Mitral valve procedures in ischemic regurgitation.
A restrictive definition of ischemic mitral regurgitation (IMR) has allowed us to select a more uniform cohort of 41 patients having undergone mitral valve surgery for IMR between January 1993 and March 1995. Thirty-six patients (88%) presented with chronic and five with acute IMR. All patients had at least one significant stenosis in the circumflex area. Left ventricular ejection fraction averaged 35%. Transesophageal echocardiography (TEE) revealed a > or = 3+ MR in 30 patients and an intermittent, fluctuating or grade 2+ MR in 11 (27%). Annulus dilatation was found in all cases, and it was the only mechanism in 10 (24.4%). Leaflet restrictive motion was clearly seen in 17 cases (41.5%) and leaflet prolapse in 14 (34%). In doubtful cases, an intra-operative dynamic testing using TEE, and associating a loading test and an afterload test, led to the indication of a valve procedure in 11/19 patients (58%). An average of three distal coronary anastomoses per patient were constructed. Mitral valve replacement (MVR) was unavoidable in four patients (9.8%); at least the posterior leaflet subvalvular apparatus was preserved in all. Repair of the mitral valve (Mvrep) was achieved in 37 cases (90%). Ring annuloplasty alone was performed in 27 cases (73%). In the remaining 10 cases, leaflet prolapse was corrected by various artifices such as flip-over technique, quadrangular resection, papillary muscle plication or commissuroplasty. At the 10th postoperative day, a residual MR was found in 4/34 cases (11.8%), only after isolated ring annuloplasty. The four patients who have died in the ICU after MVrep belonged to the same group of isolated ring annuloplasty; this mortality of 4/27 (14.8%) illustrates the mediocre prognosis of marked annulus dilatation and impaired LV function with restrictive leaflet motion. Overall, the hospital mortality (14.6%) more reflected the mode of presentation of the patients than the type of operative technique: when a short and definitive procedure is required by a precarious general condition, one should not hesitate to prefer a rapid MVR to a complicated repair. At 4.5 months, there was no significant improvement in LV dimensions. At six months, 80.5% of the patients survived, with 88% of them being in NYHA class I or II.
Dion
R
R
Department of Cardiovascular and Thoracic Surgery, University Clinic St. Luc, Brussels, Belgium.
Benetis
R
R
Elias
B
B
Guennaoui
T
T
Raphael
D
D
Van Dyck
M
M
Noirhomme
P
P
Van Overschelde
J L
JL
D000328:Adult; D000368:Aged; D005260:Female; D005500:Follow-Up Studies; D006350:Heart Valve Prosthesis; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000601:surgery*; D008944:Mitral Valve Insufficiency / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D017202:Myocardial Ischemia / Q000150:complications* / Q000601:surgery