Elsevier

The Annals of Thoracic Surgery

Volume 90, Issue 6, December 2010, Pages 1913-1920
The Annals of Thoracic Surgery

Original article
Adult cardiac
Clinical and Functional Effects of Restrictive Mitral Annuloplasty at Midterm Follow-Up in Heart Failure Patients

https://doi.org/10.1016/j.athoracsur.2010.08.010Get rights and content

Background

Restrictive mitral annuloplasty (RMA) is increasingly applied to treat functional mitral regurgitation in heart failure patients. Previous studies indicated beneficial clinical effects with low recurrence rates. However, the underlying pathophysiology is complex and outcome in terms of left ventricular function is not well known. We investigated chronic effects of RMA on ventricular function in relation to clinical outcome.

Methods

Heart failure patients (n = 11) with severe mitral regurgitation scheduled for RMA were analyzed at baseline (presurgery) and midterm follow-up by invasive pressure-volume loops, using conductance catheters. Clinical performance was evaluated by New York Heart Association class, quality-of-life-score, and 6-minute hall-walk-test.

Results

All patients were alive without recurrence of mitral regurgitation at follow-up (9.4 ± 4.1 months). Clinical parameters improved significantly (all p < 0.05). Global cardiac function, assessed by cardiac output, stroke volume, and stroke work did not change after RMA. Reverse remodeling was demonstrated by decreased end-systolic and end-diastolic volumes (16% and 11%, both p < 0.001). Systolic function improved, evidenced by increased ejection fraction (0.32 ± 0.05 to 0.36 ± 0.07, p = 0.001) and leftward shift of the end-systolic pressure-volume relation (ESV100: 116 ± 43 to 74 ± 26 mL, p < 0.001). Diastolic function, however, demonstrated impairment by increased tau (69 ± 13 to 80 ± 14 ms, p < 0.001) and stiffness constant (0.022 ± 0.022 to 0.031 ± 0.028 mL−1, p = 0.001).

Conclusions

Restrictive mitral annuloplasty significantly improved clinical status without recurrence of mitral regurgitation at midterm follow-up in patients with heart failure. Hemodynamic analyses demonstrated significant reverse remodeling with unchanged global function and improved systolic function, but some signs of diastolic impairment. Overall, RMA appears an appropriate therapy for patients with dilated cardiomyopathy and functional mitral regurgitation.

Section snippets

Patients

The study group consisted of 11 patients with cardiomyopathy, New York Heart Association (NYHA) class III/IV, LV ejection fraction (LVEF) less than 0.35, and MR grade 2 or greater, who were scheduled for RMA. The mechanism of MR was based on malcoaptation due to LV dilatation. Patients received optimal medical management for heart failure. Patients with primary mitral valve dysfunction (prolapse, rheumatic disease, stenosis) or a biologic or mechanical prosthesis in the aortic position were

Surgical and Clinical Data

We enrolled 11 patients (6 male, 5 female; 65 ± 16 years), All patients underwent RMA (median ring size, 26; range, 24 to 28). Eight patients were diagnosed with ischemic cardiomyopathy of which 6 underwent additional CABG, one was already revascularized (CABG) in the past, and one had proven irreversible ischemia. In 6 patients with severe tricuspid regurgitation, a concomitant restrictive tricuspid annuloplasty was performed (median ring size, 26; range, 26 to 30). Cardiopulmonary bypass

Comment

Recent studies demonstrated good survival rates after RMA surgery of approximately 90% and 70% at 1-year and 5-year follow-up, respectively. Although no significant difference in survival rate could be detected when comparing CABG with additional RMA versus CABG alone [13, 28, 29], the efficacy of adding RMA to CABG was demonstrated by improved clinical performance according to improved NYHA class [12]. Furthermore, improved exercise tolerance was demonstrated by treadmill stress tests in

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