title: Undersized annuloplasty for functional mitral regurgitation: is it responsible for clinically relevant mitral stenosis during exercise?
abstract: OBJECTIVE
  The study aim was to assess if an undersized mitral annuloplasty for functional mitral regurgitation (FMR) in dilated cardiomyopathy can determine a clinically relevant mitral stenosis during exercise.
  
  
  METHODS
  Both, rest and stress echocardiography were performed in 12 patients submitted to an undersized ring annuloplasty for FMR in dilated cardiomyopathy. The mean ring size was 27 +/- 1.3 mm. All patients were in NYHA functional classes I-II, were in stable sinus rhythm, and without significant residual mitral regurgitation (grade < or = 2/4).
  
  
  RESULTS
  At peak exercise (mean 81 +/- 12 W), the main cardiac performance indices were significantly improved, including systolic blood pressure (121 +/- 5.6 versus 169 +/- 14 mmHg, p < 0.001), stroke volume (63 +/- 15 versus 77 +/- 14 ml, p < 0.001), left ventricular ejection fraction (43 +/- 9% versus 47 +/- 9%, p = 0.001), and systolic right ventricular function (pulsed tissue Doppler index peak systolic velocity: 8.6 +/- 1.7 versus 11.1 +/- 3.2 cm/s, p = 0.004). A mild increase in planimetric mitral valve area was observed at peak exercise (2.12 +/- 0.4 versus 2.17 +/- 0.3 cm2, p = 0.05). Although the transmitral mean gradient was increased from 3.2 +/- 1.2 to 6.3 +/- 2.3 mmHg (p < 0.0001), the systolic pulmonary artery pressure did not change significantly (27 +/- 2.8 versus 30.1 +/- 6.4 mmHg, p = 0.3), thus revealing a preserved cardiac adaptation to exercise.
  
  
  CONCLUSIONS
  In these preliminary data, postoperative clinically relevant mitral stenosis was not observed in patients submitted to mitral repair for FMR. Stress echocardiography represents a valuable tool to assess an appropriate cardiac response to exercise and to detect a significant exercise-induced pulmonary hypertension after undersized annuloplasty ring surgery.
authors.affiliation: Cardiovascular and Thoracic Surgery Department, San Raffaele Scientific Institute, Milan, Italy. antonio.grimaldi@hsr.it
authors.forename: Antonio
authors.initials: A
authors.lastname: Grimaldi
authors.forename: Michele
authors.initials: M
authors.lastname: De Bonis
authors.forename: Federico
authors.initials: F
authors.lastname: Pappalardo
authors.forename: Maurizio
authors.initials: M
authors.lastname: Taramasso
authors.forename: Alessandro
authors.initials: A
authors.lastname: Verzini
authors.forename: Maria Chiara
authors.initials: MC
authors.lastname: Calabrese
authors.forename: Francesco
authors.initials: F
authors.lastname: Maisano
authors.forename: Ottavio
authors.initials: O
authors.lastname: Alfieri
mesh_terms: D000368:Aged; D001794:Blood Pressure / Q000502:physiology; D025401:Echocardiography, Stress; D015444:Exercise / Q000502:physiology*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006976:Hypertension, Pulmonary / Q000000981:diagnostic imaging / Q000209:etiology / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D058386:Mitral Valve Annuloplasty / Q000379:methods*; D008944:Mitral Valve Insufficiency / Q000601:surgery*; D008946:Mitral Valve Stenosis / Q000000981:diagnostic imaging / Q000209:etiology* / Q000503:physiopathology; D009929:Organ Size; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000209:etiology* / Q000503:physiopathology; D011475:Prosthesis Failure; D013318:Stroke Volume / Q000502:physiology