Echo-guided mitral repair.
BACKGROUND
Echocardiography is available in the most basic healthcare environments. Mitral repair is potentially curative and, when possible, recommended over replacement. The efficacy of echo-guided repair has not been established.


RESULTS
We developed a succinct set of precisely defined images observed to be highly concordant with intraoperative findings. These images guided intervention on 237 consecutive patients. None were lost to follow-up, and serial echocardiography was obtained on all repairs. This analysis includes 2037 echocardiograms. The intent to repair or replace was documented preoperatively in 98.7%. Concordance was associated with successful repair (97.8% versus 57.1%; P=0.001). Three-dimensional concordance was higher than 2-dimensional (100% versus 94.4%; P=0.05). Echocardiography guided a graduated surgical approach for degenerative and myopathic repairs by quantifying segmental prolapse, anterior leaflet closing angles, and tenting for integration of secondary chord lysis (P<0.001) and commissural width (P<0.01). Repair rates increased from 46.5% to 77.6% (P<0.001). Concomitant Society of Thoracic Surgeons rates were 46.6% (versus unguided 46.5%; P=0.99) and 54.9% (versus echo guided 77.6%; P<0.001). Repair was successful in 91.5% of isolated echo-guided mitral operations (versus concomitant Society of Thoracic Surgeons 70.0%; P<0.001). Echo-guided repair rates for degenerative, myopathic, and inflammatory diseases were 99.0%, 97.1%, and 84.2% with linearized annual recurrent regurgitation of 0.63%, 2.19%, and 4.37%, respectively.


CONCLUSIONS
Echocardiography can reliably identify repairable mitral disease and guide intervention. Echo-guided repair is associated with a higher rate of initial success than unguided historical and concomitant national controls. Three-dimensional echo improves concordance. Secondary chord lysis is associated with durable repair and may prevent ventricular remodeling.
Departments of Cardiology and Surgery, Munson Medical Center, Traverse City, MI.
Daniel H
DH
Drake
Karen G
KG
Zimmerman
Anne M
AM
Hepner
Cynthia D
CD
Nichols
D000368:Aged; D000704:Analysis of Variance; D016009:Chi-Square Distribution; D019560:Echocardiography, Three-Dimensional; D017548:Echocardiography, Transesophageal; D005260:Female; D006801:Humans; D007090:Image Interpretation, Computer-Assisted; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D058386:Mitral Valve Annuloplasty / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D008944:Mitral Valve Insufficiency / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D011237:Predictive Value of Tests; D012008:Recurrence; D025321:Surgery, Computer-Assisted; D013997:Time Factors; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional
chordal-cutting; echocardiography; mitral valve insufficiency