title: Management of mitral regurgitation during left ventricular reconstruction for ischemic heart failure.
abstract: OBJECTIVE
  Remodeling of the left ventricle (LV) in ischemic cardiomyopathy frequently leads to functional mitral regurgitation (MR). The indication for correcting MR in patients undergoing LV reconstruction (LVR) is unclear. In this study, we evaluated our strategy of correcting MR≥grade 2+ by restrictive mitral annuloplasty (RMA) during LVR.
  
  
  METHODS
  We studied 92 consecutive patients (76 men, mean age 61±10 years) who underwent LVR for ischemic heart failure (IHF). RMA was performed in all patients with MR≥grade 2+ on preoperative echocardiography and in patients who showed increased MR to ≥grade 2+ immediately after LVR. Patients were attributed to a RMA and no-RMA group, depending on whether or not concomitant RMA had been performed. Mean clinical and structured echocardiographic follow-up was 47±20 months and was 100% complete.
  
  
  RESULTS
  In 38 out of 40 patients (95%) with preoperative MR≥grade 2+, concomitant RMA was planned and performed. In 17 out of 52 patients (33%) with MR<grade 2+ preoperatively, MR increased after LVR to ≥grade 2+ leading to additional RMA during a second period of aortic cross-clamping. Early mortality in the RMA group (n=55) was 12.7% and survival at 36 months 78.2±11.2%. Early mortality in the no-RMA group (n=37) was 5.4% and survival at 36 months 81.1±12.8%. Patients in the RMA group had significantly more reduced LV function with greater LV dimensions and volumes preoperatively. Echocardiography demonstrated sustained improvement in LVEF with reduction of LV volumes in both patient groups. Recurrence of MR at late follow-up was observed in 2 patients (1 patient per group).
  
  
  CONCLUSIONS
  Patients with IHF eligible for LV reconstruction have MR≥grade 2+ in 44% of cases. In one-third of IHF patients with MR<grade 2+ preoperatively, MR increases to ≥grade 2+ after LVR. Concomitant mitral valve repair for MR≥grade 2+, on either preoperative echocardiography or immediately after LVR, results in favorable late clinical and echocardiographic outcome that proved to be similar to patients without concomitant mitral valve repair, despite more advanced disease.
authors.affiliation: Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands. p.klein@lumc.nl
authors.forename: Patrick
authors.initials: P
authors.lastname: Klein
authors.forename: Jerry
authors.initials: J
authors.lastname: Braun
authors.forename: Eduard R
authors.initials: ER
authors.lastname: Holman
authors.forename: Michel I M
authors.initials: MI
authors.lastname: Versteegh
authors.forename: Harriette F
authors.initials: HF
authors.lastname: Verwey
authors.forename: Robert A E
authors.initials: RA
authors.lastname: Dion
authors.forename: Jeroen J
authors.initials: JJ
authors.lastname: Bax
authors.forename: Robert J M
authors.initials: RJ
authors.lastname: Klautz
mesh_terms: D000368:Aged; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D006352:Heart Ventricles / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D058386:Mitral Valve Annuloplasty / Q000379:methods; D008944:Mitral Valve Insufficiency / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D012720:Severity of Illness Index; D016019:Survival Analysis; D016896:Treatment Outcome; D014463:Ultrasonography; D020257:Ventricular Remodeling / Q000502:physiology