Surgical treatment for functional mitral regurgitation secondary to dilated cardiomyopathy: Current options and future trends

Abstract

<p> <span style="font-size:10.0pt;">There is an increasing number of patients with mitral regurgitation secondary to dilated cardiomyopathy. Recent data suggest that mitral regurgitation (MR) can be surgically corrected in heart failure with symptomatic improvements and favourable reverse left ventricular remodeling. However, several questions remain to be answered, regarding the optimal management of functional mitral regurgitation, the correct timing of surgery and the choice of the surgical technique to perform in patients affected by dilated cardiomyopathy. In the setting of ischemic chronic cardiomyopathy, data derived from the recent literature suggest that concomitant severe ischemic MR should be addressed during CABG to improve survival and quality of life. Most surgeons perform concomitant CABG and mitral valve surgery in patients with ischemic chronic cardiomyopathy and moderate to severe MR. In the setting of chronic dilated cardiomyopathy, most clinicians would agree that correction of severe MR in heart failure is warranted, mostly due to a symptomatic benefit and reduction of number of re-hospitalizations. Moreover, reverse ventricular remodeling has been demonstrated with undersized annuloplasty rings and correction of MR: this could lead to improved contractility, reduction in left ventricular end-diastolic and end-systolic volumes, and finally to improved NYHA functional class. Recent large studies suggest that patients undergoing mitral valve repair had improved perioperative survival, shorter length of stay, and improved long-term survival than those undergoing mitral valve replacement because the preservation of the subvalvular apparatus seems to result in superior left ventricular remodelling and in greater improvement in NYHA class. In the near future, data from multi-institutional, randomized prospective trials will help to elucidate many of the questions and concerns regarding repair of severe functional mitral regurgitation. Finally, technology applied to heart surgery is continually evolving and will allow more exciting cellular and novel device therapies for the treatment of functional mitral regurgitation secondary to dilated cardiomyopathy.</span> </p

Predictors of ischemic mitral regurgitation improvement after surgical revascularization plus mitral valve repair for moderate ischemic mitral regurgitation

“…The placement of an undersized, complete remodeling annuloplasty ring to restore the annulus to its native geometry was the most crucial step in successful valve repair. 21 Sizing was performed with the goal of re-establishing the coaptation plane between the anterior and posterior leaflets. The mechanism of undersizing the annuloplasty ring brings the annulus and leaflets together and into alignment, achieving a central line of coaptation.…”

“…The placement of an undersized, complete remodeling annuloplasty ring to restore the annulus to its native geometry was the most crucial step in successful valve repair 21 . Sizing was performed with the goal of re‐establishing the coaptation plane between the anterior and posterior leaflets.…”

Guide to functional mitral regurgitation: a contemporary review

“…First introduced in 1968 by Alain Carpentier, this technique involves use of a rigid or semi-rigid ring to downsize the annulus diameter to its native geometry. This will bring the annulus and leaflets together and into alignment to achieve a central line of coaptation (62). Recurrent MR is frequent outcome after MV annuloplasty for secondary MR patients, with risk factors of recurrence include severe preoperative MR, centrally directed or multiple jets, greater amount of LV dilation, symmetric anterior leaflet tethering, ≥11 mm coaptation height and presence of basal aneurysm/ dyskinesis (63).…”

Ischemic mitral regurgitation

“…In an article which outlines the steps for repair of IMR, the authors emphasize that a complete, undersized ring is of paramount importance to successful repair and will outweigh any minute advantage gained by employing a specially designed ring. [ 37 ]…”