Functional mitral regurgitation: a 30-year unresolved surgical journey from valve replacement to complex valve repairs

Abstract

Functional mitral regurgitation remains one of the most complex and controversial aspect--for both clinicians and surgeons--in the management of mitral valve disease in the context of left ventricular dysfunction. Given the current absence of clear guidelines, as well as of results from randomized trials comparing the outcome of different surgical strategies potentially available for this complex scenario, surgical decision making for these high-risk patients poses a real dilemma in the daily practice. The resulting surgical choices often represent a questionable combination of surgeons' personal feeling, local supplies, patients' life expectancy and risk/benefit ratios, opinions and statements of the experts, and so on. This review provides an overview of the present knowledge about the complex pathophysiology underlying functional mitral regurgitation, the different pathophysiology-guided surgical techniques suggested in the last decades, as well as the current results following these different surgical techniques.

Cardioband for the treatment of secondary mitral regurgitation: a viable percutaneous option?

“…This is similar to the prevalence reported after surgical MV repair, and is a predictor of increased mortality and cardiac complications (6,7). As with surgical mitral restrictive annuloplasty, the Cardioband reduced the septolateral diameter of the mitral annulus (3.67±0.47 vs. 2.41±0.44 cm, P<0.001), but did not address the coexisting geometric subvalvular distortions.…”

“…Thus, the development of a percutaneous approach targeting both the annular and subvalvular components of the MV apparatus may be preferable, as this has been associated with improved surgical MV repair durability (12). Alternatively, a transacatheter edge-to-edge repair or MV replacement may be performed, although these techniques are also under early clinical investigation for use in secondary MR (6). With this in mind, it begs the question: is there role for minimally invasive valve surgery (MIVS) in this population?…”

Subannular reconstruction in secondary mitral regurgitation: a meta-analysis

“…Type IIIb secondary MR, defined as secondary MR with reduced systolic leaflet motion, is a disease of the left ventricle and results from a complex remodelling process of the whole ‘ventriculo-mitral unit’ 8. The European Society of Cardiology guidelines on the management of valvular heart disease define secondary MR as a sequel of geometrical distortion of the subvalvular mitral apparatus, caused by LV dilatation and remodelling in dilated/ischaemic cardiomyopathy 29.…”

“…The reported reoccurrence rate of MR after standard annuloplasty varies between 15%4 and 30%,2 5 6 up to 60% 7. Until now, there is no consensus regarding how to best address type IIIb secondary MR 8. In the recent update of the American Association of Thoracic Surgery consensus guidelines on ischaemic mitral valve regurgitation, the level of evidence for mitral valve repair in secondary MR has been downgraded from level A to B, basically due to the lack of large prospective randomised trials 9.…”

Echo-Doppler determinants of outcomes in patients with unoperated significant mitral regurgitation in current era

“…Early optimisation of medical therapy for congestive heart failure (CHF) is prudent to improve pulmonary hypertension (PH) and hence outcomes in patients with MR by preventing late LV irreversible remodelling. 12 The role of specific therapy for PH should be evaluated in patients with MR with an elevated transpulmonary gradient. MVR/MVRe is now an alternative treatment for patients with severe symptomatic MR who are not operative candidates.…”