Does Stringent Restrictive Annuloplasty for Functional Mitral Regurgitation Cause Functional Mitral Stenosis and Pulmonary Hypertension?

Abstract

Background-It remains controversial whether restrictive mitral annuloplasty (RMA) for functional mitral regurgitation (MR) can induce functional mitral stenosis (MS) that may cause postoperative residual pulmonary hypertension (PH). Methods and Results-One hundred eight patients with left ventricular (LV) dysfunction and severe MR underwent RMA with stringent downsizing of the mitral annulus. Systolic pulmonary artery pressure (PAP) and mitral valve performance variables were determined by Doppler echocardiography prospectively and 1 month after RMA. Fifty-eight patients underwent postoperative hemodynamic measurements. Postoperative echocardiography showed a mean pressure half-time of 92Ϯ14 ms, a transmitral mean gradient of 2.9Ϯ1.1 mm Hg, and a mitral valve effective orifice area of 2.4Ϯ0.4 cm

Functional Significance of Elevated Mitral Gradients After Repair for Degenerative Mitral Regurgitation

“…[23][24][25][26] In 123 such patients, Williams et al 24 reported mean diastolic MV gradient >5 mm Hg in 54% and >8 mm Hg in 13% of patients, with only ≈10% of these patients having moderate or severe MR. The term functional MS was introduced in studies of patients who underwent surgical annuloplasty for ischemic MR. [23][24][25][26] Kainuma et al 26 reported the presence of functional MS in 58 patients after surgical annuloplasty for ischemic MR and the mean diastolic mitral gradient was 2.9±1.1 mm Hg in their patients. Magne et al 23 and Kubota et al 25 also reported the ubiquitous presence of functional MS in similar patients, and both studies included a controlled group.…”

Predicting functional mitral stenosis after restrictive annuloplasty for ischemic mitral regurgitation

“…The occurrence of functional mitral stenosis after restrictive MVA has not been well studied despite its relatively high incidence (9-54%) [8,12,14]. Importantly, recent findings show that PPG can independently predict elevated systolic PAP during exercise as well as reduced 6MWT distance [4][5][6][7], which is a powerful predictor of morbidity and mortality in patients with heart failure [5,8]. Thus, elevated resting peak mitral gradients correlate well with functional mitral stenosis and could serve as a good predictor of poor functional capacity [5].…”

“…Recent studies suggest that resting PPG is an independent predictor of increased systolic PAP during exercise, and that a PPG ≥ 13 mmHg is the best predictor of poor performance on the 6-minute walk test (6MWT) distance [4][5][6][7]. What is more, reduced 6MWT distance powerfully predicts morbidity and mortality in patients with heart failure [5,8].…”

A Comparison of 2 Mitral Annuloplasty Rings for Severe Ischemic Mitral Regurgitation: Clinical and Echocardiographic Outcomes

“…6,7 Whether the degree of mitral stenosis created by restrictive mitral annuloplasty limits patients' exercise capacity and compromises the patient outcome remains controversial. 21,22 However, most studies have based stenosis grading on the mean transmitral pressure gradient at rest that largely underestimates the hemodynamic effect of stenosis. 23,24 Exercise Doppler echocardiography may provide a comprehensive evaluation of the consequences of stenosis and of its dynamic nature as for IMR.…”