oa Mitral Valve Mechanics Following Posterior Leaflet Patch Augmentation

Attention towards optimization of mitral valve repair methods is increasing. Patch augmentation strategy is used to treat functional ischemic mitral regurgitation (FIMR) and hypertrophic cardiomyopathy. When used to extend the anterior leaflet, the procedure decreases the forces exerted on the secondary chordae. The purpose of this study was therefore to investigate the force balance changes following patch augmentation of the posterior leaflet, with particular attention to the secondary chordae tendineae emanating from the posterior papillary muscle (PPM) in an FIMR simulated valve. Twelve mitral valves were obtained from 80kg pigs. An in vitro test setup simulating the left ventricle was used to hold the valves with a papillary muscle positioning system. Water pressure within the ventricular chamber was regulated manually in order to simulate different static pressures during valve closure. An oval shaped porcine pericardial patch measuring 17x29mm was introduced into the posterior leaflet approximately 2mm from the annulus and extending circumferentially from the middle of P2 to the end of the P3 scallop. In order to simulate a healthy valve, retraction of the patch was performed using sutures, which were then released to simulate patch repair. Data were acquired with and without PPM displacement to simulate the effect from one of the main contributors of FIMR, before and after patch augmentation, giving four simulation scenarios. The PPM was displaced 12mm posteriorly and 5mm apically. Dedicated miniature transducers were used to record the forces exerted on the secondary chordae tendineae. Three-way ANOVA was used to analyze the measurements. The effect of displacing the posterior papillary muscle (p < .010) and implementing patch augmentation (p<.004) are significant and independent of each other. The overall effect of displacing the PPM induced tethering on the secondary chordae tendineae from the PPM to the posterior leaflet resulting in a force increase of 28.2 %. The overall effect of implementing the patch augmentation into the posterior leaflet induced a decrease in force of 24.8 % for the healthy and PPM displaced simulations together. The repairing effect of the patch augmentation is found by comparing the specific scenarios. A 40 % increase is induced by displacing the PPM and a 31 % decrease is found by implementing the patch augmentation, leaving the repaired tethering force a mere 9 % higher than that of the healthy measurements. Posterior leaflet patch augmentation significantly reduced the forces exerted onto the secondary chordae tendineae from the PPM in both healthy and PPM displaced valves. As changes in chordal tension leads to redistribution of the total stress exerted on the valve, patch augmentation may have adverse long term influence on mitral.