Restrictive Mitral Valve Annuloplasty for Chronic Ischemic Mitral Regurgitation: A 5-Year Clinical Experience with the Physio Ring
Background: This study investigated the results of restrictive mitral annuloplasty with the semirigid Carpentier-Edwards Physio ring in patients with moderately severe to severe chronic ischemic mitral regurgitation (IMR) and advanced ischemic cardiomyopathy (ICM).
Methods: From 2003 to 2007, 100 consecutive patients (mean age ± SD, 69 ± 10 years) with chronic IMR of grades 3 to 4 (3.6 ± 0.5) and a left ventricular ejection fraction (LVEF) of 31% ± 9% (range, 12%-45%) underwent standardized restrictive prosthetic ring annuloplasty (ie, downsizing of 2.7 ± 1.0 [range, 2-4] ring sizes) and concomitant coronary artery bypass grafting. All surviving patients were restudied 8 ± 1 days, 3 ± 1 months, and 2.5 ± 1.0 years after surgery to assess survival, residual MR, New York Heart Association (NYHA) class, and LV function (end-systolic and end-diastolic dimension/volume indices and LVEF). Data were analyzed exploratatively.
Results: Survival rates at the postoperative reexamination times were 98%, 97%, and 94%, respectively (1 noncardiac and 5 cardiac deaths). NYHA class improved from 3.5 ± 0.5 to 1.4 ± 0.5 (P < .0005). The residual MR grades at discharge, early follow-up, and late follow-up were 0.4 ± 0.5, 0.5 ± 0.5, and 0.4 ± 0.6, respectively (P < .0005). Post-operative recurrence of significant IMR (>grade 2) was absent in all patients. The leaflet coaptation height was 8 ± 1 mm and did not decrease significantly over time. All LV dimension and volume indices and the LVEF (41% ± 9% at 2.5 years) improved significantly after surgery (P < .0005), even in patients with initially severely reduced myocardial function and a preoperative LVEF of <30% (n = 42; LVEF, 22% ± 5% versus 33% ± 6% at late follow-up; P < .0005).
Conclusion: Restrictive mitral valve annuloplasty using the semirigid Physio ring corrected chronic IMR in ICM patients with very low mortality and improved contractility. Surgery also prevented recurrence of significant IMR in parallel with the phenomenon of postoperative continuous reverse myocardial remodeling.
Acker MA, Bolling S, Shemin R., et al, for the Acorn Trial Principal Investigators and Study Coordinators. 2006. Mitral valve surgery in heart failure: insights from the Acorn clinical trial. J Thorac Cardiovasc Surg 132:568-77.nAklog L, Filsoufi F, Flores KQ, et al. 2001. Does coronary artery bypass grafting alone correct moderate ischemic mitral regurgitation? Circulation 104(12 Suppl 1):I68-75.nBax 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(11 Suppl 1): II103-08.nBerdat PA, Seck T, Schoenhoff F, et al. 2007. New generation annuloplasty ring systems for correction of ischemic mitral regurgitation in CAD and dilated CMP: early results. Thorac Cardiovasc Surg 55(suppl I):S38 [Presented at the 36th Annual Meeting, German Society of Thoracic, Cardiac and Vascular Surgery, Hamburg, Germany, February 11-14, 2007].nBitran D, Merin O, Klutstein MW, OD-Allah S, Shapira N, Silberman S. 2001. Mitral valve repair in severe ischemic cardiomyopathy. J Card Surg 16:79-82.nBolling SF, Deeb GM, Brunsting LA, Bach DS. 1995. Early outcome of mitral valve reconstruction in patients with end-stage cardiomyopathy. J Thorac Cardiovasc Surg 109:676-82.nCarpentier A. 1983. Cardiac valve surgery—the "French correction." J Thorac Cardiovasc Surg 86:323-37.nDe Bonis M, Lapenna E, Verzini A, et al. 2006. Recurrence of mitral regurgitation parallels the absence of left ventricular reverse remodeling after mitral repair in advanced dilated cardiomyopathy. Interact Cardiovasc Thorac Surg 5(suppl II):S219 [Presented at the 5th Joint Meeting of the EACTS/ESTS, Stockholm, Sweden, September 9-13, 2006].nDi Giammarco G, Pano M, Gagliardi M, Giancane M, Pelini P, Di Mauro M. 2006. Recurrence of functional mitral regurgitation in patients with dilated cardiomyopathy undergoing mitral valve repair: how to predict it? Interact Cardiovasc Thorac Surg 5(suppl II):S219 [Presented at the 5th Joint Meeting of the EACTS/ESTS, Stockholm, Sweden, September 9-13, 2006].nDreyfus G, Milaiheanu S. 2000. Mitral valve repair in cardiomyopathy. J Heart Lung Transplant 19(8 Suppl):S73-6.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.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.nGrossi EA, Goldberg JD, LaPietra A, et al. 2001. Ischemic mitral valve reconstruction and replacement: comparison of long-term survival and complications. J Thorac Cardiovasc Surg 122:1107-24.nHung J, Papakostas L, Tahta SA, et al. 2004. Mechanism of recurrent ischemic mitral regurgitation after annuloplasty: continued LV remodeling as a moving target. Circulation 110(11 Suppl 1):II85-90.nMenicanti L, Di Donato M, Frigiola A, et al. 2002. Ischemic mitral regurgitation: intraventricular papillary muscle imbrication without mitral ring during left ventricular restoration. J Thorac Cardiovasc Surg 123:1041-50.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.nSpoor MT, Geltz A, Bolling SF. 2006. Flexible versus nonflexible mitral valve rings for congestive heart failure: differential durability of repair. Circulation 114(1 Suppl):I67-71.nSuma H, Isomura T, Horii T, et al. 2000. Nontransplant cardiac surgery for end-stage cardiomyopathy. J Thorac Cardiovasc Surg 119:1233-44.nTrichon BH, Glower DD, Shaw LK, et al. 2003. Survival after coronary revascularization, with and without mitral valve surgery, in patients with ischemic mitral regurgitation. Circulation 108(Suppl 1):II103-10.nIsomura T, Suma H, Yamaguchi A, Kobashi T, Yuda A. 2003. Left ventricular restoration for ischemic cardiomyopathy—comparison of presence and absence of mitral valve procedure. Eur J Cardiothorac Surg 23:614-9.nMcGee EC, Gillinov AM, Blackstone EH, et al. 2004. Recurrent mitral regurgitation after annuloplasty for functional ischemic mitral regurgitation. J Thorac Cardiovasc Surg 128:916-24.nTimek TA, Glasson JR, Lai DT, et al. 2005. Annular height-to-commissural width ratio of annuloplasty rings in vivo. Circulation 112(9 Suppl):I423-8.nTrichon BH, Felker GM, Shaw LK, Cabell CH, O'Connor CM. 2003. Relation of frequency and severity of mitral regurgitation to survival among patients with left ventricular systolic dysfunction and heart failure. Am J Cardiol 91:538-43.n
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