doi:10.1510/mmcts.2004.000521
Mitral valve repair in ischemic mitral regurgitation Antonio Maria Calafiorea,*, Michele Di Maurob, Marco Continib, Luca Welterta, Antonio Bivonab a
Division of Cardiac Surgery, University Hospital, ‘‘S. Giovanni Battista’’, c.so Bramante 86, Turin, Italy b Division of Cardiac Surgery, ‘‘G D’Annunzio’’ University, Chieti, Italy Ischemic mitral regurgitation (IMR) is a common complication after acute myocardial infarction due to annulus dilatation and papillary muscles displacement. In our opinion 3/4 and 4/4 IMR have always to be indicated for MV surgery. In presence of low EF and dilated LV, moderate (2/4) IMR has to be corrected. The end-systolic distance between the coaptation point of mitral leaflets and the plane of mitral valve annulus is the key point to decide repair (F10 mm) or replacement ()10 mm). MV annuloplasty has always been addressed to the posterior annulus, whose size can be easily reduced. A specially designed 40 mm long ring has been used to achieve a posterior overreductive annuloplasty. For MV repair thirty-day mortality was 2.4%. Five-year survival and the possibility of being alive and in NYHA class I-II were 75.6"4.7 and 59.8"5.4, respectively. After a mean of 38"35 months, the NYHA class decreases from 3.2"0.5 to 2.1"0.6 (P-0.001). Most patients (77.4%) have an improvement of its own functional class. MR decreases from 3.2"0.8 to 1.2"1.1 (P-0.001). 97.5% of the survivors have MR equal to or less than moderate.
Keywords: mitral valve, ischemic mitral regurgitation, mitral valve annulopasty Introduction Ischemic mitral regurgitation (IMR) is a common (approximately 20%) complication after completed myocardial infarction (MI), which follows more frequently an inferior MI (38%) rather than an anteroseptal one (10%) w1x. The mechanisms at the base of IMR are different: 1) annular dilation w2x; 2) displacement of both papillary muscles (PM) apically, posteriorly and laterally in case of global left ventricle (LV) dilatation, with consequent increase of tethering upon closing forces and incomplete coaptation of mitral leaflets w2,3x (Schematic 1) w4,5x; 3) local malfunction of the LV wall adjacent to a single PM w1,2x (more frequently the posterior one) (Schematic 2 w4x). In this * Corresponding author: Tel.: q39 011 6335514; Fax: q39 011 6336130. E-mail: [email protected] 䉷 2005 European Association for Cardio-thoracic Surgery
case, an asymmetrical deformation of the mitral valve (MV) from the medial to the lateral side could be present, showing a funnel-shaped deformity of the medial side and a prolapse-like deformity on the lateral side. This might develop as a result of preserved or exces-
Schematic 1. (A) Ischemic mitral regurgitation due to both papillary muscles is a consequence of global left ventricle dilatation. (Reprinted from Ref. w4x with the permission of McGraw-Hill Education). (B) This produces an increasing tethering upon closing forces and incomplete coaptation of mitral leaflets. (Reprinted from Ref. w5x with the permission of BC Decker).
1
A.M. Calafiore et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000521
Photo 3. A specially designed 40 mm long ring (Sovering Miniband䊛, MMCTSLink 19). Schematic 2. Ischemic mitral regurgitation due to local malfunction of the LV wall adjacent to a single papillary muscle. (Reprinted from Ref. w4x with the permission of McGraw-Hill Education).
Patients with IMR have a worse survival than patients without IMR w7–9x. A higher degree of IMR worsens further long term survival w8,9x.
Surgical indication
Photo 1. The regurgitant jet is generally central (A), but can be double (B) due to asymmetrical deformity of the mitral valve. (Reprinted from Ref. w6x with the permission of Elsevier Inc.).
Despite these findings, the debate regarding surgical indications for MV surgery is still open. Some surgeons found no difference between isolated coronary artery bypass grafting (CABG) and CABG associated to MV surgery w10–13x, even if isolated CABG produced worse results in case of heart failure or low ejection fraction (EF) w10–12x. Other studies evidence a better outcome with MV surgery w14,15x, even in the case of moderate (2/4) IMR w15x. In our opinion 3/4 and 4/4 IMR have always to be indicated to MV surgery. In presence of low EF and dilated LV, moderate (2/4) IMR has to be corrected w6x. Although MV repair can provide better results w16x, in some cases it can fail because of excessive MV tethering w17x. Coaptation depth (CD) (Photo 2 w5x) is used by us to decide if MV repair can be performed with high possibilities to achieve good results. According to our experience w18x, when the MV coaptation depth is higher than 10 mm the abnormalities in the subvalvular apparatus prevent proper coaptation of mitral leaflets, causing residual MR. In this case MV replacement is indicated w18x. The mitral valve apparatus is left intact in all its components (leaflets, chordae and papillary muscles). Only a small triangle of the anterior leaflet is resected in order to prevent its fixed position in the outflow tract of the left ventricle.
Photo 2. Echocardiographic view: the leaflets show tented geometry; mitral annulus (A-Bs45 mm) is enlarged and mitral valve coaptation depth (C-Ds13 mm) is increased. (Reprinted from Ref. w5x with the permission of BC Decker).
sive motion of the non-tethered lateral side of the anterior leaflet w2x. As a consequence, the regurgitant jet, in some cases, is double: one central and one lateral (Photo 1 w6x) 2
Surgical technique The purpose of reconstructive MV surgery is to restore MV competence acting on dilated mitral annulus (MV annuloplasty). This can be obtained using complete or incomplete, manufactured or autologous pericardium rings w16,18–21x, or suture annuloplasty w22x. We prefer to use a posterior ring, 40 mm long (Sovering Miniband䊛, MMCTSLink 19) to achieve a strong overreduction of the mitral annulus (MA) (Photo 3). MV
A.M. Calafiore et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000521
Video 1. Trans-septal surgical approach.
Schematic 3. Each suture starts before the end of the annulus covered by the previous suture. (Reprinted from Ref. w21x with the permission of Elsevier Inc.).
Photo 4. Intraoperative view: many stitches are passed between the MV commissures. (Reprinted from Ref. w21x with the permission of Elsevier Inc.).
Video 3. All the sutures are passed trough the Miniband (Sovering Miniband䊛, MMCTSLink 19).
When the mitral annulus is exposed, several U-stitches (12 to 16) are passed between the middle point of the posteromedial commissure and the middle point of the anterolateral commissure, using a 2/0 TI-CRON姠 (MMCTSLink 7) with a small needle (20 mm) (Photo 4 w21x, Video 2).
Video 2. Several 2/0 TI-CRON姠 stitches are passed from posteromedial commissure to the antero-lateral one.
annuloplasty has always been addressed to the posterior annulus, whose size can be easily reduced. All the patients have a standard monitoring, including a Swan Ganz catheter and trans-esophageal echocardiography (TEE). The ascending aorta is cannulated for arterial inflow, whereas the inferior vena cava is cannulated as usual, and the superior one is directly cannulated. Myocardial protection is achieved by means of intermittent antegrade warm blood cardioplegia. Surgical approach is often trans-septal (Video 1). In case of incomplete vision, the incision is continued to reach the roof of the left atrium.
Each suture has to start before the end of the annulus covered by the previous suture (Schematic 3 w21x). This is necessary as MA is often soft and increasing the number of sutures reduces the stress on the MA. All the sutures are passed through the Miniband (Sovering Miniband䊛, MMCTSLink 19) (Video 3). The ring is then pulled down to the posterior annulus and the sutures are tied (Video 4), producing an overreduction of the MV annular size. In case of MV replacement (the prosthesis is inserted inside the native valve), the stitches utilized to fix the prosthesis are used to attract the remnants of the anterior leaflet toward the annulus (Video 5). 3
A.M. Calafiore et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000521
Video 4. The Miniband is pulled down and the sutures are tied.
Video 5. The mitral valve is replaced sparing the continuity between mitral valve and subvalvular apparatus.
● From June 1988 to December 2002, 102 patients with ischemic mitral regurgitation underwent mitral valve surgery, 82 repair and 20 replacement. Patients with organic MV disease, with intermittent ischemia or with PM rupture were not included in this study. ● Mean age was 66.5"8.5. Most patients (43) were older than 70 years. ● Mean preoperative NYHA class was 3.3"0.5. Ninety-nine patients were in NYHA class III-IV. Fifty-nine presented preoperative chronic heart failure. ● Thirty-day mortality was 3.9%. Death was caused by a multiorgan failure due to biologic bleeding, tracheal bleeding, rupture of abdominal aortic aneurysm and low output syndrome. Five-year survival was 73.5"4.4 (Graph 1 w6x). ● Five-year possibility of being alive and in NYHA class I-II was 56.9"5.4 (Graph 2 w6x). ● After a mean of 39"35 months, NYHA class decreases from 3.3"0.5 to 2.2"0.6 (P-0.001). ● Most patients (75%) have an improvement of the functional class. ● In patients who underwent mitral valve repair, MR decreases from 3.2"0.8 to 1.2"1.1 (P-0.001). 97.5% of the survivors have MR equal to or less than moderate. ● Preoperative NYHA class and chronic heart failure represented independent variables for lower fiveyear survival. ● Lower preoperative ejection fraction and higher end-diastolic and end-systolic volume had a negative impact on survival and quality of life.
References Graph 1. Five-year survival. (Reprinted from Ref. w6x with the permission of Elsevier Inc.).
Graph 2. Five-year possibility to be alive and in NYHA class I/II. (Reprinted from Ref. w6x with the permission of Elsevier Inc.).
Results According to our experience w6x, early and late results of patients with IMR who underwent MV repair are the following: 4
w1x Kumanohoso T, Otsuji Y, Yoshifuku S, Matsukida S, koriyama C, Kisanuki A, Minagoe S, Levine RA, Tei C. Mechanism of higher incidence of ischemic mitral regurgitation in patients with inferior myocardial infarction: quantitative analysis of left ventricular and mitral valve geometry in 103 patients with prior myocardial infarction. J Thorac Cardiovasc Surg 2003;125:135–143. w2x Kwan J, Shiota T, Agler DA, Popovic ZB, Qin JX, Gillionov MA, Stewart WJ, Cosgrove DM, McCarthy PM, Thomas JD. Geometric differences of the mitral apparatus between ischemic and dilated cardiomyopathy with significant mitral regurgitation real-time three-dimensional echocardiography study. Circulation 2003;107:1135– 1140. w3x Otsuji Y, Handschumacher MD, Schwammenthal E, Jiang L, Song JK, Guerrero JL, Vlahakes GJ, Levine RA. Insights from three-dimensional echocardiography into the mechanism of functional
A.M. Calafiore et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000521
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mitral regurgitation: direct in vivo demonstration of altered leaflet tethering geometry. Circulation 1997;96:1999–2008. Badhwar V, Bolling SF. Nontransplant surgical options for heart failure. In: Cohn LH, Edmunds H Jr, editors. Cardiac surgery in the adults, Ed. 2; McGraw-Hill, 2004. Calafiore AM, Di Mauro M, Contini M, Vitolla G, Pelini P. Left ventricular volume reduction for Dilated Cardiomyopathy. In: Franco K, Verrier E, editors. Advanced therapy in cardiac surgery, Ed. 2; BC Decker 2003. Calafiore AM, Di Mauro M, Gallina S, Di Giammarco G, Iaco` AL, Teodori G, Tavarozzi I, Mitral valve surgery for chronic ischemic mitral regurgitation. Ann Thorac Surg 2004;77:1989– 1997. Grigioni F, Enriquez-Sarano M, Zehr KJ, Bailey KR, Tajik AJ. Ischemic mitral regurgitation longterm outcome and prognostic implications with quantitative doppler assessment. Circulation. 2001;103:1759–1764. Ellis SG, Whitlow PL, Raymond RE, Schneider JP. Impact of mitral regurgitation on long-term survival after percutaneous coronary intervention. Am J Cardiol 2002;89:315–318. Ling LH, Enriquez-Sarano M, Seward JB, Orszulak TA, Schaff HV, Bailey KR, Tajik AJ, Frye RL. Early surgery in patients with mitral regurgitation due to flail leaflets; a long-term outcome study. Circulation 1997;96:1819–1825. Arcidi JM Jr, Hebeler RF, Craver JM, Jones EL, Hatcher CR Jr, Guyton RA. Treatment of moderate mitral regurgitation and coronary disease by coronary bypass alone. J Thorac Cardiovasc Surg 1988;95:951–959. Duarte IG, Shen Y, MacDonald MJ, Jones EL, Craver JM, Guyton RA. Treatment of moderate mitral regurgitation and coronary disease by coronary bypass alone: late results. Ann Thorac Surg 1999;68:426–430. Harris KM, Sundt TM, Aeppli D, Sharma R, Barzilai B. Can late survival of patients with moderate ischemic mitral regurgitation be impacted by intervention on the valve? Ann Thorac Surg 2002;74:1468–1475. Diodato MD, Moon MR, Pasque MK, Barner HB, Moazami N, Lawton JS, Bailey MS, Guthrie TJ,
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Meyers BF, Damiano RJ Jr. Repair of ischemic mitral regurgitation does not increase mortality or improve long-term survival in patients undergoing coronary artery revascularization: a propensty analysis. Ann Thorac Surg 2004;78:794–799. Aklog L, Filsoufi F, Flores KQ, Chen RH, Cohn LH, Nathan NS, Byrne JG, Adams. Does coronary artery bypass grafting alone correct moderate ischemic mitral regurgitation? Circulation 2001;104wsuppl Ix:I-68-I-75. Ryden T, Bech-Hanssen O, Brandrup-Wognsen G, Nilsson F, Svensson S, Jeppsson A. The importance of grade 2 ischemic mitral regurgitation in coronary artery bypass grafting. Eur J Cardiothorac Surg 2001;20:276–281. Gillinov AM, Wierup PN, Blackstone EH, Bishay ES, Cosgrove DM, White J, Lytle BW, McCarthy PM. Is repair preferable to replacement for ischemic mitral regurgitation? J Thorac Cardiovasc Surg 2001;122:1125–1141. Liel-Cohen N, Otsuji Y, Vlahakes GJ, Akins CW, Levine RA. Functional ischemic mitral regurgitation can persist despite ring annuloplasty: mechanistic insights. Circulation 1997;96(Suppl I):I-540. Calafiore AM, Gallina S, Di Mauro M, Gaeta F, Iaco` AL, D’Alessandro S, Mazzei V, Di Giammarco G. Mitral valve procedure in dilated cardiomyopathy: repair or replacement? Ann Thorac Surg 2001;71:1146–1153. Carpentier A, Deloche A, Dauptain J, Soyer R, Blondeau P, Piwnica A, Dubost C, McGoon DC. A new reconstructive operation for correction of mitral and tricuspid insufficiency. J Thorac Cardiovasc Surg 1971;61:1–13. Bolling SF, Deeb GM, Brunsting LA, Bach DS. Early outcome of mitral valve reconstruction in patients with end-stage cardiomyopathy. J Thorac Cardiovasc Surg 1995;109:676–683. Calafiore AM, Di Mauro M, Gallina S, Canosa C, Iaco` AL. Optimal length of pericardial strip for posterior mitral overreductive annuloplasty. Ann Thorac Surg 2003;75:1982–1984. Radovanovic N, Mihajlovic B, Selestiansky J, Torbica V, Mijatov M, Popov M, Jonjev ZS. Reductive annuloplasty of double orifices in patients with primary dilated cardiomyopathy. Ann Thorac Surg 2002;73:751–755.
5
Mitral valve repair in ischemic mitral regurgitation Antonio Maria Calafiorea,*, Michele Di Maurob, Marco Continib, Luca Welterta, Antonio Bivonab a
Division of Cardiac Surgery, University Hospital, ‘‘S. Giovanni Battista’’, c.so Bramante 86, Turin, Italy b Division of Cardiac Surgery, ‘‘G D’Annunzio’’ University, Chieti, Italy Ischemic mitral regurgitation (IMR) is a common complication after acute myocardial infarction due to annulus dilatation and papillary muscles displacement. In our opinion 3/4 and 4/4 IMR have always to be indicated for MV surgery. In presence of low EF and dilated LV, moderate (2/4) IMR has to be corrected. The end-systolic distance between the coaptation point of mitral leaflets and the plane of mitral valve annulus is the key point to decide repair (F10 mm) or replacement ()10 mm). MV annuloplasty has always been addressed to the posterior annulus, whose size can be easily reduced. A specially designed 40 mm long ring has been used to achieve a posterior overreductive annuloplasty. For MV repair thirty-day mortality was 2.4%. Five-year survival and the possibility of being alive and in NYHA class I-II were 75.6"4.7 and 59.8"5.4, respectively. After a mean of 38"35 months, the NYHA class decreases from 3.2"0.5 to 2.1"0.6 (P-0.001). Most patients (77.4%) have an improvement of its own functional class. MR decreases from 3.2"0.8 to 1.2"1.1 (P-0.001). 97.5% of the survivors have MR equal to or less than moderate.
Keywords: mitral valve, ischemic mitral regurgitation, mitral valve annulopasty Introduction Ischemic mitral regurgitation (IMR) is a common (approximately 20%) complication after completed myocardial infarction (MI), which follows more frequently an inferior MI (38%) rather than an anteroseptal one (10%) w1x. The mechanisms at the base of IMR are different: 1) annular dilation w2x; 2) displacement of both papillary muscles (PM) apically, posteriorly and laterally in case of global left ventricle (LV) dilatation, with consequent increase of tethering upon closing forces and incomplete coaptation of mitral leaflets w2,3x (Schematic 1) w4,5x; 3) local malfunction of the LV wall adjacent to a single PM w1,2x (more frequently the posterior one) (Schematic 2 w4x). In this * Corresponding author: Tel.: q39 011 6335514; Fax: q39 011 6336130. E-mail: [email protected] 䉷 2005 European Association for Cardio-thoracic Surgery
case, an asymmetrical deformation of the mitral valve (MV) from the medial to the lateral side could be present, showing a funnel-shaped deformity of the medial side and a prolapse-like deformity on the lateral side. This might develop as a result of preserved or exces-
Schematic 1. (A) Ischemic mitral regurgitation due to both papillary muscles is a consequence of global left ventricle dilatation. (Reprinted from Ref. w4x with the permission of McGraw-Hill Education). (B) This produces an increasing tethering upon closing forces and incomplete coaptation of mitral leaflets. (Reprinted from Ref. w5x with the permission of BC Decker).
1
A.M. Calafiore et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000521
Photo 3. A specially designed 40 mm long ring (Sovering Miniband䊛, MMCTSLink 19). Schematic 2. Ischemic mitral regurgitation due to local malfunction of the LV wall adjacent to a single papillary muscle. (Reprinted from Ref. w4x with the permission of McGraw-Hill Education).
Patients with IMR have a worse survival than patients without IMR w7–9x. A higher degree of IMR worsens further long term survival w8,9x.
Surgical indication
Photo 1. The regurgitant jet is generally central (A), but can be double (B) due to asymmetrical deformity of the mitral valve. (Reprinted from Ref. w6x with the permission of Elsevier Inc.).
Despite these findings, the debate regarding surgical indications for MV surgery is still open. Some surgeons found no difference between isolated coronary artery bypass grafting (CABG) and CABG associated to MV surgery w10–13x, even if isolated CABG produced worse results in case of heart failure or low ejection fraction (EF) w10–12x. Other studies evidence a better outcome with MV surgery w14,15x, even in the case of moderate (2/4) IMR w15x. In our opinion 3/4 and 4/4 IMR have always to be indicated to MV surgery. In presence of low EF and dilated LV, moderate (2/4) IMR has to be corrected w6x. Although MV repair can provide better results w16x, in some cases it can fail because of excessive MV tethering w17x. Coaptation depth (CD) (Photo 2 w5x) is used by us to decide if MV repair can be performed with high possibilities to achieve good results. According to our experience w18x, when the MV coaptation depth is higher than 10 mm the abnormalities in the subvalvular apparatus prevent proper coaptation of mitral leaflets, causing residual MR. In this case MV replacement is indicated w18x. The mitral valve apparatus is left intact in all its components (leaflets, chordae and papillary muscles). Only a small triangle of the anterior leaflet is resected in order to prevent its fixed position in the outflow tract of the left ventricle.
Photo 2. Echocardiographic view: the leaflets show tented geometry; mitral annulus (A-Bs45 mm) is enlarged and mitral valve coaptation depth (C-Ds13 mm) is increased. (Reprinted from Ref. w5x with the permission of BC Decker).
sive motion of the non-tethered lateral side of the anterior leaflet w2x. As a consequence, the regurgitant jet, in some cases, is double: one central and one lateral (Photo 1 w6x) 2
Surgical technique The purpose of reconstructive MV surgery is to restore MV competence acting on dilated mitral annulus (MV annuloplasty). This can be obtained using complete or incomplete, manufactured or autologous pericardium rings w16,18–21x, or suture annuloplasty w22x. We prefer to use a posterior ring, 40 mm long (Sovering Miniband䊛, MMCTSLink 19) to achieve a strong overreduction of the mitral annulus (MA) (Photo 3). MV
A.M. Calafiore et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000521
Video 1. Trans-septal surgical approach.
Schematic 3. Each suture starts before the end of the annulus covered by the previous suture. (Reprinted from Ref. w21x with the permission of Elsevier Inc.).
Photo 4. Intraoperative view: many stitches are passed between the MV commissures. (Reprinted from Ref. w21x with the permission of Elsevier Inc.).
Video 3. All the sutures are passed trough the Miniband (Sovering Miniband䊛, MMCTSLink 19).
When the mitral annulus is exposed, several U-stitches (12 to 16) are passed between the middle point of the posteromedial commissure and the middle point of the anterolateral commissure, using a 2/0 TI-CRON姠 (MMCTSLink 7) with a small needle (20 mm) (Photo 4 w21x, Video 2).
Video 2. Several 2/0 TI-CRON姠 stitches are passed from posteromedial commissure to the antero-lateral one.
annuloplasty has always been addressed to the posterior annulus, whose size can be easily reduced. All the patients have a standard monitoring, including a Swan Ganz catheter and trans-esophageal echocardiography (TEE). The ascending aorta is cannulated for arterial inflow, whereas the inferior vena cava is cannulated as usual, and the superior one is directly cannulated. Myocardial protection is achieved by means of intermittent antegrade warm blood cardioplegia. Surgical approach is often trans-septal (Video 1). In case of incomplete vision, the incision is continued to reach the roof of the left atrium.
Each suture has to start before the end of the annulus covered by the previous suture (Schematic 3 w21x). This is necessary as MA is often soft and increasing the number of sutures reduces the stress on the MA. All the sutures are passed through the Miniband (Sovering Miniband䊛, MMCTSLink 19) (Video 3). The ring is then pulled down to the posterior annulus and the sutures are tied (Video 4), producing an overreduction of the MV annular size. In case of MV replacement (the prosthesis is inserted inside the native valve), the stitches utilized to fix the prosthesis are used to attract the remnants of the anterior leaflet toward the annulus (Video 5). 3
A.M. Calafiore et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000521
Video 4. The Miniband is pulled down and the sutures are tied.
Video 5. The mitral valve is replaced sparing the continuity between mitral valve and subvalvular apparatus.
● From June 1988 to December 2002, 102 patients with ischemic mitral regurgitation underwent mitral valve surgery, 82 repair and 20 replacement. Patients with organic MV disease, with intermittent ischemia or with PM rupture were not included in this study. ● Mean age was 66.5"8.5. Most patients (43) were older than 70 years. ● Mean preoperative NYHA class was 3.3"0.5. Ninety-nine patients were in NYHA class III-IV. Fifty-nine presented preoperative chronic heart failure. ● Thirty-day mortality was 3.9%. Death was caused by a multiorgan failure due to biologic bleeding, tracheal bleeding, rupture of abdominal aortic aneurysm and low output syndrome. Five-year survival was 73.5"4.4 (Graph 1 w6x). ● Five-year possibility of being alive and in NYHA class I-II was 56.9"5.4 (Graph 2 w6x). ● After a mean of 39"35 months, NYHA class decreases from 3.3"0.5 to 2.2"0.6 (P-0.001). ● Most patients (75%) have an improvement of the functional class. ● In patients who underwent mitral valve repair, MR decreases from 3.2"0.8 to 1.2"1.1 (P-0.001). 97.5% of the survivors have MR equal to or less than moderate. ● Preoperative NYHA class and chronic heart failure represented independent variables for lower fiveyear survival. ● Lower preoperative ejection fraction and higher end-diastolic and end-systolic volume had a negative impact on survival and quality of life.
References Graph 1. Five-year survival. (Reprinted from Ref. w6x with the permission of Elsevier Inc.).
Graph 2. Five-year possibility to be alive and in NYHA class I/II. (Reprinted from Ref. w6x with the permission of Elsevier Inc.).
Results According to our experience w6x, early and late results of patients with IMR who underwent MV repair are the following: 4
w1x Kumanohoso T, Otsuji Y, Yoshifuku S, Matsukida S, koriyama C, Kisanuki A, Minagoe S, Levine RA, Tei C. Mechanism of higher incidence of ischemic mitral regurgitation in patients with inferior myocardial infarction: quantitative analysis of left ventricular and mitral valve geometry in 103 patients with prior myocardial infarction. J Thorac Cardiovasc Surg 2003;125:135–143. w2x Kwan J, Shiota T, Agler DA, Popovic ZB, Qin JX, Gillionov MA, Stewart WJ, Cosgrove DM, McCarthy PM, Thomas JD. Geometric differences of the mitral apparatus between ischemic and dilated cardiomyopathy with significant mitral regurgitation real-time three-dimensional echocardiography study. Circulation 2003;107:1135– 1140. w3x Otsuji Y, Handschumacher MD, Schwammenthal E, Jiang L, Song JK, Guerrero JL, Vlahakes GJ, Levine RA. Insights from three-dimensional echocardiography into the mechanism of functional
A.M. Calafiore et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000521
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w5x
w6x
w7x
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mitral regurgitation: direct in vivo demonstration of altered leaflet tethering geometry. Circulation 1997;96:1999–2008. Badhwar V, Bolling SF. Nontransplant surgical options for heart failure. In: Cohn LH, Edmunds H Jr, editors. Cardiac surgery in the adults, Ed. 2; McGraw-Hill, 2004. Calafiore AM, Di Mauro M, Contini M, Vitolla G, Pelini P. Left ventricular volume reduction for Dilated Cardiomyopathy. In: Franco K, Verrier E, editors. Advanced therapy in cardiac surgery, Ed. 2; BC Decker 2003. Calafiore AM, Di Mauro M, Gallina S, Di Giammarco G, Iaco` AL, Teodori G, Tavarozzi I, Mitral valve surgery for chronic ischemic mitral regurgitation. Ann Thorac Surg 2004;77:1989– 1997. Grigioni F, Enriquez-Sarano M, Zehr KJ, Bailey KR, Tajik AJ. Ischemic mitral regurgitation longterm outcome and prognostic implications with quantitative doppler assessment. Circulation. 2001;103:1759–1764. Ellis SG, Whitlow PL, Raymond RE, Schneider JP. Impact of mitral regurgitation on long-term survival after percutaneous coronary intervention. Am J Cardiol 2002;89:315–318. Ling LH, Enriquez-Sarano M, Seward JB, Orszulak TA, Schaff HV, Bailey KR, Tajik AJ, Frye RL. Early surgery in patients with mitral regurgitation due to flail leaflets; a long-term outcome study. Circulation 1997;96:1819–1825. Arcidi JM Jr, Hebeler RF, Craver JM, Jones EL, Hatcher CR Jr, Guyton RA. Treatment of moderate mitral regurgitation and coronary disease by coronary bypass alone. J Thorac Cardiovasc Surg 1988;95:951–959. Duarte IG, Shen Y, MacDonald MJ, Jones EL, Craver JM, Guyton RA. Treatment of moderate mitral regurgitation and coronary disease by coronary bypass alone: late results. Ann Thorac Surg 1999;68:426–430. Harris KM, Sundt TM, Aeppli D, Sharma R, Barzilai B. Can late survival of patients with moderate ischemic mitral regurgitation be impacted by intervention on the valve? Ann Thorac Surg 2002;74:1468–1475. Diodato MD, Moon MR, Pasque MK, Barner HB, Moazami N, Lawton JS, Bailey MS, Guthrie TJ,
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