title: Restrictive mitral annuloplasty cures ischemic mitral regurgitation and heart failure.
abstract: BACKGROUND
  Restrictive mitral annuloplasty with revascularization is considered the best approach to ischemic mitral regurgitation with heart failure, but late results are controversial. We report late outcome in relation to preoperative left ventricular end-diastolic diameter (LVEDD) cutoff values, previously identified to predict intermediate-term left ventricular reverse remodeling.
  
  
  METHODS
  One hundred consecutive ischemic mitral regurgitation patients underwent restrictive mitral annuloplasty (stringent downsizing by two ring sizes; median size, 26) and coronary revascularization. Survivors were clinically and echocardiographically assessed at intermediate (18 months) and late (mean, 46 months) follow-up.
  
  
  RESULTS
  Early mortality was 8%, and late mortality was 18%. Actuarial 1-, 3-, and 5-year survival rates were 87% +/- 3.4%, 80% +/- 4.1%, and 71% +/- 5.1%. Mortality predictors (Cox regression) were preoperative inotropic support (hazard ratio, 6.2; 95% confidence interval, 2.3 to 16.9) and preoperative LVEDD greater than 65 mm (hazard ratio, 4.5; 95% confidence interval, 1.9 to 10.9). Five-year survival rate for patients with LVEDD of 65 mm or less was 80% +/- 5.2%, versus 49% +/- 11% for LVEDD greater than 65 mm (p = 0.002). At 4.3 years' follow-up, New York Heart Association functional class had improved from 2.9 +/- 0.8 to 1.6 +/- 0.6 (p < 0.01). Mitral regurgitation grade was 0.8 +/- 0.7, and was less than grade 2+ in 85% of patients. Left ventricular reverse remodeling was sustained with time for the LVEDD of 65 mm or less group. Late deaths did not show intermediate-term systolic left ventricular reverse remodeling, indicating a more extensive intrinsic left ventricular abnormality.
  
  
  CONCLUSIONS
  At 4.3 years' follow-up, intermediate-term cutoff values for left ventricular reverse remodeling proved to be predictors for late mortality. For patients with preoperative LVEDD of 65 mm or less, restrictive mitral annuloplasty with revascularization provides a cure for ischemic mitral regurgitation and heart failure; however, when LVEDD exceeds 65 mm, outcome is poor and a ventricular approach should be considered.
authors.affiliation: Department of Cardiothoracic Surgery, Leids Universitair Medisch Centrum, Leiden, The Netherlands. j.braun@lumc.nl
authors.forename: Jerry
authors.initials: J
authors.lastname: Braun
authors.forename: Nico R
authors.initials: NR
authors.lastname: van de Veire
authors.forename: Robert J M
authors.initials: RJ
authors.lastname: Klautz
authors.forename: Michel I M
authors.initials: MI
authors.lastname: Versteegh
authors.forename: Eduard R
authors.initials: ER
authors.lastname: Holman
authors.forename: Jos J M
authors.initials: JJ
authors.lastname: Westenberg
authors.forename: Eric
authors.initials: E
authors.lastname: Boersma
authors.forename: Ernst E
authors.initials: EE
authors.lastname: van der Wall
authors.forename: Jeroen J
authors.initials: JJ
authors.lastname: Bax
authors.forename: Robert A E
authors.initials: RA
authors.lastname: Dion
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000379:methods; D006348:Cardiac Surgical Procedures / Q000379:methods* / Q000401:mortality; D015331:Cohort Studies; D016001:Confidence Intervals; D015150:Echocardiography, Doppler; D017548:Echocardiography, Transesophageal; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy; D006801:Humans; D008297:Male; D008875:Middle Aged; D008944:Mitral Valve Insufficiency / Q000000981:diagnostic imaging / Q000401:mortality* / Q000601:surgery*; D016343:Monitoring, Intraoperative / Q000379:methods; D017202:Myocardial Ischemia / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D009204:Myocardial Revascularization / Q000379:methods; D011183:Postoperative Complications / Q000175:diagnosis / Q000453:epidemiology; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D016019:Survival Analysis; D016896:Treatment Outcome; D020257:Ventricular Remodeling