Ischemic mitral regurgitation: intraventricular papillary muscle imbrication without mitral ring during left ventricular restoration

Impact of subvalvular procedure for ischemic mitral regurgitation on leaflet configuration, mobility, and recurrence

BACKGROUND

Procedures on the subvalvular apparatus are an etiology-based treatment for ischemic mitral regurgitation (IMR).

METHODS AND RESULTS

Fifty-nine patients with IMR were divided into 3 groups: mitral annuloplasty (MAP) (M group, n=27), MAP+left ventricular reconstruction (LVR) (LV group, n=18), and MAP+LVR+subvalvular procedure (S group, n=14). Tenting height and area, angle between the annular line and the line connecting leaflet base to the bending- or tip-point of either the anterior or posterior leaflet, and leaflet mobility were measured echocardiographically preoperatively and at immediate- and mid-term postoperative follow-up. The angles at the bending-point of the anterior leaflet in mid-systole remained greater than those at its tip-point in the M and LV groups, but became significantly smaller postoperatively only in the S group (p<0.05). Postoperative leaflet mobility at the bending-point in the S group became significantly greater than in the other groups (p<0.01). The grade of MR, after significant reduction by the procedure, increased again in the M and LV groups, but remained almost unchanged in the S group.

CONCLUSION

Subvalvular procedures improved the configuration and mobility of the anterior leaflet, and can be expected to reduce the recurrence of IMR.

Hemodynamics at rest do not match clinical improvement after surgical ventricular restoration

OBJECTIVES

The aim was to study the change in cardiac index (CI) and pulmonary artery pressure (PAP) by intra-cardiac measurements after surgical ventricular restoration (SVR) in patients with left ventricular aneurysm and symptoms of heart failure. Aspects of functional improvement were analyzed as secondary outcomes.

DESIGN

Mean PAP and CI were obtained before and 6 months postoperatively in 22 patients who underwent SVR.

RESULTS

There were no significant changes in CI (2.3 vs. 2.4 L/min/m(2); p=0.91) or mean PAP (22 vs. 22 mmHg; p=0.64) at rest before and six months after surgery. Left ventricular ejection fraction improved from 25 to 38% (p<0.001). Before surgery 15 patients (68%) were in NYHA class III-IV and 6 months after the operation 19 (86%) patients were in NYHA class I-II (p<0.001).

CONCLUSIONS

Invasive hemodynamic measurements under resting conditions do not correspond well to the significant clinical improvement noted in these patients. Studies during exercise conditions are necessary to further evaluate this procedure.

Papillary muscle approximation for functional ischemic mitral regurgitation

In patients with ischemic left ventricular dysfunction and functional mitral regurgitation, surgical treatment of mitral insufficiency remains a challenging issue. Several procedures have been described to restore a near to natural alignment between the mitral annulus and the laterally displaced papillary muscles. We report a new approach to relocate the displaced papillary muscles toward the mitral annulus and to reduce tethering in 8 patients, providing satisfactory initial results. Echocardiography showed mild or no mitral regurgitation at the follow-up (mean, 11.4 +/- 3.6 months; range = 7 to 14 months). This procedure is believed to be technically easy and beneficial in terms of mitral repair.

Effectiveness of surgical ventricular restoration in patients with dilated ischemic cardiomyopathy and unrepaired mild mitral regurgitation

OBJECTIVE

Any grade of ischemic mitral regurgitation is associated with excess mortality. Whether mild ischemic mitral regurgitation should be repaired at the time of either coronary artery bypass grafting or surgical ventricular restoration is controversial. Surgical ventricular restoration is a treatment option for dilated post-infarction cardiomyopathy and has the potential to improve mitral functioning. The present study assessed the effectiveness of surgical ventricular restoration and unrepaired mild ischemic mitral regurgitation on left ventricular geometry, cardiac and functional status, and survival.

METHODS

We analyzed 55 patients with previous anterior infarction (age 65 +/- 10 years) and mild chronic functional mitral regurgitation who underwent surgical ventricular restoration and coronary artery bypass grafting without mitral repair at our center. Left ventricular volumes, ejection fraction, and geometric parameters were measured before and after surgery.

RESULTS

Even mild ischemic mitral regurgitation is characterized by abnormal left ventricular geometry when compared with that of patients without mitral regurgitation at comparable ventricular volumes and ejection fraction. Surgical ventricular restoration induces a significant decrease in left ventricular volumes, left ventricular diameters, and papillary muscle distance; and an improvement in ejection fraction and New York Heart Association class. Ischemic mitral regurgitation significantly decreases in the majority of patients. Survival is 93% at 1 year and 88% at 3 years.

CONCLUSION

Surgical ventricular restoration improves mitral functioning by improving geometry abnormalities. Survival is optimal and greater than would be expected in patients with post-infarction dilated ventricles and depressed left ventricular function. Our data indicate that mitral repair in conjunction with surgical ventricular restoration is unnecessary in such patients.

New surgical approach to reduce tethering in ischemic mitral regurgitation by relocation of separate heads of the posterior papillary muscle

The surgical treatment of chronic ischemic mitral regurgitation remains a challenging issue. Several procedures have been developed to correct displacement of the papillary-ventricular complex and to reduce tethering-induced regurgitation. We report a geometric approach to relocate the laterally displaced posterior papillary muscle towards the mitral annulus. This procedure is believed to be technically easy and useful, especially in cases in which the displaced posterior papillary muscle contributes to tethering-induced regurgitation.

Surgical therapy for ischemic heart failure: Single-center experience with surgical anterior ventricular restoration

OBJECTIVES

Our objectives were (1) to report operative and long-term mortality in patients submitted to anterior surgical ventricular restoration, (2) to report changes in clinical and cardiac status induced by surgical ventricular restoration, and (3) to report predictors of death in a large cohort of patients operated on at San Donato Hospital, Milan, Italy.

METHODS

A total of 1161 consecutive patients (83% men, 62 +/- 10 years) had anterior surgical ventricular restoration with or without coronary artery bypass grafting and with or without mitral repair/replacement. A complete echocardiographic study was performed in 488 of 1161 patients operated on between January 1998 and October 2005 (study group). The indication for surgery was heart failure in 60% of patients, angina, and/or a combination of the two.

RESULTS

Thirty-day cardiac mortality was 4.7% (55/1161) in the overall group and 4.9% (24/488) in the study group. Determinants of hospital mortality were mitral valve regurgitation and need for a mitral valve repair/replacement. Mitral regurgitation (>2+) associated with a New York Heart Association class greater than II and with diastolic dysfunction (early-to-late diastolic filling pressure >2) further increases mortality risk. Global systolic function improved postoperatively: ejection fraction improved from 33% +/- 9% to 40% +/- 10% (P < .001); end-diastolic and end-systolic volumes decreased from 211 +/- 73 to 142 +/- 50 and 145 +/- 64 to 88 +/- 40 mL, respectively (P < .001) early after surgery. New York Heart Association functional class improved from 2.7 +/- 0.9 to 1.6 +/- 0.7 (P < .001) late after surgery. Long-term survival in the overall population was 63% at 120 months.

CONCLUSIONS

Surgical ventricular restoration for ischemic heart failure reduces ventricular volumes, improves cardiac function and functional status, carries an acceptable operative mortality, and results in good long-term survival. Predictors of operative mortality are mitral regurgitation of 2+ or more, New York Heart Association class greater than II, and diastolic dysfunction (early-to-late diastolic filling pressure >2).

Edge-to-edge mitral repair without annuloplasty in combination with surgical ventricular restoration

BACKGROUND

Functional mitral regurgitation is common in ischemic dilated cardiomyopathy. Edge-to-edge repair is an option for correction and can be performed through the ventriculotomy during surgical ventricular restoration (SVR). This report describes the durability of the edge-to-edge repair without annuloplasty in combination with SVR.

METHODS

From March 1997 to July 2002, 31 patients with left ventricular aneurysm or ischemic dilated cardiomyopathy and functional ischemic mitral regurgitation grade II (n = 18), III (n = 10), and IV (n = 3) underwent SVR and edge-to-edge repair without annuloplasty with concomitant coronary artery bypass grafting. Long-term valve competence was assessed by echocardiography. Early and late survival and hospital readmission for heart failure were analyzed.

RESULTS

Early mortality was 5 (16%) of 31 patients. At 1, 3, and 5 years, actuarial survival was 77%, 55%, and 48%. The cumulative follow-up was 117 patient-years (4.5 years mean follow-up). Late echocardiograms performed at a mean of 3.1 years postoperatively showed patients had mitral regurgitation at grade 0 (n = 4), I (n = 10), II (n = 9), and III (n = 1). Two patients underwent reoperation owing to grade III-IV recurrent mitral regurgitation. Freedom from hospital readmission or cardiac death was 56% at 1 year and 48% at 3 years.

CONCLUSIONS

Combined mitral valve repair and SVR carries high operative risk and long-term prognosis is worse than after SVR alone. The edge-to-edge repair without annuloplasty for functional ischemic mitral regurgitation seems to be fairly durable in conjunction with SVR. To improve results a transventricular annuloplasty may be added.

Outcomes Following Surgical Ventricular Restoration in Elderly Patients With Congestive Heart Failure

Despite the well described benefits of surgical ventricular restoration (SVR) for patients with ischemic cardiomyopathy, the effects of advanced age on outcomes following this procedure have not been well documented. The authors compared outcomes in 69 consecutive patients 65 years and older (n=27) and younger than 65 years (n=42) to determine the utility of SVR in an elderly population with end-stage heart failure. Patients 65 years and older demonstrated significant improvements in ejection fraction (P=.01) and left ventricular end-systolic volume index (P=.07) following SVR, which were similar to the improvements seen in patients younger than 65 years. Sixty percent (15 of 25) of patients 65 years and older in preoperative New York Heart Association class III/IV improved to class I/II at follow-up (P<.0001). Actuarial survival was 68.8% at 2.5 years. Like their younger counterparts, elderly patients demonstrate significant improvements in ventricular function and NYHA class with acceptable survival following SVR.

Surgery for ventricular tachycardia in patients undergoing surgical ventricular restoration

This article is a presentation of direct surgery for ventricular tachycardia in patients undergoing surgical ventricular restoration. The procedure includes a non-electrophysiologically guided subtotal endocardiectomy and cryoablation in addition to endoventricular patch plasty of the left ventricle. Coronary artery bypass surgery and mitral valve repair are performed concomitantly as needed. In our experience, this procedure yielded a 90% success rate in terms of freedom from spontaneous ventricular tachycardia, with an early mortality rate of 3.8%. Perioperative considerations and a short overview of the literature are presented.

Coapsys mitral annuloplasty for chronic functional ischemic mitral regurgitation: 1-year results

BACKGROUND

Untreated functional ischemic mitral regurgitation (MR) leads to reduced survival in patients undergoing coronary artery bypass grafting (CABG). However, mitral repair or replacement increases mortality and morbidity over CABG alone. The Myocor Coapsys annuloplasty system potentially reduces these risks by facilitating MR reduction on a beating heart without atriotomy. We present data from the first 11 patients completing 1-year follow-up of a total of 34 implanted patients.

METHODS

Patients referred for CABG with preoperative grade 2 or greater ischemic functional MR were included in this study. Patients with structural valve defects or who demonstrated MR less than grade 2 after CABG, despite hemodynamic challenge, were intraoperatively excluded. Coapsys consists of two epicardial pads connected by a flexible chord implanted by passing the chord across the left ventricle with special instruments without cardiopulmonary bypass. The system was sized to reduce critical valve dimensions and MR. Serial clinical and echocardiographic data were collected out to 1 year.

RESULTS

Mean age was 58.1 +/- 6.6 years and mean ejection fraction, 38.5% +/- 7.1%. From baseline to 1-year follow-up, effect on MR grade, MR jet area (cm2), and New York Heart Association class were, respectively, 2.9 +/- 0.5 to 1.1 +/- 0.8, 7.4 +/- 2.9 to 3.0 +/- 1.6, and 2.5 +/- 0.5 to 1.2 +/- 0.4 (all p < 0.05 versus baseline). During follow-up, there were no deaths, device failures, reemergence of grade 3 or 4 MR, heart failure readmission, or valve reoperations.

CONCLUSIONS

The Coapsys annuloplasty system is effective in reducing functional ischemic MR and improving NYHA class. The initial data are encouraging and suggest that the device is safe and benefits are sustained at 1 year.

Functional mitral regurgitation in heart failure

Mitral regurgitation commonly occurs in patients with heart failure. Systolic dysfunction is the hallmark of dilated cardiomyopathy. Mitral functional regurgitation is mitral incompetence in the absence of intrinsic lesions of the mitral valve apparatus. Echocardiography can make a major contribution to the diagnosis of cardiomyopathies. A more careful anatomic and hemodynamic evaluation of mitral regurgitation mechanisms is possible with spectral Doppler, color Doppler, three-dimensional echocardiography and transesophageal echocardiography. Functional mitral regurgitation is due to the incomplete closure of mitral leaflets and is based on alterations of mitral annulus, left ventricular dimensions, function and geometry, left atrial dimensions and function. Knowledge of the mechanisms of mitral regurgitation helps us to gain an insight into therapeutic interventions that modify the mechanistic factors. Medical therapy reduces the tethering forces and also augments transmitral pressure; surgical approaches can modify geometric relationships in the left ventricular chamber and resynchronization therapy can improve co-ordinated timing of mechanical activation of papillary muscles.

Surgical alternatives for the palliation of heart failure: a prospectus

BACKGROUND

Congestive heart failure (CHF) is the leading cause of hospital admissions in the United States.

METHODS AND RESULTS

CHF has a variety of palliative options for treatment and 1 curative one: cardiac transplantation. Palliative medical therapies are often limited in effectiveness by progression of the disease or patient intolerance. Because of limited donor availability, alternative surgical strategies are now being relied on for palliation of patients in end-stage CHF.

CONCLUSION

In this manuscript, we review the principles, outcomes, and practices of some of these surgical strategies often used in the palliation of end-stage CHF.

Chronic Ischemic Mitral Regurgitation: Repair, Replace or Rethink?

Ischemic mitral regurgitation (IMR) is a common complication of coronary artery disease and is the focus of a rapidly increasing amount of research. Mechanistic studies have determined that IMR is caused by apical displacement and tethering of the mitral valve leaflets after myocardial infarction, resulting in incomplete coaptation. Despite the relatively high prevalence of IMR, most centers have only a small surgical experience with this disorder. The result is that a number of different procedures have been recently developed without clear improvement in patient outcomes. The current review will examine the myriad surgical options for IMR with a focus on clinical outcomes.

Surgical Ventricular Remodeling for Patients with Clinically Advanced Congestive Heart Failure and Severe Left Ventricular Dysfunction

BACKGROUND

Surgical ventricular remodeling (SVR) is an accepted therapy for post-infarction ventricular remodeling. Current literature on SVR outcomes has focused on heterogeneous populations with regard to left ventricular function and New York Heart Association (NYHA) class. We assessed outcomes after SVR in patients with advanced congestive heart failure (CHF) (NYHA Class III/IV) and a pre-operative ejection fraction (EF) < or =20%.

METHODS

Data were analyzed for 51 consecutive SVR patients from January 2002 to June 2004. Cardiac catheterization, echocardiography and magnetic resonance imaging (MRI) identified 62.7% (32 of 51) of patients with an EF < or =20%, with the majority having an EF < or =15% (65.6%; 21 of 32). Cox regression analysis was performed to determine predictors of mortality in patients with an EF < or =20%. Follow-up was 100% (32 of 32) complete.

RESULTS

Mean age was 61.9 +/- 10.3 (range 40 to 80) years with a male:female ratio of 27:5. Operative mortality was 6.3% (2 of 32). Twenty-two percent (7 of 32) had concomitant mitral valve procedures. Follow-up demonstrated a statistically significant improvement in left ventricular volumes and EF in survivors. Cox regression analysis identified the following to be significant predictors of mortality: pre-operative left ventricular end-systolic volume index >130 ml/m2; pre-operative diabetes; and intra-aortic balloon pump usage. Pre-operatively, all patients (32 of 32) were categorized as NYHA Class III/IV, with 69% (22 of 32) improving to NYHA Class I/II at follow-up (p < 0.01). Survival did not differ statistically between patients with an EF < or =20% and an EF >20% (n = 19).

CONCLUSIONS

Our results indicate that SVR improves left ventricular function and functional status for patients with advanced CHF and a pre-operative EF < or =20%. Therefore, SVR is a viable surgical alternative for patients with severe left ventricular dysfunction.

A surgical approach to severe congestive heart failure--overlapping ventriculoplasty

BACKGROUND

Previously we developed a new procedure of overlapping cardiac volume reduction (OLCVR) surgery for patients with dilated cardiomyopathy refractory to medical treatment. Papillary muscle plication (PMP) when combined with OLCVR may achieve a better clinical outcome.

PURPOSE

To investigate the early and intermediate results of OLCVR with or without PMP.

METHODS

Twenty-five patients (21 males, 4 females, aged 60 +/- 13 years) with either ischemic (n = 7) or nonischemic (n = 18) dilated cardiomyopathy underwent either isolated OLCVR (n = 11; Original Group) or PMP combined with OLCVR (n = 14; Integrated Group).

RESULTS

Early deaths occurred in two (8%) from a noncardiac cause and late deaths in six, two from a cardiac and four from a noncardiac cause. Postoperative data in survivors were significantly improved in terms of NYHA functional class (from 3.6 +/- 1.9 to 1.6 +/- 1.1), ejection fraction (from 18 +/- 6% to 31 +/- 8%), left ventricular diastolic dimension (from 73 +/- 9 to 65 +/- 6 mm), and left ventricular end-diastolic volume index (from 194 +/- 81 to 128 +/- 43 mL/m2) (p < 0.05) in selected comparative cases. One-year crude and cause-specific survivals were 70.9% and 83.1%, respectively, at a mean follow-up of 12.8 months. One-year crude survival of the Integrated and Original Group was 85.7% and 55.6%, respectively (p = 0.24).

CONCLUSIONS

Although limitations exist in evaluating operative results, we consider OLCVR to be a relatively safe and effective procedure for selected patients with dilated cardiomyopathy. The addition of PMP to OLCVR may enhance the elliptic formation of left ventricle shape and improve mitral valve tethering, but further study is mandatory.

Functional ischemic mitral regurgitation in anterior ventricular remodeling: results of surgical ventricular restoration with and without mitral repair

Ischemic functional mitral regurgitation following ischemic cardiomyopathy is a secondary phenomenon to ventricular dilation, and therapeutic approaches to this complication are not uniform. Solutions to improve mitral function include either mitral repair or observing the effects of coronary revascularization and/or ventricular rebuilding during surgical ventricular restoration (SVR). The present study of 108 patients (comprising 18% of our 588 SVR population) reports the effects of mitral repair following SVR and CABG by comparing geometric, functional, hemodynamic and outcome changes to SVR patients without mitral repair. The degree of mitral regurgitation went from 2.9 +/- 1.2 before to 0.7 +/- 0.7 after SVR and mitral repair. SVR improved EF from 29 +/- 7% to 34 +/- 10% p 0.001; reduced end diastolic volume from 243 +/- 74 to 163 +/- 53 ml and end systolic volume from 170 +/- 63 to 107 +/- 41 ml, p 0.000. Ventricular size and shape geometric measurements improved in all patients, either with and without mitral repair. SVR improved tenting and papillary muscle width between muscle heads in all patients, but alterations in mitral annular size improved only following mitral repair. Preoperative mitral regurgitation occurred in patients with larger ventricular volume and lower ejection fraction and was an independent predictor of operative mortality risk.

Restoring papillary muscle dimensions during restoration in dilated hearts

Left ventricular papillary muscle geometry is distorted in dilated non-ischemic hearts, and following anterior infarction caused by a wrap around left anterior descending artery occlusion. Loss of the apex creates a spherical left ventricular (LV) chamber, and subsequent dilation causes secondary mitral insufficiency by stretching the annulus, altering tethering of the chords and widening the dimension between the bases of papillary muscles to impair leaflet coaptation. This report will describe an intraventricular way to narrow the widened inter papillary muscle distance toward normal.

Endoventricular Patch Reconstruction of Ischemic Failing Ventricle. A Single Center with 20 years Experience. Advantages of Magnetic Resonance Imaging Assessment

The left ventricular reconstruction (LVR) with endoventricular circular patch plasty (EVCPP) was reported in 1984 as a surgical method to rebuild left ventricular aneurysm or asynergy after myocardial infarction. Scarred LV wall can be dyskinetic or akinetic according to the type of infarction (transmural or not), and the progressive dilatation of LV (remodeling) depends on the size of the asynergic scar. Assessment of this extension and of LV volume and performances, is easy and reliable by magnetic resonance (CMR). The surgical technique is based on the insertion inside the ventricle on contractile myocardium, of a circular patch restoring curvature and physiological volume, and allowing exclusion of asynergic non resectable regions. The ventricular reconstruction method also has other components that include coronary revascularization (almost always), mitral repair (if needed) and endocardectomy when spontaneous or inducible ventricular tachycardia (VT) are present. The experience of the authors (> 1100 cases) and results obtained by other Centers, allows proposal of this technique as a way to treat the ischemic failing ventricle.

Mitral tetrahedron as a geometrical surrogate for chronic ischemic mitral regurgitation

The present study tests the hypothesis that a mitral tetrahedron (MT) is a useful geometrical surrogate for assessment of chronic ischemic mitral regurgitation (CIMR). Fifty-eight subjects were divided into three groups on the basis of left ventricular ejection fraction (LVEF) and the presence or absence of CIMR: LVEF ≥0.5 and negative CIMR ( group 1, n = 28), LVEF <0.5 and negative CIMR ( group 2, n = 12), and LVEF <0.5 and positive CIMR ( group 3, n = 18). MT was defined by its four vertices at the anterior annulus, posterior annulus, and medial and lateral papillary muscle roots, determined by MRI at peak systole. The results showed no clear cutoff values of MT parameters between groups 2 and 1. In contrast, all MT indexes were significantly different between groups 3 and 2 ( P < 0.05), and significant cutoff values differentiated the two groups. A scoring system employing parameters of the whole MT confirmed the absence of CIMR with total edge length index <268 mm/BSA1/3, total surface area index <2,528 mm2/BSA2/3, and volume index <5,089 mm3/BSA (where BSA is body surface area). The sensitivity, specificity, and positive and negative predictive values were 1.00. This preliminary study demonstrates that MT might serve as a good geometrical surrogate for assessing CIMR. The derived geometrical criteria of MT may be useful in surgical correction of CIMR.

A heart failure specialist's perspective on cardiac surgery for heart failure

Aside from cardiac transplantation, ventricular assist devices, and the total artificial heart, cardiac surgery now also plays a major role in the overall management of the heart failure patient. For patients with heart failure, cardiac surgery has steadily moved from being a predominant rescue procedure (eg, aneursymectomy, rupture repair, transplantation) to surgical interventions that can prevent or delay the progression of cardiac dysfunction and failure; these operations now include coronary artery bypass surgery, ventricular restoration, and valvular repair/replacement. This article discusses the role and impact of these specific surgical interventions in the setting of ventricular dysfunction and heart failure.

Surgical Coronary Revascularization with or without Mitral Valve Repair of Severe Ischemic Dilated Cardiomyopathy

BACKGROUND

Because patients with dilated cardiomyopathy tend to have a poor prognosis with medical therapy, surgery with coronary bypass alone or associated with mitral valve repair should be a promising feasible therapeutic option. We evaluated the early effects of surgical coronary revascularization with or without mitral valve repair in patients with severe dilated ischemic cardiomyopathy.

METHODS

The study group consisted of 38 patients aged 65 +/- 8 years with severe dilated ischemic cardiomyopathy, chest pain, and heart failure. Twenty-four patients were in a New York Heart Association (NYHA) class > or =3, and 14 patients were in class 2. Twenty patients had a degree of mitral regurgitation defined as an effective regurgitant orifice > or =20 mm2. The mean values (+/-SD) of the EuroSCORE, which evaluates operative risk, were 5 +/- 2.2. Clinical and echocardiographic reevaluation followed at 6 months.

RESULTS

All patients underwent coronary artery bypass surgery with a mean of 2.3 +/- 0.8 grafts, and mitral valve repair with annuloplasty and Cosgrove ring insertion were performed in 20 patients. No deaths occurred during the operative period. Ten patients could not be reevaluated at 6 months, and 3 patients died (7.9% mortality). At 6 months, the end-systolic volumes in 15 patients who underwent coronary bypass plus mitral valve repair (group A) and in 13 patients who underwent coronary bypass alone (group B) decreased, respectively, from 139 +/- 56 mL to 121 +/- 94 mL and from 122 +/- 48 mL to 96 +/- 36 mL (P < .05). The wall motion score index also decreased from 1.9 +/- 0.3 to 1.4 +/- 0.4 and from 2.1 +/- 0.3 to 1.8 +/- 0.2, respectively. The mean values of the ejection fraction, the peak early mitral inflow velocity, and the ratio of the peak early mitral inflow velocity to the peak late mitral inflow velocity increased significantly in both groups (P < .001, P < .01, and P < .05, respectively). The mean NYHA functional class significantly improved in both groups (P < .0001).

CONCLUSIONS

In patients with severe ischemic dilated cardiomyopathy, surgical coronary revascularization can be safely carried out during the operative and early postoperative periods with low mortality rates. This procedure decreased left ventricular end-systolic volume, consistently increased contractility, and subsequently ameliorated the ejection fraction to produce improvements in clinical condition according to the NYHA functional class. Similar results have been obtained in patients who have undergone coronary bypass surgery and mitral valve repair, despite a higher operative risk and longer cardiopulmonary bypass circulation and aortic cross-clamping times.

Anterior leaflet augmentation for ischemic mitral regurgitation

BACKGROUND

Mitral valve repair improves survival and quality of life in patients with ischemic mitral regurgitation (MR). Although many repair methods exist for this condition, the ideal approach remains unknown. The purpose of this study is to describe a simple technique for repair of ischemic MR that addresses the pathophysiology of tethered leaflets and to report its early results.

METHODS

The technique consists of pericardial patch enlargement of the anterior mitral leaflet and placement of a flexible annuloplasty band. Candidates for the repair had ischemic cardiomyopathy and echocardiographic evidence of moderate or severe Carpentier type IIIb MR. Patients were followed with serial echocardiography.

RESULTS

Between January 2002 and November 2003, 25 adult patients underwent anterior leaflet augmentation for ischemic MR. Mean age was 64.8 +/- 10.6 years, and mean left ventricular ejection fraction was 0.36 +/- 0.14. Preoperative MR by transesophageal echocardiography was severe in 84% of patients and moderate in 16%. Annuloplasty band sizes were 27 mm to 31 mm (mean, 28.4 +/- 1.1 mm). Concomitant coronary artery bypass grafting was performed in all patients. Transesophageal echocardiography immediately after repair revealed MR to be none or trace in 80% of patients and mild in 20%. No intraoperative conversion to valve replacement was performed. In follow-up, 2 patients have experienced moderate MR and are being treated medically, and no patients have mitral stenosis. At 2 years, actuarial freedom from moderate or greater MR is 81%.

CONCLUSIONS

For patients with ischemic MR, anterior leaflet augmentation is a simple and reproducible method of valve repair that addresses the pathophysiology of tethered leaflets. Early results in a small number of patients have been encouraging.

Left ventricular aneurysm/reshaping techniques

Surgical ventricular restoration (SVR) is an emerging technique aiming to restore left ventricular geometry and function in dilated ischemic cardiomyopathy. It applies not only to the classic aneurysm (Type 1) but also to the true ischemic dilated cardiomyopathy (Type 3) and to the intermediate type (Type 2). This type classification based on systolic morphology allows patient selection. SVR is performed under total cardiac arrest with antegrade crystalloid cardioplegia, following complete coronary revascularization, almost always on the left anterior descending artery and mitral repair through ventriculotomy, when needed. Results on more than 1000 patients show that SVR is safe and effective in improving pump function, clinical status and survival in patients with post-infarction ischemic cardiomyopathy.

Functional mitral regurgitation in chronic ischemic coronary artery disease: Analysis of geometric alterations of mitral apparatus with magnetic resonance imaging

BACKGROUND

Patients with chronic coronary artery disease have double the mortality rate if the condition is combined with functional mitral regurgitation. An understanding based on geometric alterations of the mitral apparatus in functional mitral regurgitation is desirable.

METHODS

Twenty-nine subjects were enrolled in the study, including 9 healthy volunteers (control group), 12 patients with chronic coronary artery disease without functional mitral regurgitation (CAD group), and 8 patients with chronic coronary artery disease with functional mitral regurgitation (CAD+FMR group). Cine magnetic resonance imaging was performed to acquire multiple short-axis cine images from base to apex. Left ventricular end-systolic volume, left ventricular ejection fraction, mitral area, and vertices of the mitral tetrahedron, defined by medial and lateral papillary muscle roots and anterior and posterior mitral annulus, were determined from reconstructed images at end-systole. Anterior-posterior annular distance, interpapillary distance, and annular-papillary distance (the distance from the anterior or posterior mitral annulus to the medial or lateral papillary muscle roots) were calculated.

RESULTS

Left ventricular end-systolic volume was inversely associated with left ventricular ejection fraction (R(2) = 0.778). Left ventricular end-systolic volume was highly associated with distances related to ventricular geometry (R(2) = 0.742 for interpapillary distance, 0.792 for the distance from the anterior mitral annulus to the medial papillary muscle root, and 0.769 for distance from the anterior mitral annulus to the lateral papillary muscle root) but was moderately associated with distances related to annular geometry (R(2) = 0.458 for anterior-posterior annular distance and 0.594 for mitral area, respectively). Moreover, interpapillary distance of greater than 32 mm and distance from the anterior mitral annulus to the medial papillary muscle root of greater than 64 mm readily distinguished the CAD+FMR group from the other groups.

CONCLUSION

In patients with coronary artery disease, an increase in left ventricular end-systolic volume is associated with inadequate approximation of the mitral tetrahedron during systole, which consequently leads to functional mitral regurgitation. Our study suggests that interpapillary distance and distance from the anterior mitral annulus to the medial papillary muscle root are sensitive to the increase in left ventricular end-systolic volume and reliably indicate the presence of functional mitral regurgitation.

Safety and Efficacy of Surgical Ventricular Restoration in Unstable Patients With Recent Anterior Myocardial Infarction

BACKGROUND

The effects and efficacy of surgical ventricular restoration (SVR) in ischemic cardiomiopathy caused by chronic anterior myocardial infarction (MI) are well established. Normally, SVR is delayed at least 3 months after MI to allow the healing of infarcted tissue. Some patients have instability <30 days after anterior MI, with increased risk for morbidity and mortality.Objectives- This study tests the safety and efficacy of SVR in the setting of subacute complicated anterior MI, in terms of early and late outcome.

METHODS AND RESULTS

74 patients (62+/-10 years) were submitted to SVR at < or =30 days after anterior MI for clinical instability and were retrospectively selected from a series of 430 patients undergoing SVR at our center, between 1998 and 2001. The surgical indications included: angina (60%); New York Heart Association class 4 (62%); clinical signs of heart failure (18%); life-threatening arrhythmias (12%); and cardiogenic shock in 4% (or 3) patients. Follow-up is available for 93% of patients. All patients had coronary artery bypass grafting (CABG) (3.1+/-1.2) with internal mammary artery (IMA) utilization. An endoventricular patch was used in 17 patients (23%); direct ventriculotomy closure was used in the remaining patients. Operative mortality was 5.4% (4/74). Hemodynamic parameters improved significantly in patients with dilated hearts and reduced ejection fraction. Mitral regurgitation that resulted was significantly reduced. Survival at 3 years was 87% in the overall population and 85% in patients 70 years or older.

CONCLUSIONS

This study reports the largest series of patients with complicated, recent anterior MI treated with SVR. The results show that SVR is feasible, has acceptable in-hospital mortality, and has good early and late outcome. Further experience is needed to establish whether SVR, which excludes the infarcted region, can prevent the long-term adverse remodeling of LV dilated hearts after anterior infarction.

Repair of ischemic mitral regurgitation does not increase mortality or improve long-term survival in patients undergoing coronary artery revascularization: A propensity analysis

BACKGROUND

The purpose of this study was to compare operative mortality and midterm outcome of patients with ischemic mitral regurgitation (MR) undergoing either coronary artery bypass grafting (CABG) alone or CABG with mitral valve (MV) repair.

METHODS

From 1996 to 2001, 51 consecutive patients underwent CABG with MV repair for ischemic MR. All patients in this group were matched to similar patients with ischemic MR undergoing CABG alone during the same 6-year period using propensity analysis (considering 24 covariates, including severity of MR and New York Heart Association [NYHA] class).

RESULTS

Propensity score matching yielded 51 closely matched control patients. Preoperative MR severity was 3+ or 4+ in 94% of CABG with MV repair and 96% of CABG-alone patients, and 86% of patients in each group were NYHA class III or IV. Operative mortality was 3.9% +/- 2.8% in both groups. Survival was also similar between CABG with MV repair and CABG alone at 1 year (84% +/- 5% versus 82% +/- 5%) and 3 years (70% +/- 7% versus 71% +/- 7% (p = 0.43). Among survivors, NYHA class improved at follow-up (50 +/- 20 months) from 3.4 +/- 0.7 to 1.7 +/- 1.0 for CABG with MV repair (p < 0.001) and from 3.4 +/- 0.7 to 1.8 +/- 1.0 for CABG alone (p < 0.001).

CONCLUSIONS

Operative mortality, midterm survival, and late functional class were similar between two well-matched groups of patients undergoing CABG for ischemic MR, differing only in the addition of MV repair. Whereas MV repair can be added safely to CABG in this group of high-risk patients without increasing mortality, its impact on late survival and functional class may be limited.

Surgical Ventricular Restoration: Technique and Outcomes

Surgical ventricular restoration is a surgical procedure developed in an attempt to reverse the negative remodeling that occurs following myocardial infarction. The goal of the procedure is to: 1) reduce the size and restore the normal elliptical shape of the heart; 2) perform a complete myocardial revascularization; and 3) repair any mitral insufficiency. This article will review the surgical procedure and describe outcomes achieved with surgical ventricular restoration.

Transventricular annuloplasty for ischemic mitral regurgitation in the Dor procedure

Since the residual mitral regurgitation after the Dor procedure contributes to increasing postoperative mortality, repair of mitral regurgitation has become one of the essential surgical approaches. We describe two cases of transventricular posterior annuloplasty using a trimmed Duran ring for surgical management of ischemic mitral regurgitation performed with the Dor procedure. This procedure is easy to perform and provides secure annuloplasty because the mitral annulus can be easily exposed through the same ventriculotomy incision.

Mitral valve surgery in patients with ischemic and nonischemic dilated cardiomyopathy

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.

Coronary artery bypass with ventricular restoration is superior to coronary artery bypass alone in patients with ischemic cardiomyopathy

BACKGROUND

Coronary artery bypass is an acceptable therapy in patients with ischemic cardiomyopathy. However, it has been demonstrated that patients with increased left ventricular volume have a worse outcome than patients with normal ventricular volume. Our hypothesis was that ventricular restoration plus coronary artery bypass provides improved outcome compared with coronary artery bypass alone in ischemic cardiomyopathy with ventricular enlargement.

METHODS

A retrospective analysis was performed of patients with ischemic cardiomyopathy (ejection fraction <30%) who underwent operation between 1998 and 2002. Patients with enlarged ventricles (end-diastolic dimension > or =6.0 cm) who underwent either coronary artery bypass alone or coronary artery bypass with ventricular restoration were compared. Preoperative and postoperative ejection fraction, morbidity, mortality, and freedom from heart failure (hospitalization secondary to heart failure) were assessed.

RESULTS

Ninety-five patients were included in the study. Thirty-nine patients had coronary artery bypass alone, whereas 56 patients had ventricular restoration with coronary artery bypass. Both groups demonstrated an improved postoperative ejection fraction; however, the improvement was significantly greater in the ventricular restoration plus coronary artery bypass group (P <.01). There were no hospital deaths in either group; however, late mortality was higher in the coronary artery bypass group. Freedom from heart failure was achieved in all but 2 of the ventricular restoration plus coronary artery bypass patients (2/56, or 3.6%) versus 7 in the coronary artery bypass group (7/39, or 18%). The combined outcomes of freedom from failure and late mortality were significantly improved in the ventricular restoration plus coronary artery bypass group (P <.05).

CONCLUSIONS

Ventricular restoration affords significant improvement in ejection fraction compared with coronary artery bypass alone, without added mortality. Most importantly, left ventricular restoration reduces late morbidity and mortality compared with coronary artery bypass alone in patients with large ventricles.

Reading tarot cards

In some patients acute myocardial infarction and/or infarct expansion induces progressive left ventricular dilatation that eventually leads to heart failure and death. The five year mortality after onset of heart failure is 50%. Chronically stretched viable myocardium adjacent to or remote from an expanding infarction initiates a myopathic process that leads to progressive myocyte apoptosis and adverse postinfarction remodeling. Revascularization of stunned or hibernating myocardium restores contractility and benefits patients in heart failure; however, revascularization does not restore contractility to myopathic, remodeling myocardium. Contemporary operations for heart failure temporarily reduce ventricular wall stress, but fail to reverse stretch induced myocyte apoptosis, which may not be reversible. Logically, prevention of this myopathic process after acute infarction seems required to extend survival. It follows that surgeons should operate before adverse postinfarction left ventricular remodeling occurs, using new operations, rather than afterwards.

The Coapsys device to treat functional mitral regurgitation: in vivo long-term canine study

OBJECTIVE

We evaluated the capability of the Myocor Coapsys device (Myocor, Inc, Maple Grove, Minn) to reduce functional mitral regurgitation in a canine model of dilated cardiomyopathy.

METHODS

Functional mitral regurgitation with heart failure was induced in 7 dogs by rapid ventricular pacing. The Coapsys device, which consists of anterior and posterior epicardial pads connected by a subvalvular chord, was then implanted. Heart failure was maintained by continued pacing for 8 weeks. Hemodynamic and echocardiographic measurements were performed at pre- and postsizing and after 8 weeks. The Coapsys subvalvular chord was cut to verify that maintenance of valve competency was due to the device.

RESULTS

All implants were performed off-pump without atriotomy. Mitral regurgitation was reduced in all animals; mean mitral regurgitation grade was reduced from 2.9 +/- 0.7 to 0.7 +/- 0.8 (P =.00005) and was maintained at 0.8 +/- 0.8 after 8 weeks, without hemodynamic compromise or structural damage to the mitral valve. Mitral regurgitation returned to 3.6 +/- 0.8 (P =.102 versus presizing) after cutting the Coapsys subvalvular chord.

CONCLUSION

The Coapsys device consistently and chronically reduced functional mitral regurgitation. This device is in clinical trials in the United States.