of MR recurrence and left ventricular reverse remodeling (LVRR). A meta-regression was carried out to investigate the impact of the type of PMI procedure on the outcomes.
RESULTS
MR recurrence in patients undergoing both PMI and MRA was lower than in those who only had MRA (log incidence rate ratio, -0.66; lower-upper limits, -1.13 to 0.20; I = 0.0%; p = .44; Egger's test: intercept 0.35 [-0.78 to 1.51]; p = .42). The group with both PMI and MRA and that with only MRA showed a slightly higher reduction in left ventricular diameters (-5.94%; -8.75% to 3.13%,). However, in both groups, LVRR was <10%. No difference was detected between PM relocation/repositioning and papillary muscle approximation in terms of LVRR (p = .33).
CONCLUSIONS
Using PMI and MRA together has a lower MR recurrence than using MRA alone. No significant LVRR was observed between the two groups nor between the PMI techniques employed.
Topics: Aged; Female; Humans; Male; Middle Aged; Mitral Valve Annuloplasty; Mitral Valve Insufficiency; Papillary Muscles; Recurrence; Secondary Prevention; Ventricular Remodeling
PubMed: 31951676
DOI: 10.1111/jocs.14407 -
Radiology Nov 2022Background The relationship between papillary muscle infarction (papMI) and the culprit coronary lesion has not been fully investigated. Delayed enhancement cardiac MRI...
Background The relationship between papillary muscle infarction (papMI) and the culprit coronary lesion has not been fully investigated. Delayed enhancement cardiac MRI may detect papMI, yet its accuracy is unknown. Flow-independent dark-blood delayed enhancement (FIDDLE) cardiac MRI has been shown to improve the detection of myocardial infarction adjacent to blood pool. Purpose To assess the diagnostic performance of delayed enhancement and FIDDLE cardiac MRI for the detection of papMI, and to investigate the prevalence of papMI and its relationship to the location of the culprit coronary lesion. Materials and Methods A prospective canine study was used to determine the accuracy of conventional delayed enhancement imaging and FIDDLE imaging for detection of papMI, with pathology-based findings as the reference standard. Participants with first-time myocardial infarction with a clear culprit lesion at coronary angiography were prospectively enrolled at a single hospital from 2015 to 2018 and compared against control participants with low Framingham risk scores. In canines, diagnostic accuracy was calculated for delayed enhancement and FIDDLE imaging. Results In canines ( = 27), FIDDLE imaging was more sensitive (100% [23 of 23] vs 57% [13 of 23], < .001) and accurate (100% [54 of 54] vs 80% [43 of 54], = .01) than delayed enhancement imaging for detection of papMI. In 43 participants with myocardial infarction (mean age, 56 years ± 16 [SD]; 28 men), the infarct-related artery was the left anterior descending coronary artery (LAD), left circumflex coronary artery (LCX), and right coronary artery in 47% (20 of 43), 26% (11 of 43), and 28% (12 of 43), respectively. The prevalence of anterior papMI was lower than posterior papMI (37% [16 of 43 participants] vs 44% [19 of 43 participants]) despite more LAD culprit lesions. Culprits leading to papMI were restricted to a smaller "at-risk" portion of the coronary tree for anterior papMI (subtended first diagonal branch of the LAD or first marginal branch of the LCX) compared with posterior (subtended posterior descending artery or third obtuse marginal branch of the LCX). Culprits within these at-risk portions were predictive of papMI at a similar rate (anterior, 83% [15 of 18 participants] vs posterior, 86% [18 of 21 participants]). Conclusion Flow-independent dark-blood delayed enhancement cardiac MRI, unlike conventional delayed enhancement cardiac MRI, was highly accurate in the detection of papillary muscle infarction (papMI). Anterior papMI was less prevalent than posterior papMI, most likely due to culprit lesions being restricted to a smaller portion of the coronary tree rather than because of redundant, dual vascular supply. © RSNA, 2022 See also the editorial by Kawel-Boehm and Bremerich in this issue.
Topics: Male; Humans; Dogs; Animals; Middle Aged; Papillary Muscles; Prospective Studies; Myocardial Infarction; Coronary Vessels; Coronary Angiography; Infarction; Magnetic Resonance Imaging
PubMed: 35880980
DOI: 10.1148/radiol.220251 -
Journal of the Mechanical Behavior of... Nov 2020The mitral valve (MV) apparatus is a complex mechanical structure including annulus, valve leaflets, papillary muscles (PMs) and connected chordae tendineae. Chordae...
The mitral valve (MV) apparatus is a complex mechanical structure including annulus, valve leaflets, papillary muscles (PMs) and connected chordae tendineae. Chordae anchor to the papillary muscles to help the valve open and close properly during one cardiac cycle. It is of paramount importance to understand the functional, mechanical, and microstructural properties of mitral valve chordae and connecting PMs. In particular, little is known about the biomechanical properties of the anterior and posterior papillary muscle and corresponding chords. In this work, we performed uniaxial and biaxial tensile tests on the anterolateral (APM) and posteromedial papillary muscle (PPM), and their respective corresponding chordae tendineae, chordae and chordae, in porcine hearts. Histology was carried out to link the microstructure and macro-mechanical behavior of the chordae and PMs. Our results demonstrate that chordae are less in number, but significantly longer and stiffer than chordae. These different biomechanical properties may be partially explained by the higher collagen core ratio and larger collagen fibril density of chordae No significant mechanical or microstructural differences were observed along the circumferential and longitudinal directions of APM and PPM samples. Data measured on chordae and PMs were further fitted with the Ogden and reduced Holzapfel - Ogden strain energy functions, respectively. This study presents the first comparative anatomical, mechanical, and structural dataset of porcine mitral valve chordae and related PMs. Results indicate that a PM based classification of chordae will need to be considered in the analysis of the MV function or planning a surgical treatment, which will also help developing more precise computational models of MV.
Topics: Animals; Chordae Tendineae; Collagen; Mitral Valve; Mitral Valve Insufficiency; Papillary Muscles; Swine
PubMed: 32835989
DOI: 10.1016/j.jmbbm.2020.104011