Changes of Myocardial Function after Combined Coronary Revascularization and Mitral Valve Downsizing in Patients with Ischemic Mitral Regurgitation and Advanced Cardiomyopathy

Abstract

Objective: At present not much data is available on changes in myocardial function after combined coronary artery bypass grafting (CABG) and downsizing of the mitral valve (MV) by restrictive prosthetic ring annuloplasty in patients with chronic ischemic mitral regurgitation (IMR) and advanced cardiomyopathy. Methods: 63 patients with coronary artery disease, chronic IMR grade 3 - 4+, ischemic cardiomyopathy and reduced left ventricular (LV) function (LV ejection fraction [LVEF] of 30 ± 9 %; range 12 - 45 %) underwent combined CABG and MV downsizing. Clinical follow-up and serial echocardiographic studies were performed to assess survival, New York Heart Association (NYHA) class, mitral regurgitation (MR), leaflet coaptation height (LCH), left atrial (LA) and LV end-systolic/end-diastolic dimensions/volumes and volume indices (LVESD, -EDD; LVESV, -EDV; LVESVI, -EDVI), fractional shortening (FS) and LVEF to evaluate the changes in myocardial function after surgery. Results: Early mortality (< 30 days) was 1.6 %, survival at follow-up was 95 % (3 ± 1 months) and 83 % (2 ± 1 years), respectively. Functional class improved significantly after surgery; recurrence of relevant MR was absent in all patients. In general, LA/LV dimensions/volumes and volume indices, FS and LVEF improved significantly, even in patients with already severely reduced preoperative LV function (LVEF ≤ 25 %, n = 23), a significant improvement of myocardial function was observed. Conclusion: Combined MV downsizing and CABG surgery can be performed with low early and late mortality, resulting in a significant improvement of myocardial function and without MR recurrence at short-term and mid-term follow-up.

Key words

ischemic mitral regurgitation - mitral valve repair - reverse myocardial remodelling - remodelling - restrictive annuloplasty

References

• 1 Trichon B H, Felker G M, Shaw L K, Cabell C H, O'Connor C M. Relation of frequency and severity of mitral regurgitation to survival among patients with left ventricular systolic dysfunction and heart failure.  Am J Cardiol. 2003;  91 538-543
• 2 Bax J J, Braun J, Somer S T, Klautz R, Holman E R, Versteegh M IM, Boersma E, Schalij M J, van der Wall E E, Dion R A. Restrictive annuloplasty and coronary revascularization in ischemic mitral regurgitation results in reverse left ventricular remodeling.  Circul. 2004;  110 (Suppl II) II103-II108
• 3 Hung J, Papakostas L, Tahta S A, Hardy B G, Bollen B A, Duran C M, Levine R A. Mechanism of recurrent ischemic mitral regurgitation after annuloplasty: continued LV remodeling as a moving target.  Circul. 2004;  110 (Suppl II) II85-II90
• 4 McGee E C, Gillinov A M, Blackstone E H, Rajeswaran J, Cohen G, Najam F, Shiota T, Sabik J F, Lytle B W, McCarthy P M, Cosgrove D M. Recurrent mitral regurgitation after annuloplasty for functional ischemic mitral regurgitation.  J Thorac Cardiovasc Surg. 2004;  128 916-924
• 5 Carpentier A. Cardiac valve surgery - the “French correction”.  J Thorac Cardiovasc Surg. 1983;  86 323-337
• 6 He S, Fontaine A, Schwammental E, Yoganathan A, Levine R A. Integrated mechanism for functional mitral regurgitation. Leaflet restriction versus coapting force: in vitro studies.  Circul. 1997;  96 1826-1834
• 7 Geidel S, Ostermeyer J, Lass M, Betzold M, Duong A, Jensen F, Boczor S, Kuck K H. Three years experience with monopolar and bipolar radiofrequency ablation surgery in patients with permanent atrial fibrillation.  Eur J Cardiothorac Surg. 2005;  27 243-249
• 8 Geidel S, Lass M, Schneider C, Groth G, Boczor S, Kuck K H, Ostermeyer J. 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. 2005;  27 1011-1016
• 9 Hall S A, Brickner M E, Willett D WL, Irani W N, Afridi I, Grayburn P A. Assessment of mitral regurgitation severity by Doppler color flow mapping of the vena contracta.  Circul. 1997;  95 636-642
• 10 Agricola E, Oppizzi M, Maisano F, De Bonis M, Schinkel A FL, Torracca L, Margonato A, Melisurgo G, Alfieri O. Echocardiographic classification of chonic ischemic mitral regurgitation caused by restricted motion according to tethering pattern.  Eur J Echocardiography. 2004;  5 326-334
• 11 Schiller N B, Shah P M, Crawford M, DeMaria A, Devereux R, Feigenbaum H, Gutgesell H, Reichek N, Sahn D, Schnittger I. Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. American Society of Echocardiography Committee on Standards, Subcommittee on Quantitation of Two-Dimensional Echocardiograms.  J Am Soc Echocardiogr. 1989;  2 358-367
• 12 Grigioni F, Enriquez-Sarano M, Zehr K J, Bailey K R, Tajik A J. Ischemic mitral regurgitation: long-term outcome and prognostic implications with quantitative Doppler assessment.  Circul. 2001;  103 1759-1764
• 13 Aklog L, Filsoufi F, Flores K Q, Chen R H, Cohn L H, Nathan N S, Byrne J G, Adams D H. Does coronary artery bypass grafting alone correct moderate ischemic mitral regurgitation?.  Circul. 2001;  104 (Suppl I) I68-I75
• 14 Trichon B H, Glower D D, Shaw L K, Cabell C H, Anstrom K J, Felker G M, O'Connor C M. Survival after coronary revascularization, with and without mitral valve surgery, in patients with ischemic mitral regurgitation.  Circul. 2003;  108 (Suppl II) II103-II110
• 15 Reece T B, Tribble C G, Ellman P I, Maxey T S, Woodford R L, Dimeling G M, Wellson H A, Crosby I K, Kern J A, Kron I L. Mitral repair is superior to replacement when associated with coronary artery disease.  Ann Surg. 2004;  239 671-677
• 16 Grossi E A, Goldberg J D, LaPietra A, Ye X, Zakow P, Sussman M, Delianides J, Culliford A T, Esposito R A, Ribakove G H, Galloway A C, Colvin S B. Ischemic mitral valve reconstruction and replacement: comparison of long-term survival and complications.  J Thorac Cardiovasc Surg. 2001;  122 1107-1124
• 17 Szalay Z A, Civelek A, Hohe S, Brunner-LaRocca H P, Klövekorn W P, Knez I, Vogt P R, Bauer E P. Mitral annuloplasty in patients with ischemic versus dilated cardiomyopathy.  Eur J Cardiothorac Surg. 2003;  23 567-572
• 18 Mallidi H R, Pelletier M P, Lamb J, Desai N, Sever J, Christakis G T, Cohen G, Goldman B S, Fremes S E. Late outcome in patients with uncorrected mild to moderate mitral regurgitation at the time of isolated coronary artery bypass grafting.  J Thorac Cardiovasc Surg. 2004;  127 636-644
• 19 Tolis Jr G A, Korkolis D P, Kopf G S, Elefteriades J A. Revascularization alone (without mitral valve repair) suffices in patients with advanced ischemic cardiomyopathy and mild-to-moderate mitral regurgitation.  Ann Thorac Surg. 2002;  74 1476-1480
• 20 Bolling S F, Deeb G M, Brunsting L A, Bach D S. Early outcome of mitral valve reconstruction in patients with end-stage cardiomyopathy.  J Thorac Cardiovasc Surg. 1995;  109 676-682
• 21 Dobre M, Koul B, Rojer A. Anatomic and physiologic correction of the restricted posterior mitral leaflet motion in chronic ischemic mitral regurgitation.  J Thorac Cardiovasc Surg. 2000;  120 409-411
• 22 Menicanti L, Di Donato M, Frigiola A, Buckberg G, Santambrogio C, Ranucci M, Santo D. Ischemic mitral regurgitation: intraventricular papillary muscle imbrication without mitral ring during left ventricular restoration.  J Thorac Cardiovasc Surg. 2002;  123 1041-1050
• 23 Isomura T, Suma H, Yamaguchi A, Kobashi T, Yuda A. Left ventricular restoration for ischemic cardiomyopathy - comparison of presence and absence of mitral valve procedure.  Eur J Cardiothorac Surg. 2003;  23 614-619
• 24 Daimon M, Shiota T, Gillinov A M, Hayase M, Ruel M, Cohn W E, Blacker S J, Liddicoat J R. Percutaneous mitral valve repair for chronic ischemic mitral regurgitation: a real-time dimensional echocardiographic study in an ovine model.  Circul. 2005;  111 2183-2189
• 25 Swan H J, Forrester J S, Diamond G, Chatterjee K, Parmley W W. Hemodynamic spectrum of myocardial infarction and cardiogenic shock: a conceptual model.  Circul. 1972;  45 1097