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      Mitral valve surgery in patients with ischemic and nonischemic dilated cardiomyopathy.

      1 , ,
      Cardiology
      S. Karger AG

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          Abstract

          Congestive heart failure (CHF) is a chronic, progressive disease and its central element is the remodeling of the cardiac chamber associated with ventricular dilatation. Secondary mitral regurgitation is a complication of end-stage cardiomyopathy and is associated with a poor prognosis. It is due to progressive mitral annular dilatation and alteration in the geometry of the left ventricle. A vicious cycle of continuing volume overload, ventricular dilatation, progression of annular dilatation, increased left ventricular wall tension and worsening mitral regurgitation and CHF occurs. The mainstays of medical therapy are diuretics and afterload reduction, which are associated with poor long-term survival in these patients. Historically, the surgical approach to patients with mitral regurgitation was mitral valve replacement, but these patients were not considered operative candidates because of their high morbidity and mortality. Heart transplantation is now considered standard treatment for select patients with end-stage heart disease; however, it is applicable only to a small number of patients. Mitral valve replacement in these patients is associated with adverse consequences on left ventricular systolic function resulting from interruption of the annulus-papillary muscle continuity. Preserving the mitral valve apparatus and left ventricle in mitral valve repair enhances and maintains left ventricular function and geometry with an associated decrease in wall stress. Using these operative techniques to alter the shape of the left ventricle, in combination with optimal medical management for heart failure, improves survival and may avoid or postpone transplantation.

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          Most cited references9

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          Dilated cardiomyopathy with mitral regurgitation: decreased survival despite a low frequency of left ventricular thrombus.

          Ninety-one patients with dilated cardiomyopathy were studied by two-dimensional, pulsed, and color Doppler echocardiography (1) to detect and quantify mitral regurgitation (MR), (2) to record apical flow velocities in systole and diastole, and (3) to detect the presence of left ventricular thrombi. MR was detected in 57% of the patients and thrombi were present in 40%, but the occurrence of both MR and thrombus was rare (8%). Apical flow velocity was significantly higher throughout the cardiac cycle in the group with MR (diastole 15 +/- 7 vs 9 +/- 7 cm/sec; systole 29 +/- 12 vs 16 +/- 13 cm/sec; p less than 0.001 for both), accounting for the rarity of thrombi in this group. Follow-up data on 89% of the patients showed markedly decreased survival in the group with MR (22% vs 60% at 32 +/- 6 months, p less than 0.005), and this was evident even in patients with mild MR. Thus although MR is a noninvasively obtainable marker of a large subgroup of patients with dilated cardiomyopathy "protected" from left ventricular thrombus formation, it is a sensitive marker of decreased survival.
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            Mitral valve replacement for isolated mitral regurgitation: Analysis of clinical course and late postoperative left ventricular ejection fraction

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              Mitral valve surgery in patients with severe left ventricular dysfunction.

              The objectives of this study were to determine (1) survival, (2) functional status and freedom from readmission for heart failure and (3) change in postoperative left ventricular (LV) dimensions and function following mitral valve repair or replacement in patients with severe LV dysfunction and mitral regurgitation. Between 1990 and 1998, 44 patients with mitral regurgitation and a LV ejection fraction <35% (mean+/-SD, 28+/-6%) underwent isolated mitral repair (n=35) or replacement (n=9). The etiology of regurgitation was valvular in 18 (40%) patients, ischemic in 13 (30%) patients and dilated idiopathic cardiomyopathy in 13 (30%) patients. Every patient had been hospitalized one to six times for symptoms of heart failure (mean+/-SD, 2.3+/-1.5). All patients were receiving maximal drug therapy with 15 (34%) in New York Heart Association (NYHA) class III and 12 (27%) in class IV. Seven (16%) patients were initially referred for consideration of transplantation. The mean+/-SD duration of follow-up was 40+/-21 months. One (2.3%) patient died 9 days postoperatively of acute bronchopneumonia. The mean+/-SD duration of ICU and hospital stay was 41+/-34 h and 9+/-3 days, respectively. The 1-, 2- and 5-year survival rates were 89, 86 and 67%, respectively. Heart failure and sudden death accounted for 62% of the late deaths. The NYHA class improved for survivors from 2.8+/-0.8 preoperatively to 1. 2+/-0.5 at follow-up (P<0.0001). Freedom from readmission for heart failure was 88, 82 and 72% at 1, 2 and 5 years, respectively. No patient has been listed for transplantation. Mitral valve surgery offers symptomatic improvement and survival benefit in patients with severe LV dysfunction and mitral regurgitation. More liberal use of this surgery for cardiomyopathy patients is warranted.
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                Author and article information

                Journal
                Cardiology
                Cardiology
                S. Karger AG
                0008-6312
                0008-6312
                2004
                : 101
                : 1-3
                Affiliations
                [1 ] Division of Cardiothoracic Surgery, The University of Illinois Medical Center at Chicago, Chicago, IL 60612, USA. Ageha@uic.edu
                Article
                75981
                10.1159/000075981
                14988622
                a57f75a4-d8cf-4cfb-b4ff-d1264555f29b
                History

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