Flexible Versus Nonflexible Mitral Valve Rings for Congestive Heart Failure

Abstract

Background-Surgical intervention is playing an increasingly important therapeutic role in congestive heart failure (CHF) patients with ischemia and dilated cardiomyopathy. Their mitral regurgitation (MR) is a result of left ventricular (LV) geometrical distortion. The optimal type of ring for CHF patients with geometric ventricular-based MR is unknown. This study reviewed the results of flexible versus nonflexible complete mitral valve rings in CHF patients with geometric mitral regurgitation. Methods and Results-Using a prospectively maintained database, patients undergoing mitral valve reconstruction (MVR) with either a flexible or nonflexible complete ring were identified on the basis of preoperative ejection fraction (EF) Յ30% and no primary mitral pathology. These 2 groups of CHF patients with severe geometric MR were then compared in terms of recurrent MR requiring reoperation. Between 1992 and 2004, 289 patients with EF Յ30%, received an undersized complete mitral annuloplasty ring as their MVR procedure. Of these, 170 patients had a flexible complete ring. In follow-up, 16 "flexible" patients (9.4%) required a repeat procedure for significant recurrent geometric MR and CHF (10 replacements, 3 re-repairs, 3 transplants). The average time to reoperation was 2.4 years. In contrast, 119 patients with an EF Յ30% received a MVR using an undersized nonflexible complete ring. Only 3 "non-flexible" patients required a repeat operation, MVR (1), and 2 patients required a transplant. The time to reoperation was 4.0 years. A significant difference in reoperation rates, for recurrent MR, between the 2 groups (Pϭ0.012). There were no differences between groups, in terms of age, ring size used, preoperative EF, LV size, MR grade, or New York Heart Association class. Conclusions-Patients

Evolving Concepts and Technologies in Mitral Valve Repair

“…68 These results have also been observed in patients with undersized, rigid, complete remodeling rings. 58 Studies using finite-element model analysis also support the concept of cause-specific annuloplasty rings. 66 …”

“…60 Recurrent MR after initially successful mitral annuloplasty led to important observations. 56,57 First, flexible annuloplasty bands can become distorted over time 58 ; second, the intertrigone distance is not fixed 23,[61][62][63] ; and third, based on studies by Miller and colleagues at Stanford, the septal-lateral dimension must be reduced and fixed at a length that leads to effective leaflet coaptation and maintains valve competence in patients with cardiomyopathy. 23,64,65 Based on these recent clinical and experimental observations, 2 innovative annuloplasty rings were specifically designed to address the unique needs of patients with functional MR, both ischemic and nonischemic forms.…”

Surgical approaches to treatment of ischemic mitral regurgitation (literature review)

“…Гибкие кольца создают физиологическую площадь и форму митрального отверстия, которое изме-няется во время сердечного цикла, а ригидные или полу-ригидные кольца обеспечивают лучшую поддержку зад-ней части ФК, что чрезвычайно важно при постинфаркт-ном ремоделировании задней стенки ЛЖ, и имеют доста-точно низкую частоту рецидива ишемической МР (M. Spoor и соавт. [14], S. Silbermanи соавт. [15]).…”

Surgical management of functional mitral regurgitation in heart failure patients

“…An annuloplasty ring is implanted that is at least two sizes smaller than the ring that would have been chosen on the basis of measuring the intertrigonal distance and the surface of the anterior leaflet as a reference [13]. With regard to the annuloplasty ring used for the treatment of functional MR, Spoor et al and Silbermann et al were able to show that complete and rigid annuloplasty rings ensure better outcomes than partial and flexible rings [14,15]. Further surgical techniques for repair of functional MR include anterior leaflet augmentation with a pericardial patch when the anterior leaflet length is less than 25 mm, in order to increase the coaptation area [16,17], or the addition of the edge-to-edge technique to the annuloplasty [18].…”