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Giuseppe Santarpino
Antonino S. Rubino
Attilio Renzulli
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J Thorac Cardiovasc Surg 2009;138:341-351
© 2009 The American Association for Thoracic Surgery

Acquired Cardiovascular Disease

Successful surgical treatment of chronic ischemic mitral regurgitation achieves left ventricular reverse remodeling but does not affect right ventricular function

Francesco Onorati, MDa,*, Giuseppe Santarpino, MDa, Domenico Marturano, MDa, Antonino S. Rubino, MDa, Eugenia Pasceri, MDb, Stefania Zinzi, MDb, Giuseppina Mascaro, MDb, Lucia Cristodoro, MDa, Attilio Renzulli, MD, PhD, FETCSa

a Cardiac Surgery, Unit Magna Graecia, University of Catanzaro, Catanzaro, Italy
b Cardiology Unit, Unit Magna Graecia, University of Catanzaro, Catanzaro, Italy

Received for publication September 26, 2008; revisions received December 9, 2008; accepted for publication December 30, 2008.

* Address for reprints: Francesco Onorati, MD, Viale dei Pini, 28, 80131 Napoli. (Email: frankono{at}libero.it).

Objective: To evaluate left-sided and right-sided heart echocardiographic results after restrictive mitral annuloplasty in chronic ischemic mitral regurgitation.

Methods: Left atrial diameter, left ventricular end-diastolic diameter, left ventricular end-systolic diameter, left ventricular ejection fraction, left ventricular indexed mass, coaptation depth, transmitral mean gradient, systolic pulmonary arterial pressure, tricuspid annular plane systolic excursion, right ventricular ejection fraction, and tricuspid insufficiency grading were evaluated preoperatively, postoperatively, at 6 months, and at the end of the follow-up period in 64 patients undergoing restrictive mitral annuloplasty and coronary artery bypass grafting. Recurrence of chronic ischemic mitral regurgitation was defined as 2+/4+ grade or greater mitral regurgitation at any time postoperatively.

Results: Twenty-two months of freedom from recurrent chronic ischemic mitral regurgitation was 58.2% ± 9.8%. Recurrent chronic ischemic mitral regurgitation did not lead to reverse remodeling of left atrial diameter, left ventricular end-diastolic diameter, left ventricular end-systolic diameter, and ventricular indexed mass (P = not significant), with increased coaptation depth, parallel to follow-up chronic ischemic mitral regurgitation worsening. Effective restrictive mitral annuloplasty induced reverse remodeling of left ventricular end-diastolic diameter, left ventricular end-systolic diameter, and ventricular indexed mass, improved left ventricular ejection fraction, shortened coaptation depth, and improved mean gradient (P ≤ .014). Recurrent chronic ischemic mitral regurgitation in patients without tricuspid surgery prevented improvements of systolic pulmonary arterial pressure, tricuspid annular plane systolic excursion, right ventricular ejection fraction, worsening New York Heart Association (P = .003), and daily diuretic need (P = .008), whereas effective restrictive mitral annuloplasty progressively improved tricuspid insufficiency grading, systolic pulmonary arterial pressure, right ventricular ejection fraction, tricuspid annular plane systolic excursion, New York Heart Association, and diuretic need (P ≤ .013). Patients undergoing tricuspid annuloplasty did not show any improvement of systolic pulmonary arterial pressure, right ventricular ejection fraction, and tricuspid annular plane systolic excursion regardless of the recurrence of chronic ischemic mitral regurgitation (P = not significant), although effective restrictive mitral annuloplasty improved tricuspid insufficiency grading, New York Heart Association, and daily diuretic need (P ≤ .010).

Conclusion: Effective restrictive mitral annuloplasty induces reverse left ventricular remodeling. Absence of recurrent chronic ischemic mitral regurgitation improves tricuspid insufficiency grading, systolic pulmonary arterial pressure, right ventricular ejection fraction, tricuspid annular plane systolic excursion, New York Heart Association, and diuretic need in patients who do not undergo tricuspid surgery, but only tricuspid insufficiency grading, New York Heart Association, and daily diuretic need in patients who undergo tricuspid surgery.

Abbreviations and Acronyms CABG = coronary artery bypass grafting; CD = coaptation depth; CIMR = chronic ischemic mitral regurgitation; LAD = left atrial diameter; LVEDD = left ventricular end-diastolic diameter; LVEF = left ventricular ejection fraction; LVESD = left ventricular end-systolic diameter; LVMi = left ventricular mass index; mean {Delta}p = transmitral mean gradient; NYHA = New York Heart Association; PAPs = systolic pulmonary arterial pressure; RMA = restrictive mitral annuloplasty; RVEF = right ventricular ejection fraction; TAPSE = tricuspid annular plane systolic excursion; TI = tricuspid insufficiency






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