Restrictive mitral valve annuloplasty versus mitral valve replacement for functional ischemic mitral regurgitation: An exercise echocardiographic study

Abstract

In patients with functional ischemic mitral regurgitation, mitral valve annuloplasty may cause functional mitral stenosis, especially during exercise. Mitral valve annuloplasty was associated with poor exercise mitral hemodynamic performance, lack of mitral valve opening reserve, and markedly elevated postoperative exercise systolic pulmonary arterial pressure compared with mitral valve replacement.

Predicting functional mitral stenosis after restrictive annuloplasty for ischemic mitral regurgitation

“…Interestingly, Murashita et al [11] showed that restrictive MVA for degenerative regurgitation resulted in small mitral valve gradients, which decreased with time after discharge. Transmitral gradients are determined by both transmitral flow and the severity of the intrinsic stenosis [4,12]. Unless there is corresponding increase in mitral effective orifice area (EOA) [4], the improvement in left ventricular diastolic function after CABG will result in higher mitral gradients…”

“…Transmitral gradients are determined by both transmitral flow and the severity of the intrinsic stenosis [4,12]. Unless there is corresponding increase in mitral effective orifice area (EOA) [4], the improvement in left ventricular diastolic function after CABG will result in higher mitral gradients…”

“…The occurrence of functional mitral stenosis after restrictive MVA has not been well studied despite its relatively high incidence (9-54%) [8,12,14]. Importantly, recent findings show that PPG can independently predict elevated systolic PAP during exercise as well as reduced 6MWT distance [4][5][6][7], which is a powerful predictor of morbidity and mortality in patients with heart failure [5,8]. Thus, elevated resting peak mitral gradients correlate well with functional mitral stenosis and could serve as a good predictor of poor functional capacity [5].…”

“…Restrictive mitral valve annuloplasty (MVA) combined with coronary artery bypass grafting (CABG) is a traditional procedure for the surgical management of CIMR [1,2]. Although restrictive MVA can reduce the risk of recurrence of mitral regurgitation (MR), it is intuitive that it may cause functional mitral stenosis, leading to higher transmitral peak pressure gradient (PPG) and pulmonary arterial pressure (PAP) and, indeed, several reports in literature support this concept [3][4][5][6]. Recent studies suggest that resting PPG is an independent predictor of increased systolic PAP during exercise, and that a PPG ≥ 13 mmHg is the best predictor of poor performance on the 6-minute walk test (6MWT) distance [4][5][6][7].…”

“…Although restrictive MVA can reduce the risk of recurrence of mitral regurgitation (MR), it is intuitive that it may cause functional mitral stenosis, leading to higher transmitral peak pressure gradient (PPG) and pulmonary arterial pressure (PAP) and, indeed, several reports in literature support this concept [3][4][5][6]. Recent studies suggest that resting PPG is an independent predictor of increased systolic PAP during exercise, and that a PPG ≥ 13 mmHg is the best predictor of poor performance on the 6-minute walk test (6MWT) distance [4][5][6][7]. What is more, reduced 6MWT distance powerfully predicts morbidity and mortality in patients with heart failure [5,8].…”