Predicting left ventricular dysfunction after valve repair for mitral regurgitation due to leaflet prolapse: additive value of left ventricular end-systolic dimension to ejection fraction

Abstract

Simple preoperative echocardiography measures allow the prediction of LV dysfunction after MVR in patients with leaflet prolapse. Patients with preoperative EF ≥ 64% and LVESD < 37 mm incur relatively low risk of post-operative LV dysfunction.

Clinical and Prognostic Impact of a New Left Ventricular Ejection Index in Primary Mitral Regurgitation Because of Mitral Valve Prolapse

“…This may suggest that LV ejection index could be a good complementary parameter to LV ejection fraction for the risk stratification and the management of patients with primary MR. Although LV ejection fraction is a powerful determinant of poor prognosis 16 and an accurate marker of LV systolic dysfunction, 6 it often underestimates the degree of dysfunction in volume overload disease such as MR. Indeed, in patients with significant MR, LV ejection fraction if often normal or mildly reduced despite marked alteration of LV myocardial function, as suggested by recent series using speckle-tracking analysis.…”

The Myocardium in Mitral Regurgitation

“…By the time EF is reduced to 60% or even 64%, prognosis worsens, presumably because myocardial damage causing reduced contractility has ensued. 5,6 The present study by Le Tourneau et al 15 adds to our knowledge of the pathophysiology of MR in several ways. First, it confirms and emphasizes previous observations that right ventricular (RV) dysfunction plays a direct role in MR prognosis.…”

“…[2][3][4] Such depression is initially reversible 3,4 but becomes irreversible at some point in the natural history of the disease, as evidenced by the poor prognosis of depressed EF that implies extensive myocardial damage. 5,6 Contractile dysfunction in MR accrues from the loss of myocyte contractile elements and from abnormal calcium handling that alters myocardial excitation-contraction. [7][8][9] In the early stages of disease, contractile dysfunction is reversible, preferably by mitral valve repair but also in part by β-adrenergic receptor blockade.…”

Long-Term Mortality Associated With Left Ventricular Dysfunction in Mitral Regurgitation Due to Flail Leaflets

“…17 Most available evidence regards the association of decreased preoperative EF with increased postoperative occurrence of LV dysfunction, heart failure, and death. 1,4,6,7,16,18 Accordingly, despite physiological reluctance to use EF in the context of MR, it has been clinically recognized as providing value in clinical decision making 19 and reduced (≤60%) EF is currently a class I indication for considering mitral surgery. 2,3 In contrast to apparently coherent guidelines, recent registry data show that too often patients with severe MR and overt LV dysfunction based on low EF are still not referred to surgery and are exposed to unacceptably high risk of death with medical management.…”

“…These doubts are supported by the fact that EF often decreases markedly after mitral valve surgery in contrast to frequent increase after aortic valve surgery. 1,4,6,7 Other reasons to doubt these thresholds in the current era are the facts that mitral valve repair tends to result in improved postoperative LV function, that there is increased use of valve repair (despite center to center variation), and that in this context, late improvement in LV function postrepair has been recently reported. 6 These combined sources of uncertainty have left doubts on whether EF is at all an appropriate current marker of LV dysfunction and outcome, whether EF <30% is the appropriate level for severe LV dysfunction, and whether EF ≤60% should continue to be used as a marker of mild/moderate LV dysfunction.…”