Posterior Pericardial Annuloplasty in Ischemic Mitral Regurgitation
Background: Ischemic mitral regurgitation (IMR) is an important risk factor in coronary artery bypass grafting (CABG) operations. The decision to perform concomitant mitral annuloplasty along with the CABG depends on the surgeon's choice. The aim of this study was to evaluate the results of posterior annuloplasty procedures with autologous pericardium performed in patients with midadvanced and advanced functional ischemic mitral regurgitation.
Methods: Study participants were 36 patients with IMR (mean age 59 ± 10 years) who underwent posterior pericardial annuloplasty and CABG operations between 2002 and 2007. Preoperative and postoperative (mean follow-up 18 ± 1 months) MR grade, left atrium diameter, left ventricle end systolic diameter, left ventricle end diastolic diameter, left ventricle ejection fraction, and mitral valve gradients were measured with transthoracic echocardiography.
Results: There was one late mortality (2, 8%) but none of the patients required reoperation for residual MR. We did not observe thromboembolism, bleeding, or infective endocarditis. The mean MR grade decreased from 3.4 ± 0.5 to 0.5 ± 0.6 (P < .01), left atrium diameter decreased from 45.3 ± 5.5 mm to 43.2 ± 3.8 mm (P < .01), left ventricle end diastolic diameter decreased from 53.2 ± 5.6 mm to 50.9 ± 5.5 mm (P < .01), and left ventricle end systolic diameter decreased from 39.7 ± 5.8 mm to 34.6 ± 6.5 mm (P < .01), whereas mean left ventricle ejection fraction increased from 37.9% ± 6.1% to 43.7% ± 7.3% (P < .01). In the late postoperative term, the functional capacity of the patients increased from mean New York Heart Association class 2.6 ± 0.9 to 1.1 ± 0.5. We did not observe any gradient in the mitral valve preoperatively in any patient, but in the follow-up, the mean gradient increased to 1.3 ± 2.1 mmHg (P < .01).
Conclusion: Posterior pericardial annuloplasty with CABG in the treatment of IMR provides efficient mitral repair and significant decrease in the left atrium and left ventricle diameters, and provides a significant increase in left ventricular function. These results show IMR to be as effective as the other annuloplasty techniques. IMR is performed with autologuous material and therefore does not entail any risk of complications from prosthetic material and is highly cost-effective.
Bax JJ, Braun J, Somer ST, et al. 2004. Restrictive annuloplasty and coronary revascularization in ischemic mitral regurgitation results in reverse left ventricular remodeling. Circulation 110:II103-8.nBevilacqua S, Cerillo AG, Gianetti J, et al. 2003. Mitral valve repair for degenerative disease: is pericardial posterior annuloplasty a durable option? Eur J Cardiothorac Surg 23:552-9.nBorghetti V, Campana M, Scotti C, et al. 2000. Biological versus prosthetic ring in mitral-valve repair: enhancement of mitral annulus dynamics and left-ventricular function with pericardial annuloplasty at long term. Eur J Cardiothorac Surg 17:431-9.nBraun J, Bax JJ, Versteegh MI, et al. 2005. Preoperative left ventricular dimensions predict reverse remodeling following restrictive mitral annuloplasty in ischemic mitral regurgitation. Eur J Cardiothorac Surg 27:847-53.nBraun J, Van de Veire NR, Klautz R, et al. 2008. Restrictive mitral annuloplasty cures ischemic mitral regurgitation and heart failure. Ann Thorac Surg 85:430-7.nChotivatanapong T, Kasemsarn C, Sungkahapong V, Chaisei P, Yosthasurodom C, Cholitkui S. 2001. Mitral valve repair with autologous pericardial ring. Asian Cardiovasc Thorac Ann 9:10-3.nCalafiore AM, D. Mauro MD, Gallina S, Canusa C, Iacò AL. 2003. Optimal length of pericardial strip for posterior mitral overreductive annuloplasty. Ann Thorac Surg 75:1982-4.nGeidel S, Lass M, Schneider C, et al. 2005. Downsizing of the mitral valve and coronary revascularization in severe ischemic mitral regurgitation results in reverse left ventricular and left atrial remodeling. Eur J Cardiothorac Surg 27:1011-6.nGeidel S, Schneider C, Lass M, et al. 2007. Changes of myocardial function after combined coronary revascularization and mitral valve downsizing in patients with ischemic mitral regurgitation and advanced cardiomyopathy. Thorac Cardiovasc Surg 55:1-6.nGillinov AM, Wierup PN, Blackstone EH, et al. 2001. Is repair preferable to replacement for ischemic mitral regurgitation? J Thorac Cardiovasc Surg 122:1125-41.nGrigioni F, Enriquez-Sarano M, Zehr KJ, Bailey KR, Tajik AJ. 2001. Ischemic mitral regurgitation: long-term outcome and prognostic implications with quantitative doppler assessment. Circulation 103:1759-64.nKimYH, Czer LSC, Soukiasian HJ, et al. 2005. Ischemic mitral regurgitation: revascularization alone versus revascularization and mitral valve repair. Ann Thorac Surg 79:1895-901.nMatsukuma S, Eishi K, Yamachika S, et al. 2005. Risk factors of posterior pericardial annuloplasty for isolated posterior leaflet prolapse. Ann Thorac Surg 80:820-4.nPrifti E, Bonacchi M, Frati G, et al. 2001. Should mild-to-moderate and moderate ischemic mitral regurgitation be corrected in patients with impaired left ventricular function undergoing simultaneous coronary revascularization? J Card Surg 16:473-83.nReece TB, Tribble CG, Ellman PI, et al. 2004. Mitral repair is superior to replacement when associated with coronary artery disease. Ann Surg 239:671-7.nSalati M, Scrofani R, Santoli C. 1991. Posterior pericardial annuloplasty: a physicological correction? Eur J Cardiothorac Surg 5:226-9.nScrofani R, Moriggia S, Salati M, Fundaro P, Danna P, Santoli C. 1996. Mitral valve remodeling: long-term results with posterior pericardial annuloplasty. Ann Thorac Surg 61:895-9.n
How to Cite
Author Disclosure & Copyright Transfer Agreement
In order to publish the original work of another person(s), The Heart Surgery Forum® must receive an acknowledgment of the Author Agreement and Copyright Transfer Statement transferring to Forum Multimedia Publishing, L.L.C., a subsidiary of Carden Jennings Publishing Co., Ltd. the exclusive rights to print and distribute the author(s) work in all media forms. Failure to check Copyright Transfer agreement box below will delay publication of the manuscript.
A current form follows:
The author(s) hereby transfer(s), assign(s), or otherwise convey(s) all copyright ownership of the manuscript submitted to Forum Multimedia Publishing, LLC (Publisher). The copyright transfer covers the exclusive rights to reproduce and distribute the article and the material contained therein throughout the world in all languages and in all media of expression now known or later developed, including but not limited to reprints, photographic reproduction, microfilm, electronic data processing (including programming, storage, and transmission to other electronic data record(s), or any other reproductions of similar nature), and translations.
However, Publisher grants back to the author(s) the following:
- The right to make and distribute copies of all or part of this work for use of the author(s) in teaching;
- The right to use, after publication in The Heart Surgery Forum, all or part of the material from this work in a book by the author(s), or in a collection of work by the author(s);
- The royalty-free right to make copies of this work for internal distribution within the institution/company that employs the author(s) subject to the provisions below for a work-made-for-hire;
- The right to use figures and tables from this work, and up to 250 words of text, for any purpose;
- The right to make oral presentations of material from this work.
Publisher reserves the right to grant or refuse permission to third parties to republish all or part of the article or translations thereof. To republish, such third parties must obtain written permission from the Publisher. (This is in accordance with the Copyright Statute, United States Code, Title 17. Exception: If all authors were bona fide officers or employees of the U.S. Government at the time the paper was prepared, the work is a “work of the US Government” (prepared by an officer or employee of the US Government as part of official duties), and therefore is not subject to US copyright; such exception should be indicated on signature lines. If this work was prepared under US Government contract or grant, the US Government may reproduce, royalty-free, all or portions of this work and may authorize others to do so, for official US Government purposes only, if the US Government contract or grant so requires.
I have participated in the conception and design of this work and in the writing of the manuscript and take public responsibility for it. Neither this manuscript nor one with substantially similar content under my authorship has been published, has been submitted for publication elsewhere, or will be submitted for publication elsewhere while under consideration by The Heart Surgery Forum, except as described in an attachment. I have reviewed this manuscript (original version) and approve its submission. If I am listed above as corresponding author, I will provide all authors with information regarding this manuscript and will obtain their approval before submitting any revision. I attest to the validity, accuracy, and legitimacy of the content of the manuscript and understand that Publisher assumes no responsibility for the validity, accuracy, and legitimacy of its content. I warrant that this manuscript is original with me and that I have full power to make this Agreement. I warrant that it contains no matter that is libelous or otherwise unlawful or that invades individual privacy or infringes any copyright or other proprietary right. I agree to indemnify and hold Publisher harmless of and from any claim made against Publisher that relates to or arises out of the publication of the manuscript and agree that this indemnification shall include payment of all costs and expenses relating to the defense of any such claim, including all reasonable attorney’s fees.
I warrant that I have no financial interest in the drugs, devices, or procedures described in the manuscript (except as disclosed in the attached statement).
I state that the institutional Human Subjects Committee and/or the Ethics Committee approved the clinical protocol reported in this manuscript for the use of experimental techniques, drugs, or devices in human subjects and appropriate informed consent documents were utilized.
Furthermore, I state that any and all animals used for experimental purposes received humane care in USDA registered facilities in compliance with the “Principles of Laboratory Animal Care” formulated by the National Society for Medical Research and the “Guide for the Care and Use of Laboratory Animals” prepared by the Institute of Laboratory Animal Resources and published by the National Institutes of Health (NIH Publication No. 85-23, revised 1985).