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Journal ArticleDOI

Mitral repair for functional mitral regurgitation in idiopathic dilated cardiomyopathy: a good operation done well may help.

01 Oct 2012-European Journal of Cardio-Thoracic Surgery (Oxford University Press)-Vol. 42, Iss: 4, pp 646-647

TL;DR: This issue described a very interesting retrospective series of 54 patients with idiopathic dilated cardiomyopathy who underwent mitral valve repair for severe functional mitral regurgitation, and found that the strongest predictor of a recurrent MR, following mitral repair was a residual large AP diameter.

AbstractIn this issue, De Bonis et al. [1] described a very interesting retrospective series of 54 patients with idiopathic dilated cardiomyopathy who underwent mitral valve repair for severe functional mitral regurgitation. No patients had coronary artery disease. These patients, very typically, had severe mitral regurgitation, class III–IV New York Heart Association failure with large ventricles, poor ejection fractions, and many had atrial fibrillation and tricuspid regurgitation. In this series, as has been shown by others, the patients underwent correction of their mitral regurgitation with low in-hospital mortality (5%). The actuarial survival at 6.5 years was 70%. The survival was further improved if the patients had either atrial fibrillation ablation or cardiac resynchronization therapy. In follow-up, patients showed improvement in their left ventricular geometry, ejection fraction and in NYHA class. Most importantly, in this series, the freedom from recurrence of significant mitral regurgitation was 90% at 6.5 years. Functional mitral regurgitation is a complication of idiopathic dilated cardiomyopathy, occurring secondary to left ventricle geometrical distortion from stenting, inferobasilar migration, apical displacement, annular dilation and posterior leaflet restriction, with altered ventricular shape and/or regional LV wall dysfunction. Mitral regurgitation (MR) leads to a vicious cycle of LV volume overload, geometric distortion and progressive MR. MR complicating congestive heart failure (CHF) predicts poor survival [2]. Mitral reconstruction surgery to treat MR in dilated cardiomyopathy has been undertaken with an acceptably low operative mortality [3, 4]. However, MR surgery for these patients remains controversial, as substantial residual or recurrent MR has been noted, and may mitigate any benefits. In fact, some series show an early (6 months) recurrence rate of significant MR of up to 50%, which certainly negatively influences or obscures potential survival advantage [5, 6]. When reviewing literature series of both surgical and percutaneous outcome studies on patients with MR in dilated idiopathic cardiomyopathy, one should be critically aware of the negative impact, mechanism and rates of recurrent MR. At present, many of the mechanisms of recurrent functional MR have been elucidated and include annular level and subvalvular components. Predictors of recurrent MR have included LV size >65 mm, a coaptation depth of >1 cm below the annular plane and angulation of the mitral valve apparatus, all of which indicate a degree of LV distortion [6]. We have also learned that the intertrigonal distance is not stable, with dilatation occurring along both the insertion of the posterior leaflet, but also in the anterior portion. This intertrigonal portion dilates and, although at one time, was considered to be a stable ‘measurable’ standard by which to size annuloplasty rings, we now know from a landmark paper of Hueb et al. [7] that this is not the case. Therefore, our previous method of sizing was incorrect and ‘undersizing’ rings has become the standard for these functional MR patients. This may partly explain the operation ‘failing’ and recurrence of mitral regurgitation in functional MR patients when using too large ‘standard-sized’ rings or when using a partial or flexible rings. Perhaps, the most important mechanistic predictor of recurrent mitral regurgitation is an increased anterior–posterior or septal– lateral mitral annular diameter. This CHF-related change has been shown not only in animal models, but also in humans. Three-dimensional magnetic resonance imaging and echo studies showed that the mitral annulus flattens and significantly increases its anterior-posterior (AP) diameter. Kongsaerepong et al. [8] found that the strongest predictor of a recurrent MR, following mitral repair, was a residual large AP diameter, i.e. a ‘too large’ ring size. Finally, Spoor et al. [9] demonstrated that the use of flexible rings (which flex and allow the largest AP diameter) as opposed to a rigid complete ring was associated with a five times higher recurrent mitral regurgitation rate. At present, numerous rigid, complete rings with stable AP dimension reduction are available [10]. In this present series, all patients were uniformly treated with an undersized rigid complete ring. The authors noted an extremely low long-term rate of recurrent MR, with excellent LV remodelling and survival. The use of a rigid complete ring has been adopted for these functional MR patients by a majority of surgeons and is becoming our best practice standard. Of course, many factors in these difficult patients determine the long-term outcome including patient comorbidities, some of which (atrial fibrillation, tricuspid regurgitation, cardiac resynchronization therapy) have been shown by these authors to be beneficial when corrected. In dealing with functional MR in idiopathic cardiomyopathy, it has been noted that a good operation when done poorly will not help; however, the manuscript by De Bonis et al. reveals that a good operation done well will help these functional MR patients.

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Journal ArticleDOI
TL;DR: Three-dimensional transthoracic echocardiographic data sets acquired with current scanners have enough spatial and temporal resolution to allow the quantitative analysis of the mitral annulus, and quantitative analysis by 3D TTE in unselected patients with mitral valve disease was accurate and reproducible in healthy subjects.
Abstract: Background Quantitative assessment of the mitral annulus provides information regarding the pathophysiology of mitral regurgitation and aids in the planning of reparative surgery. Three-dimensional (3D) transthoracic echocardiographic data sets acquired with current scanners have enough spatial and temporal resolution to allow the quantitative analysis of the mitral annulus. Accordingly, the authors performed (1) a validation study to assess the agreement of quantitative analysis of the mitral annulus performed on 3D transthoracic echocardiography (TTE) and 3D transesophageal echocardiography (TEE) and (2) a normative study to obtain the reference values of 3D transthoracic echocardiographic parameters for mitral annular (MA) geometry and dynamics. Methods Mitral valve data sets were obtained by 3D TEE and 3D TTE in 30 consecutive patients with clinically indicated TEE (validation study) and 3D TTE in 224 healthy volunteers (aged 18–76 years) (normative study). Results In the validation study, MA measurements obtained by 3D TTE were similar to those obtained by 3D TEE ( P = NS). In the normative study, MA analysis by 3D TTE was feasible (94.5%) and reproducible (intraclass correlation coefficient = 0.78–0.97). MA diameters, area, and circumference were correlated with body surface area ( r > 0.50 for all) but not with age. Men had larger MA areas than women (4.9 ± 1.0 vs 4.5 ± 0.7 cm 2 /m 2 , P = .004). During systole, MA area decreased by 29 ± 5%. This decrease was related mainly to anteroposterior diameter shortening (20 ± 7%). Conclusions MA quantitative analysis by 3D TTE was accurate compared with 3D TEE in unselected patients with mitral valve disease. In healthy subjects, it was highly feasible and reproducible. The availability of reference values for MA geometry and dynamics may foster the implementation of MA quantitative analysis by 3D TTE in clinical settings.

52 citations


Journal ArticleDOI
TL;DR: A ground-truth data-set is generated by quantifying the effects of isolated mitral annular flattening, asymmetric annular dilatation, symmetric papillary muscle (PM) displacement and asymmetric PM displacement on leaflet coaptation, mitral regurgitation (MR) and anterior leaflet strain to improve MV computational models and provide a platform for the development of future surgical planning tools.
Abstract: Computational models for the heart's mitral valve (MV) exhibit several uncertainties that may be reduced by further developing these models using ground-truth data-sets. This study generated a ground-truth data-set by quantifying the effects of isolated mitral annular flattening, symmetric annular dilatation, symmetric papillary muscle (PM) displacement and asymmetric PM displacement on leaflet coaptation, mitral regurgitation (MR) and anterior leaflet strain. MVs were mounted in an in vitro left heart simulator and tested under pulsatile haemodynamics. Mitral leaflet coaptation length, coaptation depth, tenting area, MR volume, MR jet direction and anterior leaflet strain in the radial and circumferential directions were successfully quantified at increasing levels of geometric distortion. From these data, increase in the levels of isolated PM displacement resulted in the greatest mean change in coaptation depth (70% increase), tenting area (150% increase) and radial leaflet strain (37% increase) while a...

10 citations


Journal ArticleDOI
TL;DR: Patients with DCM and FMR have MA geometry remodeling and contractile dysfunction, correlated with the severity of FMR, and these results provide new insights that might help with better selection of patients for MV transcatheter procedures.
Abstract: Introduction and Objectives. Patients with dilated cardiomyopathy (DCM) and functional mitral regurgitation (FMR) present altered geometry and dynamics of the mitral annulus (MA). We aimed to further assess the relationship between the MA dysfunction, FMR severity, and LA dysfunction in patients with ischemic and nonischemic DCM by using three-dimensional transthoracic echocardiography (3DTTE). Methods. 56 patients (58 ± 17 years, 42 men) with DCM and FMR and 52 controls, prospectively enrolled, underwent 3DTTE dedicated for mitral valve (MV), LA, and left ventricle (LV) quantitative analysis. Results. Patients with FMR vs. controls presented increased MA size and sphericity during the entire systole, whereas MA fractional area change (MAFAC) and MA displacement were decreased (15 ± 5 vs. 28 ± 5%; and 5 ± 3 vs. 10 ± 2 mm, ). In patients with moderate/severe FMR, MA diameters correlated with PISA radius, EROA, and regurgitant volume (Rvol), as also did the MA area (with PISA radius, EROA, and Rvol: r = 0.48, r = 0.58, and r = 0.47, ). MAFAC correlated inversely with EROA and Rvol (r = −0.32 and r = −0.35, ), with both active and total LA emptying fractions and with LV ejection fraction as well. In a stepwise multivariate regression model, decreased MAFAC and increased LA volume independently predicted patients with severe FMR. Conclusions. Patients with DCM and FMR have MA geometry remodeling and contractile dysfunction, correlated with the severity of FMR. MA contractile dysfunction correlated with both LA and left LV pumps dysfunctions and predicted patients with severe FMR. Our results provide new insights that might help with better selection of patients for MV transcatheter procedures.

3 citations


Journal ArticleDOI
TL;DR: A review of the increasing evidence with the Mitraclip device reported to date and how it mimics the surgical edge-to-edge leaflet repair technique, reducing the regurgitant area is reviewed.
Abstract: Mitral regurgitation is an increasing valvular disease that represents a difficult management challenge. Surgical treatment for degenerative mitral regurgitation is the standard of care treatment. Percutaneous therapies have emerged rapidly over the past years as an option for treatment of mitral regurgitation for selected, predominantly high-risk patients. Catheter-based devices mimic these surgical approaches with less procedural risk. Mitraclip® implantation mimics the surgical edge-to-edge leaflet repair technique, reducing the regurgitant area. We review the increasing evidence with the Mitraclip device reported to date.

1 citations


References
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Journal ArticleDOI
TL;DR: There is no clearly demonstrable mortality benefit conferred by MVA for significant MR with severe LV dysfunction, and a prospective randomized control trial is warranted for further study of mortality with MVA in this population.
Abstract: Objectives: This study was designed to assess effects of mitral valve annuloplasty (MVA) on mortality in patients with mitral regurgitation (MR) and left ventricular (LV) systolic dysfunction.Backg...

604 citations


Journal ArticleDOI
TL;DR: Although initial mitral valve replacement would eliminate the risk of postoperative mitral regurgitation, this strategy has been associated with reduced survival, and the development of additional techniques is necessary to achieve more secure repair of functional ischemic mitral Regurgitation.
Abstract: Objectives We sought to characterize the temporal return of mitral regurgitation after annuloplasty for functional ischemic mitral regurgitation; to identify its predictors, particularly with respect to annuloplasty type; and to determine whether annuloplasty type influences survival. Methods From April 1985 through November 2002, 585 patients underwent annuloplasty alone for repair of functional ischemic mitral regurgitation, generally with concomitant coronary revascularization (95%). A flexible band (Cosgrove) was used in 68%, a rigid ring (Carpentier) in 21%, and bovine pericardial annuloplasty (Peri-Guard) in 11%. Six hundred seventy-eight postoperative echocardiograms were available in 422 patients to assess the time course of postoperative mitral regurgitation and its correlates. Most echocardiograms were performed early after the operation (median, 8 days); 17% were performed at 1 year or beyond. Results During the first 6 months after repair, the proportion of patients with 0 or 1+ mitral regurgitation decreased from 71% to 41%, whereas the proportion with 3+ or 4+ regurgitation increased from 13% to 28% ( P P = .2), although Cosgrove bands were used in most patients receiving 26- and 28-mm annuloplasties. Freedom from reoperation was 97% at 5 years. Annuloplasty type was not associated with survival. Conclusions Although initial mitral valve replacement would eliminate the risk of postoperative mitral regurgitation, this strategy has been associated with reduced survival. Therefore the development of additional techniques is necessary to achieve more secure repair of functional ischemic mitral regurgitation.

576 citations


Journal ArticleDOI
TL;DR: Recurrent MR late after ring annuloplasty is associated with continued LV remodeling, emphasizing its dynamic relation to the LV.
Abstract: Background— Patients who undergo ring annuloplasty for ischemic mitral regurgitation (MR) often have persistent or recurrent MR. This may relate to persistent leaflet tethering from left ventricle (LV) dilatation that is not relieved by ring annuloplasty. Therefore, the purpose of this study was to test the hypothesis that recurrent MR in patients after ring annuloplasty relates to continued LV remodeling. Methods and Results— Serial echoes were reviewed in 30 patients (aged 72±11 years) who showed recurrent MR late (47±27 months) versus early (3.8±5.8 months) after ring annuloplasty for ischemic MR during coronary artery bypass grafting without interval infarction. Patients with intrinsic mitral valve disease were excluded. Echocardiographic measures of MR (vena contracta and jet area/left atrial area) and LV remodeling (LV dimensions, volumes, and sphericity) were assessed at each stage. The degree of MR increased from mild to moderate, on average, from early to late postoperative stages, without significant change in LV ejection fraction. Changes in MR paralleled increases in LV volumes and sphericity index at end-systole and end-diastole. The only independent predictor of late postoperative MR was LV sphericity index at end-systole. Conclusions— Recurrent MR late after ring annuloplasty is associated with continued LV remodeling, emphasizing its dynamic relation to the LV.

424 citations


Journal ArticleDOI
TL;DR: For patients with cardiomyopathy and severe mitral regurgitation, mitral valve reconstruction as opposed to replacement can be accomplished with low operative and early mortality, yielding improvement in symptomatic status and survival.
Abstract: Uncontrollable severe mitral regurgitation is a frequent complication of end-stage cardiomyopathy, significantly contributing to heart failure in these patients, and predicts a poor survival. Although elimination of mitral valve regurgitation could be most beneficial in this group, corrective mitral valve surgery has not been routinely undertaken in these very ill patients because of the presumed prohibitive operative mortality. We studied the early outcome of mitral valve reconstruction in 16 consecutive patients with cardiomyopathy and severe, refractory mitral regurgitation operated on between June 1993 and April 1994. There were 11 men and five women, aged 44 to 78 years (64 ± 8 years) with left ventricular ejection fractions of 9% to 25% (16% ± 5%). Preoperatively all patients were in New York Heart Association class IV, had severe mitral regurgitation (graded 0 to 4+ according to color flow Doppler transesophageal echocardiography) and two were listed for transplantation. Operatively, a flexible annuloplasty ring was implanted in all patients. Four patients also had single coronary bypass grafting for incidental coronary disease. In four patients the operation was performed through a right thoracotomy because of prior coronary bypass grafting, and four patients also underwent tricuspid valve reconstruction for severe tricuspid regurgitation. No patient required support with an intraaortic balloon pump. There were no operative or hospital deaths and mean hospital stay was 10 days. There were three late deaths at 2, 6, and 7 months after mitral valve reconstruction, and the 1-year actuarial survival has been 75%. At a mean follow-up of 8 months, all remaining patients are in New York Heart Association class I or II, with a mean postoperative ejection fraction of 25% ± 10%. There have been no hospitalizations for congestive heart failure, and a decrease in medications required has been noted. For patients with cardiomyopathy and severe mitral regurgitation, mitral valve reconstruction as opposed to replacement can be accomplished with low operative and early mortality. Although longer term follow-up is mandatory, mitral valve reconstruction may allow new strategies for patients with end-stage cardiomyopathy and severe mitral regurgitation, yielding improvement in symptomatic status and survival. (J T HORAC C ARDIOVASC S URG 1995;109:676-83)

398 citations


Journal ArticleDOI
Abstract: Mitral regurgitation frequently complicates dilated cardiomyopathy, aggravates volume overload of the left ventricle, and contributes to symptoms of congestive heart failure. This study was performed to assess the impact of mitral valve reconstruction in nine consecutive patients with severe mitral regurgitation resulting from end-stage dilated cardiomyopathy. Clinical and echocardiographic follow-up were obtained 17 ± 5 and 16 ± 6 weeks after surgery, respectively. There were no operative or early deaths. All patients noted symptomatic improvement postoperatively, and there was a decrease of at least one New York Heart Association functional class (3.9 ± 0.3 to 1.7 ± 0.5, p < 0.001). Quantitative echocardiography/Doppler demonstrated a small but significant decrease in left ventricular end-diastolic volume (317 ± 111 ml to 291 ± 105 ml, p = 0.04) and increases in ejection fraction (18 ± 5% to 24 ± 9%, p = 0.02) and forward cardiac output (3.1 ± 1.0 to 4.6 ± 0.8 Umin, p < 0.01) on follow-up. Mitral valve reconstruction for the correction of mitral regurgitation in patients with end-stage dilated cardiomyopathy results in improved symptomatic status on early follow-up accompanied by evidence of improvement in left ventricular performance. (Ann HEART J 1995;129:1165-70.)

199 citations