Valvular heart disease
Echocardiographic Predictors of Successful Versus Unsuccessful Mitral Valve Repair in Ischemic Mitral Regurgitation

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Mitral valve (MV) annuloplasty is the standard surgical technique for the management of ischemic mitral regurgitation (MR). However, ≤1/3 of patients develop recurrent MR after annuloplasty. Therefore, we sought to identify the preoperative echocardiographic parameters that predict annuloplasty failure in patients with ischemic MR. Intraoperative transesophageal echocardiograms from 365 patients who underwent MV repair for ischemic MR were reviewed. Of the 365 patients, 297 (81%) had satisfactory outcomes with <2+ MR, and 68 (19%) had recurrent MR (≥2+) during a mean follow-up of 269 days. The mitral annular parameters, including mitral annular diameter, tethering height, and tethering area of the mitral leaflets, were determined in 3 different echocardiographic views. On multiple logistic stepwise regression analysis, a higher mitral annular diameter, higher tethering area, and higher MR severity were identified as independent predictors for failure of MV repair (p <0.0001). In conclusion, these results demonstrated that preoperative echocardiographic findings can be used to identify patients with ischemic MR at increased risk of repair failure. These echocardiographic measurements should be used to guide the cardiologist and cardiac surgeon in the choice of MV repair versus replacement in patients with ischemic MR.

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Study patients

Examination of the Cardiovascular Information Registry and Echocardiography Databases at the Cleveland Clinic identified 365 patients who had undergone annuloplasty for ischemic MR and who had complete preoperative transesophageal echocardiographic (TEE) studies from April 1990 to November, 2002. The institutional review board approved the use of the database for clinical research. All patients had functional ischemic MR according to established definitions,5 and none had organic MV disease.

Baseline characteristics

The mean patient age was 66 ± 9 years (range 41 to 83). A total of 344 patients (94%) underwent coronary artery bypass grafting in addition to MV repair, and 21 patients (6%) underwent isolated MV repair. Also, 21 patients (6%) underwent tricuspid valve annuloplasty for severe tricuspid regurgitation.

Success and failure of MV repair

According to the follow-up echocardiographic criteria, 297 patients (81%) had successful mitral repair and 68 (19%) had failed repair (Figure 2). The patients with successful and unsuccessful MV

Discussion

The results of this study demonstrated that routine measurements on preoperative transesophageal echocardiography can be used to identify patients with ischemic MR who are likely to have recurrent MR after surgical annuloplasty. Specifically, increased mitral annular diameter, tethering area, and MR grade were associated with repair failure.

Several echocardiographic studies have detailed the mechanisms of ischemic MR and the results of surgical annuloplasty.12, 13, 14 The recognition that the

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This study was supported in part by Bangkok Metropolitan Administration, Bangkok, Thailand.

Dr. Gillinov is a consultant to Edwards Lifesciences, LLC and has an equity interest in Viacor, Inc., Wilmington, Massachusetts.

Dr. McCarthy is a consultant to Edwards Lifesciences, LLC and an inventor, for which he receives royalties from Edwards Lifesciences, LLC, Irvine, California.

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