Operative correction of ischemic mitral regurgitation (IMR) is associated with high risk approach. The objective of this retrospective study was to examine the interaction between the various underlying pathophysiologic mechanisms, the operative procedure, and their influence on short- and long-term outcomes. Over a 10-year period starting January 1984, mitral valve repair or replacement was performed on 150 patients with IMR. The age range was 42-86, mean 67, years; 71 (47%) were females; 139 (93%) were in NYHA functional class III or IV; 23 (15%) were reoperations; and 30 (20%) were in atrial fibrillation. Functional IMR due to annular dilatation or restrictive leaflet motion was present in 106 (71%), and structural IMR due to ruptured chordae or papillary muscle in 44 (29%). Mitral valve repair was performed in 94 (63%) with an annuloplasty ring employed in 80 (85%) patients. Mitral valve replacement was performed in 56 (37%), with 40 (71%) receiving a bioprosthesis (32 Hancock and 8 Carpentier-Edwards valves) and 16 (29%) a St. Jude valve. Coronary artery bypass graft surgery was performed in 139 (93%) patients. The overall operative mortality (OM) was 14/150 (9.3%). The OM for repair was 9.5% compared to 8.9% for replacement (P = NS). There was higher OM in the elderly, particularly in the repair group (P = 0.053), and a trend towards reduced OM in the recent years of the study (P = NS). No predictors of OM were identified by multivariate logistic regression analysis. Long-term follow-up was 98% complete and ranged from 2-120, mean 31.2, months for a total of 935 patient-years. The overall 5-year survival rate was 71 +/- 6%, with 91 +/- 5% for the replacement group compared to 56% +/- 10% for the repair group (P = 0.01). The functional subset of IMR who had a repair had the worse long-term survival (43 +/- 13%) compared to the structural/repair (76 +/- 13%) and structural/replacement groups (89 +/- 8%), and 92 +/- 7% for the functional/replacement group ((P = 0.0049). Multivariate logistic regression analysis identified the functional/repair group (hazards ratio 4.4; +/- 95%, confidence interval 1.6, 11, (P = 0.0031); and earlier years of surgery (hazards ratio 4.7; +/- 95% confidence interval 1.021; (P = 0.046) to be predictors of worse long-term survival. These results suggest that, in IMR, the underlying responsible pathophysiologic mechanisms appear to be the major determinants of survival, rather than the choice of the operative procedure.

The myxomatous degenerated, prolapsed, or floppy mitral valve is the most common etiology of mitral regurgitation in North American populations. We performed mitral valve reconstruction for this diagnosis in 252 patients from 1984 to 1993. There were 165 males and 87 females ranging in age from 23 to 84 years (mean 64 years); 93 (37%) were > or = 70 years. One hundred eighty-six were New York Heart Association Functional Class III or IV and 29% (72) underwent concomitant coronary bypass operation. Operations included posterior leaflet resection, anterior leaflet resection treatment of chordal pathology by shortening or Gore-Tex replacement, and ring annuloplasty. There were five operative deaths for an operative mortality of 2%. The operative risk in patients under 70 years was 1 of 159 (0.6%) and 4 of 93 (4%) in patients older than 70 years. Ninety percent of patients are asymptomatic in a follow-up period extending 10 years, while structural valve degeneration requiring reoperation at 5 years was 85%. From 1990 to 1993 there has been a less than 5% absolute incidence of structural valve degeneration. Mitral valve reconstruction for complicated floppy mitral valve is feasible and offers excellent early and medium-term results.

A 53-yr-old woman with a left ventricular assist device (LVAD), placed 4 mo before admission for idiopathic dilated cardiomyopathy, was awaiting heart transplantation. She was found unresponsive at home with low cardiac output from her LVAD. No signs of fractures or thoracic bruising were present and she did not require chest compressions for resuscitation. During transport to the hospital, she was tracheally intubated, started on inotropic drugs, and transferred directly to the operating room on arrival to the hospital for surgical evaluation.Transesophageal echocardiography (TEE) was performed in the operating room to evaluate the patient's critical condition. TEE demonstrated a fluid collection adjacent to the right ventricle (RV) in the midesophageal four-chamber view at 0°and midesophageal long axis view at 87°rotation (Fig. 1, video clip 1; please see video clip available at www.anesthesia-analgesia.org). The LVAD inflow cannula in the left ventricle did not show any signs of obstruction or malpositioning, the LVAD outflow cannula in the aorta was not visible on TEE, although TEE is an ideal technique for evaluating LVAD placement and function. 1 A drain was placed percutaneously via a subxiphoid approach under TEE guidance by visualizing the position of the paracentesis cannula in the fluid cavity. The patient remained hemodynamically unstable with continuing drainage of a large amount of blood. Further inspection on TEE with color flow Doppler revealed a communication between the fluid cavity and the RV (Fig. 2, top). Pulsed wave Doppler identified flow from the RV into the RV dissection cavity (Fig. 2, bottom). Cardiopulmonary bypass was initiated via cannulation of the femoral vessels. During surgical exploration, the RV was found to be dissected in a large portion, producing an intramural pocket. Therefore, the surgical finding confirmed the primary diagnosis made on TEE. The RV was considered irreparable by the surgeon because of the large ventricular dissection in conjunction with extremely friable myocardial tissue. The patient's overall detrimental condition before surgery in conjunction with an irreparable RV resulted in the decision to discontinue cardiopulmonary bypass and declare the patient dead. Postmortem autopsy confirmed the surgical finding of an intramural RV dissection.RV dissection is infrequent, and can result from myocardial infarction, coronary artery balloon angioplasty, thrombolytic therapy, cardiac operation, or chest trauma. 2,3 It may also occur spontaneously with unknown etiology. 4 The differential diagnosis for RV fluid collection includes pericardial hematoma, RV This article has supplementary material on the Web site:www.anesthesia-analgesia.org.