Five-year echocardiographic results of combined undersized mitral ring annuloplasty and coronary artery bypass grafting for chronic ischaemic mitral regurgitation

Abstract

AimsWe present 5-year echocardiographic results of combined undersizing mitral ring annuloplasty (UMRA) and coronary artery bypass grafting (CABG) in chronic ischaemic mitral regurgitation (CIMR). Methods and resultsTwo hundred and fifty-one patients (aged 68.4 + 8.1, 62.5% male) undergoing combined CABG and UMRA in our Institution (Cardiac Surgery, Careggi Hospital, Florence, Italy) between September 2001 and March 2007 were prospectively enrolled in the study. Median follow up was 32.9 months [interquartile range (IQR) 17.5-51.6]. Fourteen patients with significant residual mitral regurgitation (MR) needing immediate intraoperative revision (n ¼ 3) or at discharge (n ¼ 11) were excluded from the study. Serial echocardiograms were performed in 220 survivors at baseline, discharge, and annually thereafter. Additionally, 17 patients died (2 early and 15 late deaths) and were also excluded from the study. MR remained stable at 1 year and re-increased at 3 years (P , 0.001) and 5 years (P , 0.001). Fiveyear actuarial survival was 83.2 + 4.4. Five-year freedom from re-operation for failed repair was 78.2 + 4.9%. Mean systolic and diastolic diameters decreased significantly at discharge (P ¼ 0.001 and P ¼ 0.01, respectively) and at early follow up (P ¼ 0.004 and P ¼ 0.02) but raised at 3 years (P , 0.001) and 5 years (P , 0.001). Systolic and diastolic sphericity indexes improved at discharge (P , 0.001) remained stable at 1 year but they re-increased at 3-year control (P ¼ 0.006 and P ¼ 0.03, respectively) with a late raise exceeding the pre-operative value (P , 0.001). Left ventricular reverse remodelling was observed in 44.2% of the study population with 10.3% of patients showing further left ventricular dilatation. At multivariable model, end-systolic volume 145 mL, systolic sphericity index 0.7, myocardial performance index 0.9, and wall motion score index 1.5 were predictors of recurrent MR. ConclusionOur findings emphasize the need for improved repair technique and better patient selection to identify patients with anticipated repair failure who could benefit more from valve replacement or other procedure directly addressing ventricular tethering.--

Percutaneous Versus Surgical Revascularization in Patients With Ischemic Mitral Regurgitation

“…22 Myocardial viability and LV size are important variables related to ventricular remodeling after revascularization and mitral annuloplasty. 24,25 Because all study patients showed evidence of myocardial ischemia or viability and preoperative LV volumes were smaller than those of previous studies, 23 LV remodeling was attenuated in the present study. These findings that LV volumes did not increase during follow-up and that late postoperative LV volume was maintained significantly lower than preoperative volume might contribute to the lower rate of recurrent MR observed in the present study.…”

“…22,23 Progressive ventricular remodeling in ischemic heart disease can increase tethering and render initial successful repair ineffective. 22 Myocardial viability and LV size are important variables related to ventricular remodeling after revascularization and mitral annuloplasty.…”

Restrictive Mitral Annuloplasty for Functional Mitral Regurgitation - Acute Hemodynamics and Serial Echocardiography -

“…21 In contrast, in recent studies using smaller rings (≤26 mm), the absence of significant recurrent MR has been reported. 23, 24 The present results for the 24-mm Carpentier rings are in line with recent reports.…”

“…15,20, 21 Gelsomino et al observed significant LV reverse remodeling (responders) in 44% of 251 patients who underwent RMA for ischemic MR, and continued or progressive LV remodeling (non-responders) in 56%, including 10% who exceeded their preoperative level after 5 years. 21 Braun et al noted 60.5% of responders and 39.5% of non-responders among 87 consecutive patients with ischemic MR undergoing RMA at 18-month followup. 16 We noted significant reverse remodeling in 58% of the present patients at 5 years after surgery.…”

Therapeutic decision-making for patients with fluctuating mitral regurgitation

“…30,40 Although CABG surgery alone seems to produce long term survival rates similar to those for combined surgery, patients with untreated secondary MR at the time of isolated CABG surgery have an increased risk of hospitalization for heart failure during follow up. 41,42 The main aim of combined surgery is to improve long term functional status and quality of life. 1,2 In the RIME trial, 38 mitral annuloplasty at the time of CABG surgery in patients with moderate ischaemic MR, present either at rest or developed upon physical exertion, was associated with improved functional capac ity, reversal of adverse LV remodelling, reduced severity of MR, and decreased B type natriuretic peptide levels.…”