Repair or prosthesis insertion in ischemic mitral regurgitation: Two faces of the same medal

Abstract

ObjectiveThe proper treatment of chronic ischemic mitral regurgitation (CIMR) is still under evaluation. The different role of mitral valve repair (MVr) or mitral valve prosthesis insertion (MVPI) is still not defined.MethodsFrom May 2009 to December 2011 167 patients with ejection fraction (EF) ≤ 40% had MV surgery for CIMR, MVr in 135 (80.8%) and MVPI in 32 (19.2%). Indication to MVPI was a MV coaptation depth > 10 mm. EF was lower (26 ± 7 vs 32 ± 6, p = 0.0000) in MVPI, whereas MR grade (3.6 ± 0.8 vs 2.7 ± 0.9, p = 0.0000), left ventricle dimensions (end diastolic, LVEDD, 62 ± 7 vs 57 ± 6 mm, p = 0.0001; end systolic, LVESD, 49 ± 8 vs 44 ± 8 mm, p = 0.0018), systolic pulmonary artery pressure (51 ± 22 vs 41 ± 16 mm Hg, p = 0.0037) and NYHA Class (3.6 ± 0.5 vs 2.8 ± 0.6, p = 0.0000) were higher.ResultsIn-hospital mortality was similar (3.1 vs 3.7%) as well as 3-year survival (86 ± 6 vs 88 ± 4) and survival in NYHA Class I/II (80 ± 5 vs 83 ± 4). One hundred thirty nine patients had an echocardiographic evaluation after a minimum of 4 months (13 ± 8). EF rose significantly in both groups (from 26 ± 7% to 30 ± 4%, p = 0.0122, and from 32 ± 6% to 35 ± 8%, p = 0.0018). LVESD reduced significantly in both groups (from 49 ± 8 to 43 ± 9 mm, p = 0.0109, and from 44 ± 8 to 41 ± 7 mm, p = 0.0033). MR grade was significantly lower in patients who had MVPI (0.1 ± 0.2 vs 0.3 ± 0.3, p = 0.0011).ConclusionsWith appropriate indications, MVPI is a safe procedure which provides similar results to MVr with lower MR return, even if addressed to patients with worse preoperative parameters.

Comparison of transcatheter edge-to-edge and surgical repair in patients with functional mitral regurgitation using a meta-analytic approach

“…The included surgical studies mainly used annuloplasty for MV repair ( 20 – 22 ). Several studies additionally reported chordal cutting ( 23 ), chordal replacement ( 21 ), papillary muscle relocation ( 20 , 24 ) or left ventricular remodeling ( 24 , 25 ). Only one study explicitly reported edge-to-edge repair in combination with annuloplasty ( 26 ).…”

“…It has to be mentioned that MV surgery often comprises different treatment strategies like sternotomy or minimally invasive access, additional subvalvular treatment or ventricular remodeling such as chordal cutting/replacement ( 21 , 23 ), edge-to-edge repair ( 29 ) or papillary muscle approximation ( 20 , 24 ). Moreover, concomitant procedures like coronary artery bypass graft, tricuspid valve repair, Maze procedures or pulmonary vein isolation and left atrial appendage occlusion are frequently performed.…”

“…Likewise, follow-up periods of the reported post-interventional NYHA and MR grades substantially differed between TEER and SMVr, which might affect comparability. NYHA and MR grade reduction were treated as numeric variables because many studies reported mean with standard deviation only, which necessitated a general comparison of means ( 22 , 23 , 40 ). Eventually, the fact that only studies reporting on first and second generation MC devices were included in this investigation limits its value.…”

Comparison of Outcomes of Edge‐to‐Edge Mitral Valve Repair Versus Surgical Mitral Valve Repair for Functional Mitral Regurgitation

“…MV surgery frequently includes several treatment modalities, such as sternotomy or minimally invasive access, further subvalvular therapy, or ventricular remodeling, such as chordal cutting/replacement [ 14 , 15 ], edge‐to‐edge repair [ 16 ], or papillary muscle approximation [ 17 , 18 ]. Additionally, simultaneous treatments like a tricuspid valve repair, coronary artery bypass graft, pulmonary vein isolation, maze procedures or pulmonary vein isolation, or a left atrial appendage occlusion are commonly carried out.…”

Mechanical Complications of Myocardial Infarction

“…Mitral valve repair is generally preferred whenever possible based on valve pathology and patient stability: it avoids longterm anticoagulation, decreases infective endocarditis risk, and provides greater leaflet durability. Among repairs, different techniques are available, but annuloplasty with prosthetic ring is the gold standard [41,42]. On the other hand, valve replacement is usually reserved for situations where the valve cannot be reasonably repaired, or when repair is unlikely to be tolerated clinically.…”