Predicting recurrent mitral regurgitation after mitral valve repair for severe ischemic mitral regurgitation

Abstract

Objectives The Cardiothoracic Surgical Trials Network recently reported no difference in the primary end point of left ventricular end-systolic volume index at 1 year postsurgery in patients randomized to repair (n = 126) or replacement (n = 125) for severe ischemic mitral regurgitation. However, patients undergoing repair experienced significantly more recurrent mitral regurgitation than patients undergoing replacement (32.6% vs 2.3%). We examined whether baseline echocardiographic and clinical characteristics could identify those who will develop moderate/severe recurrent mitral regurgitation or die. Methods Our analysis includes 116 patients who were randomized to and received mitral valve repair. Logistic regression was used to estimate a model-based probability of recurrence or death from baseline factors. Receiver operating characteristic curves were constructed from these estimated probabilities to determine classification cut-points maximizing accuracy of prediction based on sensitivity and specificity. Results Of the 116 patients, 6 received a replacement before leaving the operating room; all other patients had mild or less mitral regurgitation on intraoperative echocardiogram after repair. During the 2-year follow-up period, 76 patients developed moderate/severe mitral regurgitation or died (53 mitral regurgitation recurrences, 13 mitral regurgitation recurrences and death, and 10 deaths). The mechanism for recurrent mitral regurgitation was largely mitral valve leaflet tethering. Our model (including age, body mass index, sex, race, effective regurgitant orifice area, basal aneurysm/dyskinesis, New York Heart Association class, history of coronary artery bypass grafting, percutaneous coronary intervention, or ventricular arrhythmias) yielded an area under the receiver operating characteristic curve of 0.82. Conclusions The model demonstrated good discrimination in identifying patients who will survive 2 years without recurrent mitral regurgitation after mitral valve repair. Although our results require validation, they offer a clinically relevant risk score for selection of surgical candidates for this procedure.

Analysing the reasons of failure of surgical mitral repair approaches—do we need to better think in biomechanics?

“…Given the high rate of recurrent mitral regurgitation in patients after RA-repair, surgeons have to consider chordalsparing mitral-valve replacement or combined procedure with subvalvular repair and undersizing mitral annuloplasty to solve ischemic mitral disorder (9)(10)(11)(12)(13)(14). The results of the two-years randomized trial in patients with moderate and severe IMR by the Cardiothoracic Surgical Trials Network (CTSN) imposed the need to revise the surgical dogma regarding the superiority of mitral valve repair over replacement (9,10).…”

A Comparison of 2 Mitral Annuloplasty Rings for Severe Ischemic Mitral Regurgitation: Clinical and Echocardiographic Outcomes

“…20 This is traditionally attributed to a potentially excessive reduction of mitral annular area by the ring and abnormal leaflet opening function (diastolic tethering of anterior mitral leaflet). 6,7 Whether the degree of mitral stenosis created by restrictive mitral annuloplasty limits patients' exercise capacity and compromises the patient outcome remains controversial. 21,22 However, most studies have based stenosis grading on the mean transmitral pressure gradient at rest that largely underestimates the hemodynamic effect of stenosis.…”

“…2 To date, restrictive MVA represents the most performed techniques used to treat patients with secondary MR. 3 Several studies have shown that the recurrence of MR at 1-year remains high (10%-30%). [4][5][6] Moreover, it has been reported that restrictive MVA could be associated with impaired hemodynamic profile with higher transmitral gradient and systolic pulmonary artery pressure (PAP) at exercise and worsening in functional New York Heart Association (NYHA) class. 7 Several types of prosthetic rings exist to remodel the mitral annulus.…”

Transcatheter Treatment of Mitral Valve Disease

“…Although surgical annuloplasty can correct the MR for the short term, it recurs in about one third of patients at 1 year. 11 A recent randomized trial of repair versus replacement in ischemic MR demonstrated a more durable correction with valve replacement at 2 years. It is in this arena that the field of transcatheter mitral valve replacement is most commonly being used in early feasibility trials.…”