Efficacy of Mitral Valve Replacement for Patients With Mitral Regurgitation and a Dilated Left Ventricle
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Abstract:
Mitral regurgitation is a significant complication of end-stage cardiomyopathy, and its existence predicts poor survival. In general, it is thought that mitral valve replacement (MVR) alone is ineffective; however, there are few detailed reports of the clinical course of patients who have undergone MVR. Five patients with mitral regurgitation whose preoperative left ventricular end-systolic volume index was more than 100ml/m2 were studied. Although their prognosis late after MVR became poor, none of them died within 30 days of the operation. Postoperative cardiac catheterization was performed 6.3±1.1 months after surgery; the end-diastolic volume had reduced (before: 193±26ml/m2; after: 166±34ml/m2, p<0.05), but the end-systolic volume had not (before: 110±7ml/m2; after: 112±32ml/m2). The end-systolic wall stress was substantially elevated preoperatively (238±29kdyne/cm2) and tended to increase after surgery (295±96kdyne/cm2). All the patients were able to return to work at some stage postoperatively (their New York Heart Association functional class improved to I or II), but 3 of the 5 patients died suddenly of heart failure at 3.3±1.6 years after surgery and the New York Heart Association functional class of the others worsened to III again. Mitral valve surgery, including MVR, can manage severe end-stage heart disease with mitral regurgitation.Keywords:
Mitral valve replacement
Dilated Cardiomyopathy
Mitral valve annuloplasty
Recurrent mitral regurgitation is a significant problem after mitral valve repair in patients with functional valve disease. We report the safety and feasibility of a novel adjustable mitral annuloplasty device that permits downsizing of the anterior–posterior diameter late after initial surgery. In this multicentre, non-randomized, observational register, patients with moderate or severe mitral regurgitation undergoing surgical mitral valve repair with the MiCardia En CorSQ ™ Mitral Valve Repair system were evaluated. Patient characteristics, operative specifications and results as well as postoperative follow-up were collected for all five centres. Ninety-four patients with a median age of 71 (64–75) years (EuroSCORE II 6.7 ± 6.3; 66% male, 48% ischaemic MR, 37% dilated cardiomyopathy and 15% degenerative disease) were included. Operative mortality was 1% and the 1-year survival was 93%. Ring adjustment was attempted in 12 patients at a mean interval of 9 ± 6 months after surgery. In three of these attempts, a technical failure occurred. In 1 patient, mitral regurgitation was reduced two grades, in 2 patients mitral regurgitation was reduced one grade and in 6 patients, mitral regurgitation did not change significantly. The mean grade of mitral regurgitation changed from 2.9 ± 0.9 to 2.1 ± 0.7 ( P = 0.02). Five patients were reoperated after 11 ± 9 months (Ring dehiscence: 2; failed adjustment: 3). We conclude that this device may provide an additional treatment option in patients with functional mitral regurgitation, who are at risk for reoperation due to recurrent mitral regurgitation. Clinical results in this complex disease were ambiguous and patient selection seems to be a crucial step for this device. Further trials are required to estimate the clinical value of this therapeutic concept.
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Abstract — Mitral valve prolapse due to myxomatous degeneration is the most common etiology of mitral regurgitation in developed countries. In recent years, mitral valve repair has been shown to be preferable to mitral valve replacement for the majority of patients undergoing surgery for severe symptomatic mitral regurgitation. Surgeons have recently evaluated experimental techniques to further improve mitral valve repair and, together with cardiologists, nourish strong interest in the potential of the percutaneous approaches. The edge-to-edge technique has been advocated for the complex repair of myxomatous mitral valves. We report here a complication of moderate functional mitral stenosis after “edge to edge” mitral valve repair that can happen in case of not concomitant annuloplasty and of reduced mitral annulus size. Therefore, correctly size concomitant annuloplasty is required to improve the long-term results of the “edge to edge” repair both in terms of efficacy and durability.
Mitral valve prolapse
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Mitral annuloplasty is a reliable mitral valve repair technique. There are two types of annuloplasy rings: the rigid ring and the flexible ring. This study sought to examine the long-term results of mitral valve repair using a Duran flexible ring.We retrospectively reviewed 226 patients who underwent primary mitral valve repair using the Duran flexible ring for mitral regurgitation between September 1994 and March 2003. Patients' mean age was 56.7 years, and 39% were female. The mean follow-up was 10.6 years (0.04 ∼ 18.3), and echocardiographic follow-up was 83.3% complete.There were three early and 25 late deaths. Survival was 89.3 ± 2.2 for 10 years, and 83.5 ± 3.2% for 15 years. The 10- and 15-year freedom from reoperation on the mitral valve were 96.4 ± 1.4 and 95.3 ± 1.7%, respectively. The 10- and 15-year freedom from moderate or severe mitral regurgitation were 92.5 ± 2.2 and 73.7 ± 7.1%, respectively. Cox regression analysis revealed that age, male gender, and isolated anterior leaflet prolapse were predictive of recurrent moderate or severe mitral regurgitation.Mitral valve repair for mitral regurgitation using a flexible Duran ring is safe and durable for more than 10 years.
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A best evidence topic was written according to a structured protocol. The question addressed was whether patients undergoing coronary bypass grafting and mitral intervention for moderate to severe ischaemic mitral regurgitation are best treated with mitral repair or replacement. Five hundred and fifty papers were found using the reported search. Based on the 14 non-randomised studies judged to represent best evidence, we concluded that whilst there is some evidence that the operative mortality may be less following mitral valve repair, long-term data are equivocal. Even with contemporary techniques, recurrent mitral regurgitation is not uncommon following repair. Replacement was more frequently performed for patients with greater co-morbidity. Whilst two studies attempted to control for this using propensity analysis, in the majority of studies this introduced considerable bias. No data was available on long-term functional outcomes and quality of life. As there is currently insufficient evidence to inform clinical practice, a randomised trial is warranted in this important area.
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Mitral valve annuloplasty
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We retrospectively reviewed 16 patients (7 men and 9 women, aged 36 to 77 years) who underwent mitral valve repair with chordal reconstruction for isolated posterior mitral leaflet prolapse. Preoperative echocardiography demonstrated moderate mitral regurgitation in 1, and severe regurgitation in 15. We routinely used expanded polytetrafluoroethylene sutures as artificial chords, and ring annuloplasty was performed in all cases (mean ring size, 30 ± 2 mm). After implanting the ring, the length of the artificial chords was adjusted repeatedly using saline solution. Early postoperative echocardiography at 7.1 ± 1.1 days after surgery showed mitral regurgitation grades reduced to none or trivial in 15/16 patients. One required reoperation for recurrent mitral regurgitation 1.5 years after surgery. In the other patients, intermediate-term echocardiography at 9.1 ± 10.1 months after surgery demonstrated that residual mitral regurgitation was less than mild. We concluded that chordal reconstruction is an effective and highly reproducible procedure for the repair of isolated posterior mitral leaflet prolapse. Artificial chords for the posterior mitral leaflet should not be too long, to avoid systolic anterior motion or recurrent mitral regurgitation after surgery.
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