Functional impact of transmitral gradients at rest and during exercise after restrictive annuloplasty for ischemic mitral regurgitation.

Restrictive mitral valve annuloplasty combined with coronary artery bypass grafting is the treatment of choice for ischemic mitral regurgitation. Postoperative functional mitral stenosis and its potential impact on functional capacity remain the object of debate. The aim of this study was to assess functional and hemodynamic outcome at rest and during exercise in a population with ischemic mitral regurgitation after a standardized restrictive mitral valve annuloplasty. A total of 23 patients with ischemic mitral regurgitation who were previously treated with coronary artery bypass grafting and restrictive mitral valve annuloplasty underwent a semi-supine (bicycle) exercise test with Doppler echocardiography and ergospirometry. The surgical technique was identical in all patients, using a complete semi-rigid ring downsized by 2 sizes after measuring the height of the anterior mitral leaflet, to achieve a coaptation length of at least 8 mm. At a mean follow-up of 28 ± 15 months, mean transmitral gradients at rest and maximal exercise were 4.4 ± 1.8 mm Hg and 8.2 ± 4.2 mm Hg, respectively (P < .001). Transmitral gradients did not correlate with exercise capacity (maximal oxygen uptake) or pulmonary artery pressures. Patients with a resting mean gradient of 5 mm Hg or greater (n = 9) reached a significantly higher maximal oxygen uptake; however, they had a better ejection fraction and cardiac output at rest and reached a higher cardiac output at peak exercise. Transmitral gradients after restrictive mitral valve annuloplasty for ischemic mitral regurgitation did not correlate with functional capacity as measured by maximal oxygen uptake during semi-supine bicycle testing. Functional capacity and transmitral gradients are determined not only by the severity of mitral stenosis but also by hemodynamic factors, such as ejection fraction and cardiac output. Transmitral gradients should be interpreted with respect to patient hemodynamics and not necessarily be considered as detrimental for functional capacity.

Bertrand PB ，Gutermann H ，Smeets CJ ，Van Kerrebroeck C ，Verhaert D ，Vandervoort P ，Dion R ... -  《-》

Mitral stenosis after IMR ETlogix ring annuloplasty for ischemic regurgitation.

Martín CE ，Castaño M ，Gomez-Plana J ，Gualis J ，Comendador JM ，Iglesias I ... -  《-》

Restrictive mitral valve annuloplasty versus mitral valve replacement for functional ischemic mitral regurgitation: an exercise echocardiographic study.

Mitral valve annuloplasty and mitral valve replacement are common strategies for the management of functional ischemic mitral regurgitation with ischemic cardiomyopathy. However, mitral valve annuloplasty may create some degree of functional mitral stenosis. The purpose of this study was to compare the mitral valve hemodynamics in patients with functional ischemic mitral regurgitation undergoing mitral valve annuloplasty or mitral valve replacement, using exercise echocardiography. We performed resting and exercise echocardiography in 70 patients matched for indexed effective orifice area, systolic pulmonary arterial pressure, and left ventricular ejection fraction after mitral valve annuloplasty or mitral valve replacement with coronary artery bypass grafting. There was no significant difference between the 2 groups regarding baseline demographic and clinical data. Exercise systolic pulmonary arterial pressure was higher in the mitral valve annuloplasty group compared with the mitral valve replacement group (from 36.3 ± 8.1 mm Hg to 55 ± 12 mm Hg, vs mitral valve replacement: 33 ± 6 mm Hg to 42 ± 6.2 mm Hg, P = .0001). Exercise-induced improvement in effective orifice area and indexed effective orifice area was better in the mitral valve replacement group (mitral valve replacement: +0.23 ± 0.04 vs mitral valve annuloplasty: -0.1 ± 0.09 cm², P = .001, for effective orifice area; mitral valve replacement: +0.14 ± 0.03 vs mitral valve annuloplasty: -0.04 ± 0.07 cm²/m², P = .03, for indexed effective orifice area). Exercise indexed effective orifice area was correlated with exercise systolic pulmonary arterial pressure (r = -0.45; P = .01). In a multivariable analysis mitral valve annuloplasty, postoperative indexed effective orifice area and resting mitral peak gradients were independent predictors of elevated systolic pulmonary arterial pressure during exercise. In patients with functional ischemic mitral regurgitation, mitral valve annuloplasty may cause functional mitral stenosis, especially during exercise. Mitral valve annuloplasty was associated with poor exercise mitral hemodynamic performance, lack of mitral valve opening reserve, and markedly elevated postoperative exercise systolic pulmonary arterial pressure compared with mitral valve replacement.

Fino C ，Iacovoni A ，Ferrero P ，Senni M ，Merlo M ，Cugola D ，Ferrazzi P ，Caputo M ，Miceli A ，Magne J ... -  《-》

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

Controversies regarding the choice of annuloplasty rings for treatment of ischemic mitral regurgitation still exist. Aim of the study is to compare early performance of 2 different rings in terms of rest and exercise echocardiographic parameters (transmitral gradient, systolic pulmonary artery pressure, and mitral valve area), clinical outcomes, and recurrence of mitral regurgitation. From January 2008 till December 2013, prospectively collected data of patients who underwent coronary artery bypass grafting and undersizing mitral valve annuloplasty for severe chronic ischemic mitral regurgitation at our Institution were reviewed. A total of 93 patients were identified; among them 44 had semirigid Memo 3D ring implanted (group A) whereas 49 had a rigid profile 3D ring (group B). At 6 months, recurrent ischemic mitral regurgitation, equal or more than moderate, was observed in 4 and 6 patients in the group A and B, respectively (P = 0.74). Group A showed certain improved valve geometric parameters such as posterior leaflet angle, tenting area, and coaptation depth. Transmitral gradient was significantly higher at rest in the group B (P < 0.0001). During exercise, significant increase of transmitral gradient and systolic pulmonary artery pressure was observed in group B (P < 0.0001). Mitral valve area was not statistically significantly smaller at rest in between groups (P = 0.09); however, it significantly decreased with exercise in group B (P = 0.01). At midterm follow-up, patients in group B were more symptomatic. In patients with chronic ischemic mitral regurgitation, use of semirigid Memo 3D ring when compared to the rigid Profile 3D may be associated with early improved mitral valve geometrical conformation and hemodynamic profile, particularly during exercise. No difference was observed between both groups in recurrent mitral regurgitation.

Fattouch K ，Moscarelli M ，Castrovinci S ，Guccione F ，Dioguardi P ，Speziale G ，Lancellotti P ... -  《-》

Three-dimensional valve repair-the better care? Midterm results of a saddle-shaped, rigid annuloplasty ring in patients with ischemic mitral regurgitation.

Guenzinger R ，Schneider EP ，Guenther T ，Wolf P ，Mazzitelli D ，Lange R ，Voss B ... -  《-》