Mitral Valve Replacement Is a Viable Alternative to Mitral Valve Repair for Ischemic Mitral Regurgitation: A Case-Matched Study

Division of Cardiac Surgery, University of Ottawa, Ottawa, Ontario, Canada.
The Annals of thoracic surgery (Impact Factor: 3.65). 10/2011; 92(4):1358-65; discussion 1365-6. DOI: 10.1016/j.athoracsur.2011.05.056
Source: PubMed

ABSTRACT Comparisons of mitral valve repair with mitral valve replacement for ischemic mitral regurgitation (IMR) have been limited by differences in preoperative and operative characteristics of patients undergoing these two types of surgical treatment. We performed a propensity-based, case-matched analysis to examine whether patients who undergo mitral valve repair and those who undergo mitral valve replacement for IMR have similar long-term outcomes.
We compared 65 patients who underwent mitral valve replacement for IMR between 2001 and 2010 with 65 patients who underwent mitral repair during the same period on the basis of age, concomitant coronary bypass grafting, gender, left ventricular function, preoperative pulmonary hypertension, and urgency of operation. Mitral replacement involved preservation of the subvalvular apparatus. The mean study follow-up period was 2.5 ± 2.1 years.
Two patients who underwent mitral valve repair died at 30 days postoperatively and three patients died after valve replacement. Late survival was the same in the two groups (p = 0.4). Recurrent mitral regurgitation (MR) (grade 2+ or higher) at late follow-up was observed in 15 patients (23%) after repair; however, only 1 patient (2%) had MR with a grade of more than 2+. Mitral valve repair was more commonly associated with recurrent MR (grade 2+ or higher) than was mitral valve replacement (p = 0.04). Patients in both groups had similar freedom from valve-related complications and similar left ventricular function at follow-up (both p > 0.2).
Mitral valve replacement remains a viable option for the treatment of IMR. Although mitral valve repair effectively protects against persistent or recurrent moderate-to-severe MR, mitral valve replacement provides better freedom from mild-to-moderate MR in this population, with a low incidence of valve-related complications. Notably, there was no significant difference in left ventricular function between the valve-repair and valve-replacement groups at follow-up.

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    ABSTRACT: There is an increasing number of patients with mitral regurgitation secondary to dilated cardiomyopathy. Recent data suggest that mitral regurgitation (MR) can be surgically corrected in heart failure with sym-ptomatic improvements and favourable reverse left ventricular remodeling. However, several questions remain to be answered, regarding the optimal man-agement of functional mitral regurgitation, the cor-rect timing of surgery and the choice of the surgical technique to perform in patients affected by dilated cardiomyopathy. In the setting of ischemic chronic cardiomyopathy, data derived from the recent litera-ture suggest that concomitant severe ischemic MR should be addressed during CABG to improve sur-vival and quality of life. Most surgeons perform con-comitant CABG and mitral valve surgery in patients with ischemic chronic cardiomyopathy and moderate to severe MR. In the setting of chronic dilated car-diomyopathy, most clinicians would agree that cor-rection of severe MR in heart failure is warranted, mostly due to a symptomatic benefit and reduction of number of re-hospitalizations. Moreover, reverse ven-tricular remodeling has been demonstrated with un-dersized annuloplasty rings and correction of MR: this could lead to improved contractility, reduction in left ventricular end-diastolic and end-systolic vol-umes, and finally to improved NYHA functional class. Recent large studies suggest that patients undergoing mitral valve repair had improved perioperative sur-vival, shorter length of stay, and improved long-term survival than those undergoing mitral valve replace-ment because the preservation of the subvalvular ap-paratus seems to result in superior left ventricular remodelling and in greater improvement in NYHA class. In the near future, data from multi-institutional, randomized prospective trials will help to elucidate many of the questions and concerns regarding repair of severe functional mitral regurgitation. Finally, technology applied to heart surgery is continually evolving and will allow more exciting cellular and novel device therapies for the treatment of functional mitral regurgitation secondary to dilated cardiomyo-pathy.
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    ABSTRACT: Objective The proper treatment of chronic ischemic mitral regurgitation (CIMR) is still under evaluation. The different role of mitral valve repair (MVr) or mitral valve prosthesis insertion (MVPI) is still not defined. Methods From May 2009 to December 2011 167 patients with ejection fraction (EF) ≤ 40% had MV surgery for CIMR, MVr in 135 (80.8%) and MVPI in 32 (19.2%). Indication to MVPI was a MV coaptation depth > 10 mm. EF was lower (26 ± 7 vs 32 ± 6, p = 0.0000) in MVPI, whereas MR grade (3.6 ± 0.8 vs 2.7 ± 0.9, p = 0.0000), left ventricle dimensions (end diastolic, LVEDD, 62 ± 7 vs 57 ± 6 mm, p = 0.0001; end systolic, LVESD, 49 ± 8 vs 44 ± 8 mm, p = 0.0018), systolic pulmonary artery pressure (51 ± 22 vs 41 ± 16 mm Hg, p = 0.0037) and NYHA Class (3.6 ± 0.5 vs 2.8 ± 0.6, p = 0.0000) were higher. Results In-hospital mortality was similar (3.1 vs 3.7%) as well as 3-year survival (86 ± 6 vs 88 ± 4) and survival in NYHA Class I/II (80 ± 5 vs 83 ± 4). One hundred thirty nine patients had an echocardiographic evaluation after a minimum of 4 months (13 ± 8). EF rose significantly in both groups (from 26 ± 7% to 30 ± 4%, p = 0.0122, and from 32 ± 6% to 35 ± 8%, p = 0.0018). LVESD reduced significantly in both groups (from 49 ± 8 to 43 ± 9 mm, p = 0.0109, and from 44 ± 8 to 41 ± 7 mm, p = 0.0033). MR grade was significantly lower in patients who had MVPI (0.1 ± 0.2 vs 0.3 ± 0.3, p = 0.0011). Conclusions With appropriate indications, MVPI is a safe procedure which provides similar results to MVr with lower MR return, even if addressed to patients with worse preoperative parameters.
    06/2014; 3:32–36. DOI:10.1016/j.ijchv.2014.02.002
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    ABSTRACT: Data regarding durability and midterm benefits of mitral valve (MV) repair in elderly patients are scarce. To evaluate the feasibility and safety of MV repair in elderly patients, we performed a retrospective data analysis.
    Interactive Cardiovascular and Thoracic Surgery 10/2014; DOI:10.1093/icvts/ivu337 · 1.11 Impact Factor


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