Treatment of severe functional mitral regurgitation: is cardiac surgery always indicated?
ABSTRACT Severe functional mitral regurgitation associated with myocardial ischemia is conventionally a Class I indication for cardiac surgery. Mitral annuloplasty or mitral valve replacement are performed during coronary bypass surgery with the aim of improving the patient's ventricular function and symptoms. With the advancement of stent technology, sustained myocardial perfusion and improvement of ventricular function could be achieved by revascularization alone, leading to a reduction in the severity of mitral regurgitation. The purpose of this case is to review the role of transcatheter coronary revascularization in the management of myocardial ischemia associated with severe functional mitral regurgitation and heart failure.
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ABSTRACT: The standard treatment for functional ischemic mitral regurgitation (FIMR) is revascularization and reduction annuloplasty. Although the immediate results are excellent, some patients develop recurrent mitral regurgitation (MR) at mid-term follow up. The study aim was to identify possible preoperative echocardiographic parameters that might predict the risk of recurrent FIMR. From 124 consecutive patients who underwent revascularization and ring annuloplasty, 48 were selected if they: (i) had a complete preoperative and follow up transthoracic echocardiogram; and (ii) left the operating room with grade 1+ MR. Those patients with moderate or greater late MR were classified as having significant recurrent FIMR (MR group), and those with mild or no MR were classified as no significant FIMR (No-MR group). Left ventricular ejection fraction (LVEF), left ventricular (LV) sphericity, percentage MR jet area, mitral valve tenting area, mitral valve coaptation height, papillary muscle (PM) tethering distance, PM depth, and PM angle were measured by echocardiography preoperatively and at mid-term follow up. No preoperative differences were found between groups except in posterior PM depth and PM angle. The posterior PM depth and angle in the MR group were significantly smaller than in the No-MR group. In the No-MR group, the posterior PM tethering distance decreased and the PM angle increased significantly with decreasing LV sphericity. In contrast, in the MR group, posterior PM tethering distance, PM depth, and PM angle were unchanged, and the anterior PM depth and PM angle decreased significantly with decreasing LVEF. FIMR is primarily due to PM displacement, and posterior PM relocation is especially important. Ring annuloplasty does not protect against recurrent FIMR in patients with severe outward displacement of the posterior PM. The severity of posterior PM displacement might be a predictor of ring annuloplasty failure.The Journal of heart valve disease 06/2004; 13(3):390-7; discussion 397-8. · 0.73 Impact Factor
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ABSTRACT: The most appropriate treatment for patients with ischemic mitral regurgitation (IMR) is often debated. We compared the survival rates of patients with IMR undergoing different treatment strategies, namely: medical therapy, percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), and CABG + mitral valve (MV) surgery. Patients undergoing catheterization between 1986 and 2001 were included. IMR was defined as: >or=grade 2+ mitral regurgitation (MR) and significant coronary artery disease (CAD) without primary mitral valve disease. Patients undergoing catheterization for the evaluation of congenital or other valvular heart disease were excluded. Multivariable Cox proportional hazards modeling was utilized to assess the independent relation between treatment and survival. Propensity score methods were used to correct for the nonrandom assignment of treatment. Of the 2,757 patients who met study criteria: 1,305 were treated medically, 537 underwent PCI, 687 underwent CABG, and 228 underwent CABG + MV surgery. The median duration of follow-up was 3.2 (0.9, 7.1) years. Patients undergoing CABG + MV surgery had more severe MR and more severe heart failure than those treated by other modalities. After adjusting for differences in baseline characteristics, patients undergoing PCI, CABG, and CABG + MV surgery had a 31% (hazards ratio [HR]=0.69; P=0.0001), 42% (HR=0.58; P=0.0001), and 42% (HR=0.58; P=0.0001) reduction in the risk of death, respectively, compared with those undergoing medical therapy. The performance of mitral valve surgery with CABG was not associated with improved survival versus CABG alone (P=0.258). Among patients with IMR, treatment with PCI, CABG, or CABG + MV surgery is associated with improved survival compared with medical therapy.Circulation 09/2003; 108 Suppl 1(10):II103-10. DOI:10.1161/01.cir.0000087656.10829.df · 14.95 Impact Factor