Left ventricular performance after mitral reconstruction for mitral regurgitation

Preoperative transaortic forward flow: Prediction of surgical outcomes in patients with DCM and mitral regurgitation

BACKGROUND

In patients with dilated cardiomyopathy and mitral regurgitation, preoperative prognostic factors are very important.

METHODS

We hypothesized that preoperative transaortic forward flow might be related to postoperative survival, despite mitral regurgitant volume. We retrospectively evaluated surgical outcomes and echocardiographic parameters, including forward flow through the aortic valve.

RESULTS

Seventy-nine patients (54 males, 25 females; mean age 59 ± 12 years) with dilated cardiomyopathy and mitral regurgitation were divided into two groups according to postoperative outcome: 19 patients in group A suffered cardiac death, 60 in group B survived or died of another cause. In group A, death occurred after 227 ± 116 days, group B patients survived (except one who died of infection) for 505 ± 446 days; p < 0.01. Preoperatively, there was no significant difference in ejection fraction, end-diastolic and end-systolic volume index, mitral regurgitant volume, effective regurgitant orifice area, or right ventricular systolic pressure. Preoperative transaortic forward flow was significantly lower in group A vs. group B (1.57 ± 0.33 vs. 1.81 ± 0.46 L m(-2); p 0.04). In group B, transaortic forward flow was increased significantly before discharge (1.81 ± 0.51 vs. 2.43 ± 0.62 L m(-2); p < 0.01). Ejection fraction was significantly alleviated before discharge (28% ± 9% vs. 23% ± 8%; p < 0.01) and recovered to the preoperative value without repeat dilation of the left ventricle in late follow-up.

CONCLUSIONS

Preoperative transaortic forward flow may be a predictor of survival in patients with dilated cardiomyopathy and mitral regurgitation, irrespective of mitral regurgitant volume.

Mitral chordal-leaflet-myocardial interactions in mitral valve prolapse

BACKGROUND

The submitral apparatus maintains annular-papillary continuity and myocardial geometry. In mitral valve prolapse (MVP), elongated chords and redundant leaflets can interact at the region of myocardial attachment, leading to apparent discordant motion of the basal inferolateral wall. The aim of this study was to test the hypothesis that basal inferolateral wall inward motion would occur later in MVP and that this delay is associated with MVP severity.

METHODS

Thirty consecutive patients with MVP and matched controls underwent stress echocardiography. Time to peak transverse displacement (TPD) of the inferolateral wall compared with the anteroseptal wall was measured using speckle-tracking echocardiography. The time difference was analyzed as raw data, normalized to the RR interval, and as a percentage of the time to maximal displacement of the anteroseptal segment(s).

RESULTS

Compared with controls, TPD was delayed in patients with MVP both at rest and at peak stress, when evaluating basal segments or basal-mid segments as a unit, both in real time and, more importantly, when correcting for anteroseptal TPD. In patients compared with controls, observed delay at rest and at peak stress was 50 ± 90 versus -30 ± 90 msec (P = .006) and 70 ± 80 versus -30 ± 60 msec (P < .0001), respectively; relative to TPD of the anteroseptal segment, the observed delay at rest and at peak stress was 117 ± 24% versus 97 ± 22% (P = .007) and 144 ± 68% versus 95 ± 21% (P = .003), respectively. Similar significant findings were observed in basal-mid segments. TPD results were not statistically significant when stratified by prolapse severity. Intraclass correlation coefficients were 0.88 and 0.93, and two-tailed t tests indicated good interobserver and intraobserver variability.

CONCLUSIONS

Inferolateral wall TPD is delayed in MVP. TPD is a novel method to characterize chordal-leaflet-myocardial interactions in patients with MVP. Prolapse severity does not predict TPD, likely because of the timing of prolapse and dynamic loading conditions. Implications of this observation include attribution of a perceived wall motion abnormality in MVP during stress echocardiography to a physiologic state and new mechanistic insights into mitral valve physiology.

The Impact of Sub-valvular Apparatus Preservation on Prosthetic Valve Dysfunction During Mitral Valve Replacement

BACKGROUND

Sub-valvular apparatus preservation (SAP) during mitral valve replacement (MVR) is not a new concept. Some surgeons prefer to excise the apparatus.

OBJECTIVES

The aim of this study was to reduce the risk of prosthetic valve dysfunction.

MATERIALS AND METHODS

This retrospective study included 151 patients with the mean age of 46 years who underwent MVR (Female/male = 93/58). In the group I consisting of 39 patients, MVR with chordae preservation was performed (Bi-leaflet preservation = 20; posterior leaflet preservation = 19). In the group II consisting of 112 patients, sub-valvular apparatus was resected completely during MVR. Preoperative patients' characteristics, including age, sex, functional status, left ventricular ejection fraction, and end-diastolic or end-systolic dimensions were statistically similar in both groups. Mean follow-up period was 60.3 ± 26 months.

RESULTS

The improvement of functional status was seen in almost all survivors but was more obvious in the group I. In early follow-up, 56.4% of group I cases and 44.1% of group II patients were classified as New York Heart Association class I. These rates were 84.2% and 71.2% in mid-term follow-up, respectively (P < 0.001). Mortality rate was significantly lower in the group I (2.6%) compared to the group II (8.9%) (P = 0.03). There was a trend for higher frequency of postoperative atrial fibrillation in the group II compared to that in the group I (52.7% vs. 38.5%, P = 0.12).The incidence of prosthetic valve dysfunction (PVD) was 5.1% in the group I and 4.5% in the group II, but this difference was not statistically significant (P = 0.56).

CONCLUSIONS

Preservation of mitral annulus and papillary muscle continuity may enhance post- MVR cardiac performance with low mortality and morbidity rates. The risk of PVD was not significantly higher than conventional MVR in our series.

Left ventricular remodeling early after correction of mitral regurgitation: maintenance of stroke volume with decreased systolic indexes

OBJECTIVE

Mitral valve repair for mitral regurgitation is followed by left ventricle adjustment to new preload and afterload. We evaluated left ventricular geometry and function immediately after mitral valve repair for degenerative prolapse.

METHODS

We prospectively studied 25 patients undergoing mitral valve repair; 15 patients undergoing a coronary artery bypass graft served as controls to determine the impact of cardiopulmonary bypass and cardioplegic arrest on left ventricular function. Intraoperative transesophageal echocardiography was conducted after sternotomy before initiation of cardiopulmonary bypass and after termination of cardiopulmonary bypass and protamine infusion. Simultaneous pulmonary catheter data ensured that the images were obtained under similar hemodynamic conditions.

RESULTS

Immediately after mitral valve repair, left ventricular fractional area change decreased significantly from 65% ± 7% to 52% ± 8% (P < .001). Left ventricular end-diastolic area decreased minimally (21.3 ± 5.3 cm(2) vs 19.4 ± 4.5 cm(2); P = .005), whereas left ventricular end-systolic area increased significantly (7.5 ± 2.3 cm(2) vs 9.3 ± 2.5 cm(2); P < .001). Notably, forward stroke volume (thermodilution) remained similar (63 ± 24 mL vs 66 ± 19 mL; P = .5). No significant difference was found in controls between pre- cardiopulmonary bypass and post-cardiopulmonary bypass fractional area change (54% ± 12% vs 57% ± 10%; P = .19), left ventricular end-diastolic area (16.6 ± 6.2 cm(2) vs 15.7 ± 5.0 cm(2); P = .32), and stroke volume (72 ± 29 mL vs 65 ± 19 mL; P = .15); they had a slight decrease in left ventricular end-systolic area (7.9 ± 4.4 cm(2) vs 6.9 ± 3.2 cm(2); P = .03).

CONCLUSIONS

Early after correction of mitral regurgitation, left ventricular fractional area change decreases significantly, primarily as the result of a larger end-systolic dimension. This may be a compensatory mechanism to prevent augmentation of forward stroke volume after mitral valve repair.

Tei index to assess perioperative left ventricular systolic function in patients undergoing mitral valve repair

BACKGROUND

Using echocardiography, perioperative assessment of systolic function by fractional area change (FAC) is questionable in patients suffering from mitral regurgitation (MR). Tei index, an index expressing global cardiac function, has been reported to be unchanged after mitral valve surgery. We tested the hypothesis where the Tei index could be useful in assessing the perioperative cardiac function in patients undergoing mitral valve repair (MVR).

METHODS

Twenty-five patients were enrolled. Transoesophageal echocardiography was performed perioperatively before and after the correction of MR. We compared the impact of the MVR on the left ventricular FAC and the Tei index. FAC was calculated from the transgastric short-axis view and Tei index was determined from the four chambers and deep transgastric views.

RESULTS

Two patients were excluded because of poor acoustic windows. FAC significantly decreased after MVR from 53 (9)% to 42 (10)% (P<0.001), while Tei index was unaffected [0.46 (0.16) vs 0.47 (0.17), NS]. A significant relationship was found between the preoperative Tei index and the postoperative FAC (R=-0.64, P<0.001). Moreover, a significant and clinically relevant relationship was determined between the predicted (using preoperative Tei index) and the measured postoperative FAC (R=0.64, P<0.001).

CONCLUSIONS

FAC but not the Tei index is influenced by MVR. The preoperative determination of the Tei index allows predicting postoperative FAC and offers the opportunity to identify patients in whom a severe unsuspected systolic dysfunction could render difficult the weaning from cardiopulmonary bypass.

Acute hemodynamic effects of restrictive mitral annuloplasty in patients with end-stage heart failure: Analysis by pressure-volume relations

OBJECTIVE

Recent studies show beneficial long-term effects of restrictive mitral annuloplasty in patients with end-stage heart failure. However, concerns are raised about possible adverse effects on early postoperative systolic and diastolic function, which might limit application of this approach in patients with heart failure. Therefore we evaluated the acute effects of restrictive mitral annuloplasty on left ventricular function by using load-independent pressure-volume relations.

METHODS

In 23 patients (heart failure, n = 10; control, n = 13) we determined left ventricular systolic and diastolic function before and after surgical intervention by means of pressure-volume analysis with a conductance catheter. All patients with heart failure underwent stringent restrictive mitral annuloplasty (2 sizes smaller than the measured size), and 4 received additional coronary artery bypass grafting. Transesophageal echocardiography was used for evaluation of valve repair. Patients with preserved left ventricular function who underwent isolated coronary artery bypass grafting served as control subjects.

RESULTS

Restrictive mitral annuloplasty (ring size, 25 +/- 1) restored leaflet coaptation (8.0 +/- 0.2 mm) with normal pressure gradients (2.9 +/- 1.8 mm Hg). Restrictive mitral annuloplasty did not change cardiac output (5.0 +/- 1.8 to 5.3 +/- 0.9 L/min, P = .516), left ventricular ejection fraction (29% +/- 5% to 32% +/- 8%, P = .315), or end-systolic elastance (0.86 +/- 0.50 to 0.99 +/- 1.05 mm Hg/mL, P = .688). After restrictive mitral annuloplasty, end-diastolic volume tended to decrease (237 +/- 89 to 226 +/- 52 mL, P = .564), whereas end-diastolic pressure remained unchanged (14 +/- 6 to 15 +/- 5 mm Hg, P = .356). Diastolic chamber stiffness tended to increase (0.027 +/- 0.035 to 0.041 +/- 0.047 mL -1 , P = .542) but not significantly. Peak left ventricular wall stress was unchanged (356 +/- 91 to 346 +/- 85 mm Hg, P = .668). Baseline values in the control group were different, but changes in most parameters after surgical intervention showed similar nonsignificant trends.

CONCLUSION

Mitral valve repair by means of restrictive mitral annuloplasty effectively restores mitral valve competence without inducing significant acute changes in left ventricular systolic or diastolic function in patients with end-stage heart failure.

Patient survival characteristics after routine mitral valve repair for ischemic mitral regurgitation

BACKGROUND

Ischemic mitral regurgitation has been associated with diminished survival compared with nonischemic mitral regurgitation. Conversion from mitral valve replacement to valve repair has improved prognosis, but it is unclear whether ischemic mitral regurgitation remains an independent predictor of outcome after mitral valve repair.

METHODS

Five hundred thirty-five patients undergoing mitral valve repair (primarily rigid ring annuloplasty) with or without coronary bypass from 1993 through 2002 were reviewed retrospectively (ischemic mitral regurgitation, n = 141; nonischemic mitral regurgitation, n = 394). A Cox proportional hazards model evaluated survival as a function of 9 simultaneous covariates: ischemic versus nonischemic mitral regurgitation, age, sex, number of medical comorbidities, ejection fraction, New York Heart Association class, coronary disease, reoperation, and year of operation.

RESULTS

According to univariable analysis, patients with ischemic mitral regurgitation had greater age, higher comorbidity, lower ejection fraction, higher New York Heart Association, and higher reoperation rate (all P < .001) compared with those having nonischemic mitral regurgitation. Univariable 30-day mortality was as follows: 4.3% for patients with ischemic mitral regurgitation versus 1.3% for patients with nonischemic mitral regurgitation (P = .01). Unadjusted 5-year mortality was as follows: 44% +/- 5% for patients with ischemic mitral regurgitation versus 16% +/- 3% for patients with nonischemic mitral regurgitation (P < .001). In the multivariable model, however, only the number of preoperative comorbidities and advanced age were independent predictors of survival (P < .0001), whereas ischemic mitral regurgitation, sex, ejection fraction, New York Heart Association class, coronary disease, reoperation, and year of operation did not achieve significance (all P > .19). After being adjusted for differences in all preoperative risk factors, survival was not statistically different between ischemic mitral regurgitation and nonischemic mitral regurgitation (P = .33).

CONCLUSIONS

With routine application of rigid ring annuloplasty, long-term patient survival is more influenced by baseline patient characteristics and comorbidity than by ischemic cause of mitral regurgitation per se. Future risk assessment and decision making should be based on patient condition and should not be biased by ischemic cause of mitral regurgitation.

Long-term Assessment of Mitral Valve Reconstruction With Resection of the Leaflets: Triangular and Quadrangular Resection

BACKGROUND

The procedure of quadrangular resection and suture for prolapsed posterior leaflet of the mitral valve is a reliable and reproducible method that achieves excellent long-term results. However, triangular resection and suture of a prolapsed anterior leaflet is not widely supported and different techniques have been advocated. The aim of this study was to review our experience of mitral valve repair in which resection of the anterior and/or posterior leaflets was performed.

METHODS

Between October 1991 and September 2003, 105 patients with mitral regurgitation underwent mitral valve reconstruction with leaflet resection, including 55 patients with quadrangular resection of the posterior leaflet (P), 32 patients with triangular resection of the anterior leaflet (A), and 18 patients with resection of both leaflets (A+P).

RESULTS

The mean follow-up period was 63.6 (1 to 139) months. Reoperation was required in 2 patients, each after resection of the anterior or posterior leaflet. The freedom from reoperation rates at 10 years in 93% +/- 5% of patients after triangular resection of the anterior leaflet, 96% +/- 3% after quadrangular resection of the posterior leaflet, and 100% after resection of both leaflets. There were no significant differences of survival or risk of reoperation among these three groups. The postoperative mitral valve area was significantly smaller than the preoperative area in all three groups, but remained large enough (A: 2.84 +/- 1.07; P: 2.6 +/- 0.87; A+P: 3.09 +/- 1.20 cm2) for adequate valve function.

CONCLUSIONS

Triangular resection of a prolapsed anterior mitral leaflet is a reliable, reproducible, and durable procedure, like quadrangular resection of a prolapsed posterior leaflet.

Both Leaflet Preservation During Mitral Valve Replacement:. Modified Anterior Leaflet Preservation Technique

BACKGROUND

Satisfactory results of bileaflet preserving mitral valve replacement (MVR) had forced several institutes to preserve both leaflets during MVR. Modifications were required to prevent the preserved tissue from interfering with prosthetic valve function, to implant an adequate size of valve and to prevent left ventricle outflow tract (LVOT) obstruction.

MATERIALS AND METHODS

Conventional MVR was performed to 51 patients (group 1) and bileaflet preserving MVR was performed to 43 patients (group 2). Mitral anterior leaflet incised from the middle of the leaflet to mitral annulus without chordal injury in group 2 patients. Sutures were placed through the mitral annulus first and then passed from the bottom to the tip of anterior leaflet. Posterior leaflet was also preserved. Prosthetic valve was put down into the mitral annulus and sutures were ligated. Excessive anterior leaflet tissue was attached to left atrial wall.

RESULTS

Cross-clamping time was 45 +/- 5.33 minutes versus 61.32 +/- 4.43 minutes (p = 0.0001) and total cardiopulmonary bypass time was 60.80 +/- 4.44 minutes versus 80.55 +/- 3.65 minutes (p = 0.0001) in groups 1 and 2, respectively. Inotropy requirement was higher in group 1 (p = 0.0058). When compared with preoperative values postoperative left ventricle ejection fraction (LVEF) increased both at rest (from 52.74% +/- 3.88% to 62.86% +/- 3.18%, p = 0.0001) and during exercise (from 53.16% +/- 3.16% to 64.11% +/- 2.46%, p = 0.0001) in bileaflet preserving MVR group. But in conventional MVR group LVEF decreased postoperatively both at rest (from 51.45% +/- 4.27% to 48.27% +/- 3.35%, p = 0.0001) and during exercise (from 54.47% +/- 7.36% to 42.96% +/- 3.58%, p = 0.0001).

CONCLUSION

Leaflet preserving MVR operation not only improves the left ventricular performance but also reduces the mortality and morbidity after MVR. LVEF increases both at rest and during exercise. Risk of LVOT obstruction can be completely eliminated with our simple technique.

Management of Mitral Regurgitation Due to Mitral Prolapse

Notable advances have been made in the treatment of mitral regurgitation, especially the advances resulting from prolapse of the mitral valve with or without a flail leaflet. Prosthetic mitral valve replacement results in a high incidence of postoperative left ventricular systolic dysfunction. Recognition of the importance of the subvalvular apparatus for preserving contractile function has fostered development of new repair techniques that preserve native valve tissue and reduce or eliminate postoperative systolic dysfunction and the need for anticoagulation. Vasoactive medications have a very limited role in the management of patients with primary mitral regurgitation. Better screening tools enable detection of early ventricular decompensation, and appropriate operative interventions continue to significantly reduce the morbidity and mortality associated with mitral regurgitation. Mortality associated with ischemic mitral regurgitation resulting from annular ring dilatation or structural damage associated with rupture of a papillary muscle continues to be high, and the simplest and most expeditious operative intervention is emphasized.

The Use of Echocardiography in the Intensive Care Unit

Echocardiography is a powerful diagnostic tool that has become an indispensable part of intensive care medi cine. There is a broad clinical application for the noninva sive real-time structural and functional assessment of the critically ill patient. The echocardiograph provides on-line visual information and software for data manipu lation at the intensive care bedside without significant discomfort or risk. Assessment of ventricular function, hemodynamics, pericardial pathology, valvular status, and the outcomes of cardiac surgical interventions are naturally suited to this modality. Transesophageal echo cardiography is an important adjunct to the standard transthoracic examination, particularly in those pa tients with inadequate precordial images. Anatomic, physiologic, and hemodynamic findings can be corre lated in a variety of clinical conditions to make and confirm diagnoses and to direct management in a manner complementary to routine intensive care. Indi cations for echocardiography in the intensive care unit at this institution included assessment of ventricular function, valvular function, endocarditis, complications of surgery, abnormal hemodynamics, evaluation of intra cardiac source of embolus, and echocardiographic- guided endomyocardial biopsy. In this review, the tech niques, indications, and clinical applications of transthoracic and transesophageal echocardiography in the intensive care setting are explored, with a focus on experience in the cardiac surgical patient.

Echocardiographic Assessment of Dynamic Changes in Left Ventricular Shape

Changes in resting left ventricular shape have been related to underlying left ventricular dysfunction and may precede detectable hemodynamic abnormalities. The significance of dynamic changes in left ventricular shape has only recently been examined. In patients with systolic left ventricular dysfunction, dynamic changes in heart shape correlate strongly with exercise duration. Patients whose ventricles develop a more spheric left ventricular shape during exercise have diminished exercise capacity compared to patients whose ventricles become more ellipsoidal. In patients having mitral valve surgery for chronic, severe mitral regurgitation, mitral valve repair results in improved rest and exercise ejection indexes when compared to valve replacement, primarily due to a marked reduction in end-systolic stress and maintenance of a more ellipsoidal left ventricular shape. Potential mechanisms for these observations are discussed.

Preservation of left ventricular function in mitral valve surgery

Surgery for degenerative mitral regurgitation has become complex. Preservation of annulo-ventricular continuity through the chordae tendineae is an important determinant of operative survival, postoperative left ventricular function, long-term survival, and quality of life. Some cardiologists believe that NYHA I function is never achieved after conventional mitral replacement with chordal transection. Valve repair is the procedure of choice but when valve replacement is inevitable every effort should be made to preserve the posterior leaflet and its chordal attachments. Valve replacement with preservation of the subvalvar apparatus provides a functional outcome similar to that after valve repair but usually leads to life long anti-coagulation.

Importance of preserving the mitral subvalvular apparatus in mitral valve replacement

BACKGROUND

This clinical study sought to determine whether mitral valve replacement (MVR) with the preservation of both anterior and posterior chordae tendineae (MVR group II) would be more effective on the improvement of left ventricular regional wall motion than MVR with the preservation of posterior chordae tendineae alone (MVR group I).

METHODS

Postoperative left ventricular wall motion was analyzed by a centerline method in three groups of MVR--group I (n = 13), group II (n = 15), and repair group (n = 15)--for mitral regurgitation. Shortening fraction of chordal length was determined in 100 chords, and these chords were divided into five regions.

RESULTS

The comparison of postoperative versus preoperative shortening fraction among the three groups revealed that postoperative wall motion improved more strikingly at apical and diaphragmatic regions in the MVR group II and repair group in comparison to the MVR group I. The postoperative shortening fraction at the apical region in the MVR group II was significantly increased in comparison to preoperative shortening fraction (preoperative, 3.68% +/- 1.87%; postoperative, 5.38% +/- 2.33%; p < 0.05). However, postoperative shortening fraction in cardiac base was decreased in the MVR group II as well as other two groups.

CONCLUSIONS

The MVR with the preservation of both anterior and posterior chordae tendineae contributed to the improvement of left ventricular regional wall motion in the apical and diaphragmatic regions.

Enhanced regional deformation at the anterior papillary muscle insertion site after chordal transsection

BACKGROUND

Clinical and experimental studies of mitral valve replacement have shown a depression of ventricular function after chordal transsection; most recent studies have proposed that this is secondary to a depression of local function near the papillary muscle insertion site. However, there is no direct experimental evidence for changes in local fiber shortening in the wall of the left ventricle overlying the papillary muscle. Accordingly, we investigated the effect of chordal transsection on left ventricular shape and on three-dimensional regional deformation of the myocardium near the insertion of the anterior papillary muscle.

METHODS AND RESULTS

In six open-chest dogs, two sets of three transmural columns of radiopaque markers were implanted in the anterior wall, one set at the tip of the papillary muscle (basal) and one at the site of papillary muscle fiber insertion (apical). A Björk-Shiley mitral valve was placed in the left atrium adjacent to the native valve. Markers were then tracked with biplane cineradiography, and deformation was quantified with the use of finite strain analysis. Chordal transection resulted in reduced left ventricular end-systolic pressure and slowed relaxation. After chordal transsection, outward displacement of the ventricular wall and transverse shearing deformation were observed in the area of the papillary muscle during isovolumic contraction. Circumferential and radial strains during ejection were maintained at our basal site and enhanced on our apical site.

CONCLUSIONS

Chordal transsection led to enhanced local shortening and wall thickening and regional strain nonuniformity. These results indicate that chordal transsection induces an unloading of myocardium at the papillary muscle insertion site and that the resulting heterogeneity of regional function is the mechanism for the reduced global function and slowed ventricular relaxation.

The "physio-ring": an advanced concept in mitral valve annuloplasty

BACKGROUND

A new annuloplasty ring has been developed with the aim of adding flexibility to the remodeling annuloplasty concept. Here we report its clinical use with special emphasis on segmental valve analysis and valve sizing.

METHODS

From October 1992 through June 1994, 137 patients aged 4 to 76 years (mean age, 49.1 years) were operated on. The main causes of mitral valve insufficiency were degenerative, 90; bacterial endocarditis, 15; and rheumatic, 13. The indication for operation was based on the severity of the mitral valve insufficiency (90 patients were in grade III or IV) rather than on functional class (60 patients were in class III or IV). At echocardiography 6 patients had normal leaflet motion (type I), 119 leaflet prolapse (type II), and 12 restricted leaflet motion (type III). Surgical repair was carried out using Carpentier techniques of valve reconstruction. In 3 patients, inadequate ring sizing was responsible for systolic anterior motion of the anterior leaflet diagnosed by intraoperative echo. The valve was replaced in 2 patients. There were three hospital deaths, no late deaths, one reoperation for recurrent mitral valve insufficiency due to chordal rupture 1 month after repair, one reoperation for atrial thrombus formation 5 months after repair, one anticoagulant-related hemorrhage, and one thromboembolic episode.

RESULTS

Mid-term follow-up between 6 and 18 months was available in 94 patients. Echocardiography showed trivial or no regurgitation in 93.2% of the patients and minimal regurgitation in 6.8%. The average transmitral diastolic gradient was 3.55 +/- 1.93 mm Hg. Left ventricular end-systolic diameter and volume decreased postoperatively, demonstrating an improved left ventricular function.

CONCLUSIONS

This preliminary experience has provided promising results and allowed us to define the indications of the Physio-Ring versus the classic ring. It has also shown that valve sizing and proper ring selection are of primary importance.

Valve repair improves the outcome of surgery for mitral regurgitation. A multivariate analysis

BACKGROUND

Mitral valve repair has been suggested as providing a better postoperative outcome than valve replacement for mitral regurgitation, but this impression has been obscured by differences in baseline characteristics and has not been confirmed in multivariate analyses.

METHODS AND RESULTS

The outcomes in 195 patients with valve repair and 214 with replacement for organic mitral regurgitation were compared using multivariate analysis. All patients had preoperative echocardiographic assessment of left ventricular function. Before surgery, patients with valve repair were less symptomatic than those with replacement (42% in New York Heart Association functional class I or II versus 24%, respectively; P = .001), had less atrial fibrillation (41% versus 53%; P = .017), and had a better ejection fraction (63 +/- 9% versus 60 +/- 12%, P = .016). After valve repair, compared with valve replacement, overall survival at 10 years was 68 +/- 6% versus 52 +/- 4% (P = .0004), overall operative mortality was 2.6% versus 10.3% (P = .002), operative mortality in patients under age 75 was 1.3% versus 5.7% (P = .036), and late survival (in operative survivors) at 10 years was 69 +/- 6% versus 58 +/- 5% (P = .018). Late survival after valve repair was not different from expected survival. After surgery, ejection fraction decreased significantly in both groups but was higher after valve repair (P = .001). Multivariate analysis indicated an independent beneficial effect of valve repair on overall survival (hazard ratio, 0.39; P = .00001), operative mortality (odds ratio, 0.27; P = .026), late survival (hazard ratio, 0.44; P = .001), and postoperative ejection fraction (P = .001).

CONCLUSIONS

Valve repair significantly improves postoperative outcome in patients with mitral regurgitation and should be the preferred mode of surgical correction. The low operative mortality is an incentive for early surgery before ventricular dysfunction occurs.

Mitral valve replacement with complete retention of native leaflets

Although both mitral leaflets contribute equally to the preservation of left ventricular function after mitral valve replacement, most surgeons routinely excise the anterior mitral leaflet. Possible disadvantages of leaflet retention are left ventricular outflow tract obstruction and interference with prosthetic valve motion. In 31 patients undergoing mitral valve replacement, all mitral valvular and subvalvular tissue was completely retained using a technique that involved reefing the native leaflets into the valve sutures. Fifteen Carpentier-Edwards porcine and 16 St. Jude Medical valves were implanted. Two patients died of causes unrelated to this technique. In the others, echocardiography demonstrated either no or an insignificant left ventricular outflow tract gradient, and, in most, no valvular tissue could be seen in the left ventricular outflow tract. No interference with prosthetic leaflet mobility occurred. The salutary results of mitral valve replacement with complete leaflet retention recommend its use.

Left ventricular function in chronic mitral regurgitation: preoperative and postoperative comparison

OBJECTIVES

The present study was designed to evaluate the effects of surgical procedure on left ventricular systolic and diastolic function in patients with mitral regurgitation.

BACKGROUND

Left ventricular systolic function has been shown to decline after operation in patients with chronic mitral regurgitation.

METHODS

Using simultaneous cineangiography and left ventricular micromanometry, we evaluated left ventricular systolic and diastolic function in 14 patients with chronic mitral regurgitation both preoperatively and at an average of 22 months after operation. Eight patients underwent mitral valve reconstruction, and six had a valve replacement with interruption of the chordae tendineae. We compared these patients with 10 control subjects.

RESULTS

Preoperatively, patients with mitral regurgitation demonstrated normal global and regional left ventricular systolic function. Peak rate of diastolic filling was increased (p < 0.01), and passive chamber stiffness was decreased, compared with that in control subjects (p < 0.01), and there was normal myocardial stiffness. Postoperatively, systolic and diastolic function returned to normal in patients undergoing mitral valve reconstruction. In contrast, global systolic function was depressed in patients after valve replacement (p < 0.05), with regional dysfunction in the area of papillary muscle attachment (p < 0.01). Diastolic function was depressed in this group, with a prolonged time constant of pressure decay (p < 0.01) and a depressed rate of early diastolic filling and strain rate (p < 0.05). Passive elastic stiffness was within the normal range in all postoperative patients.

CONCLUSIONS

The type of operation performed to correct chronic mitral regurgitation has an important effect on postoperative left ventricular function. Systolic and diastolic function are preserved after mitral valve reconstruction. Mitral valve replacement with chordal interruption is associated with global and regional systolic dysfunction and early diastolic filling and relaxation abnormalities.

Regression of left ventricular mass after mitral valve repair of pure mitral regurgitation

To evaluate the effect of mitral valve repair on the regression of left ventricular mass, we studied 50 consecutive patients with severe, pure mitral regurgitation undergoing mitral valve repair. Two-dimensional echocardiograms were recorded a mean 2.5 +/- 2.0 weeks before and 6.5 +/- 2.5 months after valve operation. Postoperative significant mitral regurgitation was present in 3 patients. After mitral valve repair there were significant decreases in left ventricular end-diastolic volume index (133 +/- 39 mL/m2 to 79 +/- 35 mL/m2; p < 0.001), end-systolic volume index (44 +/- 26 mL/m2 to 30 +/- 26 mL/m2; p < 0.001), stroke volume index (89 +/- 29 mL/m2 to 49 +/- 19 mL/m2; p < 0.001), and mass index (211 +/- 82 g/m2 to 134 +/- 52 g/m2; p < 0.001). There also were significant decreases in left atrial dimension (47 +/- 9 mm to 38 +/- 9 mm; p < 0.001), left ventricular end-diastolic dimension (61 +/- 8 mm to 48 +/- 7 mm; p < 0.001), and end-systolic dimension (39 +/- 8 mm to 32 +/- 7 mm; p < 0.001). Left ventricular ejection fraction decreased slightly from 0.69 +/- 0.12 to 0.64 +/- 0.12; p < 0.01) after repair. Thus, correction of pure mitral regurgitation leads to reduction of the cardiac chamber size and left ventricular volumes as well as regression of the left ventricular mass.

Echocardiographic prediction of survival after surgical correction of organic mitral regurgitation

BACKGROUND

Left ventricular dysfunction is a frequent cause of death after successful surgical repair of mitral regurgitation. The role of preoperative echocardiographic left ventricular variables in the prediction of postoperative survival and thus their clinical implications remain uncertain.

METHODS AND RESULTS

The survival of 409 patients operated on between 1980 and 1989 for pure, isolated, organic mitral regurgitation and with a preoperative echocardiogram (within 6 months of operation) was analyzed. The overall survival was 75% at 5 years (90% of expected), 58% at 10 years (88% of expected), and 44% at 12 years (73% of expected). Operative mortality was 6.6% and markedly improved from 1980 to 1984 (10.7%) to 1985 to 1989 (3.7%). Multivariate analysis showed that age (P = .0003), date of operation (P = .003), and functional class (P = .016) but not left ventricular function were predictors of operative mortality. In the most recent period (1985 to 1989), operative mortality was 12.3% in patients age 75 years or older and 1.1% in patients younger than 75 years. Late survival was analyzed in the operative survivors. Multivariate analysis showed that the most powerful predictor was echocardiographic ejection fraction (EF) (P = .0004), followed by age (P = .0031), creatinine level (P = .0062), systolic blood pressure (P = .0164), and presence of coronary artery disease (P = .0237). The late survival at 10 years was 32 +/- 12% for patients with EF < 50%, 53 +/- 9% for EF 50% to 60%, and 72 +/- 4% for EF > or = 60%. The hazard ratio compared with EF > or = 60% was 2.79 (95% confidence interval, 1.65 to 4.72) for EF < 50% and 1.81 (95% confidence interval, 1.11 to 2.95) for EF 50% to 60%. Echocardiographic EF remained the best predictor of late survival, even when combined with left ventricular angiographic variables. The survival of patients with EF > or = 60% was 100% of expected at 10 years but was better in patients in class I or II than in those in class III or IV (82 +/- 6% versus 59 +/- 6%, respectively, at 10 years; P = .0021). The preoperative predictors of operative and late mortality remained significant independent of the type of surgical correction performed in combined multivariate analyses.

CONCLUSIONS

In organic mitral regurgitation, (1) operative mortality has markedly decreased recently, being at a low 1.1% in patients younger than 75 years, and is predicted by age and symptoms and not by left ventricular function, and (2) left ventricular EF measured by echocardiography is the most powerful predictor of late survival. These results suggest that surgical treatment should be considered early, even in the absence of severe symptoms, in patients with severe mitral regurgitation, before left ventricular dysfunction occurs.

Prediction of outcome after valve replacement for rheumatic mitral regurgitation in the era of chordal preservation

BACKGROUND

Noninvasive predictors of important outcomes after valve replacement for mitral regurgitation have not been examined in a rheumatic population (in whom the results of valve repair are suboptimal) in the era of chordal preservation. Timing of valve replacement thus remains a difficult question in rheumatic mitral regurgitation.

METHODS AND RESULTS

Of 278 patients followed after valve replacement, 66 had pure or predominant mitral regurgitation, and in 61 of these the etiology was rheumatic. The mean age was 24 years. After a mean follow-up of 24 +/- 10 months, the ability of preoperative clinical and echocardiographic data to predict outcome was assessed prospectively, and the possible impact of chordal preservation (n = 35) on survival and post-operative left ventricular function was examined retrospectively. There were no perioperative deaths. There were six postoperative deaths, all the result of heart failure and all related to left ventricular dysfunction. The mean probability of survival was .90 at 16 months. In a stepwise Cox proportional hazards regression analysis, the only independent predictor of postoperative death was preoperative end-systolic diameter. According to a logistic model, the probabilities of death (n = 6) and death or severe heart failure (n = 7) increased abruptly at a preoperative end-systolic diameter of 51 mm (probabilities, .23 and .31, respectively), and the accuracy of this cut point for predicting outcomes was 97% and 98%, respectively. Multiple linear regression analysis identified a large preoperative end-systolic diameter and the need to use tricuspid annuloplasty as significant independent predictors of postoperative fractional shortening; the use of chordal preservation (n = 35) was not a predictor of postoperative fractional shortening. A good outcome was predicted at a preoperative end-systolic diameter of 40 mm: probability of death or heart failure was .0001, and predicted mean postoperative fractional shortening was 0.27 after mitral valve replacement without tricuspid annuloplasty.

CONCLUSIONS

When preoperative end-systolic diameter is more than 50 mm, a poor postoperative outcome is predicted despite chordal preservation in relatively young patients with rheumatic mitral regurgitation, and alternative strategies should therefore be considered. When preoperative end-systolic diameter is 40 mm or less, an excellent outcome is predicted, and close observation without surgery would appear to be reasonable in the absence of symptoms.

Mitral valve replacement versus mitral valve repair. A Doppler and quantitative stress echocardiographic study

BACKGROUND

Standard mitral valve replacement (MVR) in patients with chronic mitral regurgitation results in consistent reductions in resting postoperative ejection fraction. This has been attributed to removal of the low-impedance ejection pathway into the left atrium or to disruption of the chordal apparatus. Mitral valve repair (MVP) does not reduce ejection fraction at rest. However, whether MVP confers any advantages with regard to dynamic left ventricular performance has not been investigated. The aim of this study was to directly compare standard MVR with MVP and to determine their respective influences on ventricular ejection performance during bicycle exercise.

METHODS AND RESULTS

Ten consecutive patients with pure chronic mitral regurgitation who underwent MVP and 10 patients matched for age, sex, and preoperative ejection fraction who underwent standard MVR for pure chronic mitral regurgitation performed symptom-limited, graded upright bicycle exercise with simultaneous Doppler and quantitative two-dimensional echocardiography. Patients with MVP had significantly greater rest (55 +/- 12%) and exercise (63 +/- 11%) ejection fractions than matched patients with MVR (40 +/- 13% [P < .0001] and 42 +/- 17% [P < .005], respectively). End-systolic circumferential wall stress was significantly lower at rest (190 +/- 36 versus 244 +/- 46; P < .03) and at peak exercise (231 +/- 46 versus 300 +/- 52; P < .02) in patients with MVP. At peak exercise, left ventricular shape was significantly more spherical in patients with MVR than those with MVP (1.84 +/- 0.31 versus 2.45 +/- 0.59; P < .02).

CONCLUSIONS

MVR with chordal transection resulted in significant reductions in rest and exercise ejection fraction. This was caused in part by a significant increase in end-systolic circumferential wall stress. MVP resulted in improved rest and exercise ejection indexes, primarily due to a marked reduction in end-systolic stress and maintenance of a more ellipsoidal chamber geometry.

Mitral valve prosthetic implantation with preservation of native mitral valve apparatus

To avoid postoperative morbidity and mortality often associated with left ventricular dysfunction after mitral valve replacement (MVR) for chronic mitral insufficiency, reconstruction or preservation of the native mitral valve apparatus may be attempted during mitral prosthetic implantation (MPI). The effects of mitral surgery on heart function, studied with echocardiography and radionuclide angiography, were compared in seven patients with MPI (study group) and five with MVR (control group) who underwent complete preoperative, early postoperative and 3-6 months follow-up examinations. Preoperatively there was significant intergroup difference only in right ventricular ejection fraction measured at radionuclide angiography, which was lower in the MPI group (p < 0.05). At follow-up the MPI group had improved as regards this fraction (p < 0.005) and stroke volume index (p < 0.05). The number of patients with improved NYHA class at follow-up was significantly greater in the MPI group. Our preliminary experience with preservation of the native mitral valve apparatus thus suggests that the method offers haemodynamic advantages for postoperative right ventricular function.

Repair of the anterior mitral leaflet

BACKGROUND

Repair rather than replacement of the diseased mitral valve has been the goal of the cardiac surgeon. Although well accepted for posterior leaflet pathology, a diseased anterior leaflet was believed by some to be irreparable.

AIMS

To assess the result of reconstructive mitral valve surgery involving the anterior mitral leaflet in a selected group of patients.

METHODS

Twenty consecutive patients with degenerative (19), ischaemic (one) and congenital/calcific mitral regurgitation were evaluated. There were five females and 15 males with a mean age of 62 +/- 12 years (41-75 years). The technique used to repair these valves included chordal transposition, leaflet plication commissuroplasty and a new technique we call leaflet repositioning.

RESULT

There were no deaths, follow-up is complete with mean follow-up of 31 +/- five months (two-102) months. All patients have had 2DE and 13 TOE as well. There have been no reoperations due to failure of the repair, 95% of patients are in NYHA Class I-II post operative, while 15% have significant residual regurgitation.

Mitral valve replacement with and without chordal preservation in patients with chronic mitral regurgitation. Mechanisms for differences in postoperative ejection performance

BACKGROUND

Standard mitral valve replacement (MVR) in patients with chronic mitral regurgitation consistently results in a decrease in postoperative left ventricular (LV) ejection performance. This fall in ejection performance has been attributed, at least in part, to unfavorable loading conditions imposed by the elimination of the low-impedance pathway for LV emptying into the left atrium. In contrast to standard MVR in which the chordae tendineae are severed, however, MVR with chordal preservation (MVR-CP) does not usually decrease LV ejection performance despite similar removal of the low-impedance pathway. The purpose of the present study was to define the mechanisms responsible for this discordance in postoperative ejection performance between MVR with and without chordal preservation.

METHODS AND RESULTS

Echocardiography and sphygmomanometer blood pressures were obtained in 15 patients with pure chronic mitral regurgitation before and 7-10 days after mitral valve surgery. These measurements were used to calculate ventricular volume, wall stress, and ejection fraction. Seven patients underwent MVR with chordal transection (MVR-CT), and eight patients underwent MVR-CP. MVR-CT resulted in no postoperative change in LV end-diastolic volume, a significant increase in LV end-systolic volume, a significant increase in end-systolic stress, from 89 +/- 9 to 111 +/- 12 g/cm2 (p < 0.05), and a significant decrease in ejection fraction, from 0.60 +/- 0.02 to 36 +/- 0.02 (p < 0.05). In contrast, patients who underwent MVR-CP had a significant decrease in LV end-diastolic and end-systolic volumes. End-systolic wall stress actually fell from 95 +/- 6 to 66 +/- 6 g/cm2 (p < 0.05), and ejection fraction was unchanged (0.63 +/- 0.01 before and 0.61 +/- 0.02 after mitral valve surgery) instead of reduced.

CONCLUSIONS

MVR-CT resulted in a decrease in ejection performance caused in part by an increase in end-systolic stress, which in turn increased end-systolic volume. Conversely, MVR-CP resulted in a smaller LV size, allowing a reduced end-systolic stress and preservation of ejection performance despite closure of the low-impedance left atrial ejection pathway.

Mitral valve repair: a valuable procedure with good long term results even when performed infrequently

OBJECTIVE

To assess the results of mitral valve repair in a series with a low frequency of repair despite a policy to conserve the valve whenever possible.

DESIGN

Retrospective review of case notes with clinical and echocardiographic examination of survivors.

SETTING

Cardiac surgery unit in a university teaching hospital.

PATIENTS

62 consecutive patients undergoing mitral valve repair by one surgeon between 1979 and 1989.

INTERVENTIONS

Mitral valve repair according to the criteria and techniques of Carpentier.

MAIN OUTCOME MEASURES

Frequency of repair, operative mortality, actuarial survival, freedom from reoperation and thromboembolism, clinical state, and echocardiographic state.

RESULTS

The 62 patients, median age 58 years (interquartile range 51 to 64 years), represent 14% (70% confidence interval 12% to 15%) of the 454 mitral valve operations performed in the study period. Operative mortality was 8% (70% CI 5% to 13%). Actuarial survival was 62% (70% CI 43% to 81%) at nine years. At nine years actuarial freedom from reoperation was 91% (70% CI 79% to 102%) and freedom from thromboembolism 91% (70% CI 80% to 102%). At a median follow up of 33 months (interquartile range 21 to 74 months), 38 of 46 survivors had improved functional state. Of 21 patients who underwent echocardiography one had severe mitral regurgitation and one mitral stenosis.

CONCLUSION

Although compared with other reports of mitral valve repair the prevalence of repair was low in this series the results are comparable and justify a positive approach to repair in all patients undergoing mitral valve surgery even if this can only be achieved in a small proportion of patients.

Prediction of outcome after mitral valve replacement in patients with symptomatic chronic mitral regurgitation. The importance of left atrial size

BACKGROUND

The ability to predict outcome after mitral valve replacement remains limited in patients with symptomatic chronic mitral regurgitation. The aims of this study were to determine the preoperative predictors of postoperative cardiac-related mortality and to assess the additive prognostic value of tests performed in such patients.

METHODS AND RESULTS

Accordingly, 176 patients (mean age, 57 +/- 14 years) who underwent mitral valve replacement were followed up for 3.8 +/- 0.5 years. Four categories of variables were analyzed to predict postoperative cardiac-related mortality: clinical, laboratory, two-dimensional echocardiographic (2DE), and cardiac catheterization. There were 39 cardiac-related deaths (29 due to congestive heart failure and 10 sudden). When the four categories were analyzed separately, two clinical, one laboratory, two 2DE, and one catheterization variable best predicted postoperative death. When these six variables were examined simultaneously, only three (one clinical and two 2DE) remained significant predictors of cardiac-related mortality: presence of pulmonary rales, left atrial size, and the ratio of left ventricular wall thickness to left ventricular cavity dimension in end systole. A model based on these three variables may predict cardiac-related death with considerable accuracy. Laboratory data did not add to clinical information for predicting death. 2DE variables provided significant additional information in this regard (p less than 0.001). Further addition of catheterization variables was not useful. Prognostic value did not change significantly when 50 patients with prior mitral valve surgery or 49 patients undergoing concomitant aortic valve replacement or coronary artery bypass surgery were excluded from analysis.

CONCLUSIONS

We conclude that 1) measures of both left ventricular systolic function and left atrial size are equally important in predicting postoperative cardiac-related mortality in patients with symptomatic chronic mitral regurgitation undergoing mitral valve replacement; 2) left atrial size may be important because it reflects the "history" (severity and duration) of mitral regurgitation; 3) 2DE assessment of left atrial size and left ventricular function provides prognostic information that is significantly greater than that obtained from clinical and laboratory parameters alone; the addition of catheterization variables does not increase the prognostic value of the clinical and 2DE data.

Effect of abrupt mitral regurgitation after balloon valvuloplasty on myocardial load and performance

The concept that mitral regurgitation masks myocardial dysfunction by reducing afterload and augmenting ejection performance has not been well established in humans. The effect of abruptly produced mitral regurgitation on left ventricular loading and performance was therefore evaluated in five patients who developed this complication after an otherwise successful percutaneous balloon mitral valvuloplasty. Mitral valve area by Gorlin formula calculated with forward flow increased from 0.92 +/- 0.14 to 2.75 +/- 0.82 cm2. Mean left atrial pressure did not decrease (19 +/- 4 to 19 +/- 6 mm Hg). The size of the left atrial V wave relative to mean left atrial pressure (peak V - mean left atrial pressure) increased from 7 +/- 4 to 19 +/- 6 mm Hg. Angiographic mitral regurgitation increased from 0+ or 1+ to greater than 3+ in each patient and regurgitant fraction increased from 0.23 +/- 0.11 to 0.55 +/- 0.09 (p less than 0.01). End-diastolic volume increased modestly from 148 +/- 15 to 159 +/- 15 ml (p = NS). Heart rate increased from 54 +/- 5 to 71 +/- 8 beats/min (p less than 0.05), which may have prevented further increases in preload by shortening the filling period. End-systolic stress decreased by 32% from 277 +/- 34 to 188 +/- 52 kdyn/cm2 (p less than 0.01) as a result of a 25% decrease in end-systolic pressure from 121 +/- 8 to 91 +/- 7 mm Hg and a 16% decrease in end-systolic volume from 67 +/- 13 to 56 +/- 8 ml (p = NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of standard mitral valve replacement on left ventricular function

Recent studies have suggested that excision of the mitral valve apparatus during mitral valve replacement impairs left ventricular performance. However, functional measurements in humans have been difficult to obtain in a load-independent fashion. To investigate this concept, 12 patients (mean age, 65 +/- 8 years; mean New York Heart Association functional class, 3.3 +/- 0.7) with 4+ mitral regurgitation (n = 8) or mitral stenosis (valve area, 1.2 +/- 0.2 cm2) (n = 4) underwent prosthetic valve replacement using crystalloid cardioplegia. No patient required therapeutic inotropic support, every patient had at least the anterior mitral leaflet excised, and paced heart rate was maintained constant throughout. Left ventricular volume was measured with radionuclide angiocardiography, left ventricular pressure with a 3F micromanometer, and left ventricular wall volume with two-dimensional transesophageal echocardiography. Left ventricular preload was varied over a mean end-diastolic pressure range of 9 to 20 mm Hg and an end-diastolic volume range of 134 to 170 mL to generate four to five steady-state pressure-volume loops before and ten minutes after cardiopulmonary bypass. Left ventricular performance was estimated with the stroke work/end-diastolic volume relationship, which is insensitive to load. After bypass, no significant change (p greater than 0.1) was noted in wall volume for patients with mitral regurgitation or mitral stenosis (175 +/- 68 to 189 +/- 63 mL/m2 and 130 +/- 22 to 127 +/- 19 mL/m2, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Determinants of survival and left ventricular performance after mitral valve replacement. Department of Veterans Affairs Cooperative Study on Valvular Heart Disease

To determine how survival and clinical status were related to left ventricular (LV) size and systolic function after mitral valve replacement, 104 patients (48 mitral regurgitation [MR], 33 mitral stenosis [MS], and 23 MS/MR) with isolated mitral valve replacement were evaluated before and after surgery. Preoperative hemodynamic abnormalities by cardiac catheterization were improved 6 months after surgery in all three patient groups. The patients with MR exhibited reductions in LV end-diastolic volume index (EDVI) (117 +/- 51 to 89 +/- 27 ml/m2, p less than 0.001) and ejection fraction (EF) (0.56 +/- 0.15 to 0.45 +/- 0.13, p less than 0.001); however, the ratio of forward stroke volume to end-diastolic volume increased (0.32 +/- 0.21 to 0.45 +/- 0.17, p less than 0.001) because of the elimination of regurgitant volume. Survival analysis revealed that mortality was significantly higher in MS or MS/MR patients with postoperative EDVI more than 101 ml/m2 (p less than 0.001 and p less than 0.042, respectively) and in MR patients with postoperative EF less than or equal to 0.50 (p less than 0.031). Also, the majority of patients with MR or MS/MR and postoperative EDVI more than 101 ml/m2 and EF less than or equal to 0.50 were in New York Heart Association class III or IV. Multivariate logistic regression analysis in the patients with MR revealed that the strongest predictor of postoperative EF was preoperative EF (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)