Heart failure
Predictors of Mitral Regurgitation Recurrence in Patients With Heart Failure Undergoing Mitral Valve Annuloplasty

https://doi.org/10.1016/j.amjcard.2010.03.042Get rights and content

Restrictive mitral annuloplasty is a surgical treatment option for patients with heart failure (HF) and functional mitral regurgitation (MR). However, recurrent MR has been reported at mid-term follow-up. The aim of the present study was to identify the echocardiographic predictors of recurrent MR in patients with HF undergoing mitral annuloplasty. During a mean follow-up of 2.6 ± 1.6 years, 109 patients with HF (49% ischemic and 51% idiopathic dilated cardiomyopathy) who had undergone mitral valve repair were followed up (of 122 total patients). The severity of MR was quantified, and the following parameters were measured before intervention and at the mid-term follow-up examination: left ventricular (LV) and left atrial volumes and dimensions, LV sphericity index, mitral annular area, and mitral valve geometry parameters. At mid-term follow-up, 21 patients presented with significant MR (grade 2 to 4), and 88 patients had only MR grade 0 to 1. Both groups of patients had had a similar preoperative MR grade, mitral annular area, and LV volume and dimension. In contrast, patients with recurrent MR had had increased preoperative posterior and anterior leaflet angles, tenting height, tenting area, and LV sphericity index compared to the patients without recurrent MR. Of the different parameters of mitral and LV geometry, the distal mitral anterior leaflet angle (hazard ratio 1.48, 95% confidence interval 1.32 to 1.66, p <0.001) and posterior leaflet angle (hazard ratio 1.13, 95% confidence interval 1.07 to 1.19, p <0.001) were independent determinants of MR at mid-term follow-up. In conclusion, in patients with HF of ischemic or idiopathic etiology and functional MR, distal mitral leaflet tethering and posterior mitral leaflet tethering were associated with recurrent MR after restrictive mitral annuloplasty.

Section snippets

Methods

A total of 122 patients with HF and moderate to severe MR were included. The patients were scheduled for restrictive mitral annuloplasty, accompanied by coronary artery bypass grafting if indicated. In patients with HF with idiopathic cardiomyopathy, restrictive mitral annuloplasty was performed with concomitant placement of a CorCap (Acorn Cardiovascular, St. Paul, Minnesota) cardiac support device if significant LV dilation (LV diameter >65 mm) was measured on the preoperative

Results

The demographic, clinical, and surgical characteristics of the patients are listed in Table 1. The mean age was 62 ± 11 years, and 61% of patients were men. Most patients (85%) had New York Heart Association functional class III or IV. Patients were receiving optimal medical treatment for HF. No clinically relevant difference was found in the demographic or clinical characteristics between the patients with recurrent MR and those without recurrent MR at mid-term follow-up.

In 37% of patients,

Discussion

The results of the present study have identified baseline echocardiographic predictors of mid-term recurrent MR after restrictive mitral annuloplasty for functional MR. In a cohort of patients with HF of ischemic or nonischemic origin, distal mitral anterior leaflet tethering, as estimated by the ALAtip, and posterior leaflet tethering, as estimated by the PLA, were independent predictors of recurrent MR after mitral annuloplasty.

The spherical shape of the left ventricle plays an important role

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    Indeed, in patients without advanced LV remodeling and severe leaflet tethering, mitral valve repair with an undersized complete ring may offer satisfactory results.45 Conversely, in patients with echocardiographic predictors of annuloplasty failure46–48 (Table 4), additional valvular/subvalvular techniques or chordal sparing valve replacement should be considered to achieve a more durable solution.49 Nevertheless, it is important to acknowledge that no one of these singular echocardiographic parameters demonstrated a strong and highly reproducible association with annuloplasty failure, while discrepant results have been reported by different studies on this topic.50,51

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Dr. Ciarka received a training grant in noninvasive imaging in cardiology from the European Society of Cardiology (Sophia Antipolis, France) and a grant from the Horlait-Dapsens Foundation (Brussels, Belgium). Dr. Bax received grants from Biotronik (Berlin, Germany), Medtronic (Minneapolis, Minnesota), Boston Scientific Corporation (Natic, Massachusetts), Bristol-Myers Squibb Medical Imaging (New York, New York), St Jude Medical (St. Paul, Minnesota), GE Healthcare (Milwaukee, Wisconsin), and Edwards Lifesciences (Irving, California). Dr. Dion is on the speakers' bureau of Edwards Lifesciences (Irving, California).

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