HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): J. Braun Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Braun, J. Articles by Dion, R.A.E. Search for Related Content PubMed PubMed Citation Articles by Braun, J. Articles by Dion, R.A.E. Related Collections Myocardial infarction Valve disease

J Thorac Cardiovasc Surg 2003;126:284-286
© 2003 The American Association for Thoracic Surgery

Brief communication

Restrictive mitral annuloplasty in refractory cardiogenic shock with acute postinfarction mitral insufficiency and intact papillary muscle

^a Department of Cardiothoracic Surgery, Leiden, The Netherlands

Received for publication August 26, 2002; accepted for publication October 9, 2002.

^* Address for reprints: R. A. E. Dion, MD, Leiden University Medical Center, Department of Cardiothoracic Surgery, PO Box 9600, 2300 RC Leiden, The Netherlands
r.a.e.dion{at}lumc.nl

Acute severe mitral insufficiency after myocardial infarction usually results from rupture of a papillary muscle, which should be treated on an emergency basis with mitral valve repair or replacement. In the case of acute postinfarction mitral regurgitation with intact papillary muscle, no consensus exists, even with regard to the indication for surgery.

Restrictive mitral annuloplasty (RMA) has been applied in chronic ischemic mitral insufficiency, with encouraging midterm results.^1,2 In this report, we describe 2 patients in whom RMA was applied as a lifesaving procedure in the presence of refractory cardiogenic shock in postinfarction mitral insufficiency with intact papillary muscle.

Clinical summaries

PATIENT 1. A 55-year-old woman had an acute inferior wall infarction with cardiogenic shock. She received an intra-aortic balloon pump (IABP) and inotropes and was intubated. Coronary angiography revealed occlusion of the right coronary and circumflex arteries. Transesophageal echocardiography (TEE) showed grade 4 mitral insufficiency resulting from systolic restrictive motion of both leaflets (Carpentier type IIIb; Figures 1 and 2). The regurgitation jet was slightly eccentric because of the more restrictive posterior leaflet. Because of further hemodynamic deterioration, we decided to attempt correction of the mitral regurgitation as a lifesaving procedure.

View larger version (46K): [in this window] [in a new window]   Figure 1. Transesophageal echocardiogram showing restrictive systolic motion of anterior and posterior leaflets with reduced coaptation. LA, Left atrium; LV, left ventricle; ECG, electrocardiogram.

View larger version (44K): [in this window] [in a new window]   Figure 2. Color Doppler echocardiographic imaging demonstrating grade mitral regurgitation resulting from systolic restriction with reduced coaptation. ECG, Electrocardiogram.

Troponin T rose to 22 µg/L on day 1. The IABP was removed after 8 days. The patient was discharged after 23 days. Nine months after surgery, she is in New York Heart Association functional class I, with no mitral insufficiency on echocardiographic follow-up.

PATIENT 2. A 69-year-old woman was referred because of hemodynamic deterioration 3 days after an inferior wall infarction. Coronary angiography revealed occlusion of the right coronary artery. During balloon angioplasty, the patient went into cardiogenic shock, was resuscitated, and received an IABP. Troponin T rose to 19 µg/L. TEE showed grade 4 mitral regurgitation as a result of restrictive leaflet motion in systole (Carpentier IIIb).

Initially, hemodynamic stabilization was obtained with inotropes in addition to the IABP. Three weeks later, the patient could not yet be weaned from mechanical ventilation. She acquired gram-negative sepsis, and during exchange of the IABP catheter she suffered hemodynamic collapse and was again resuscitated. Apart from nonoliguric renal insufficiency, she had neither major organ dysfunction nor neurologic complications, but she required continuous administration of epinephrine at 0.20 µg/kg/min, dobutamine at 10 µg/kg/min, and enoximon at 2 µg/kg/min. In an attempt to overcome this deadlock situation, we decided to try to correct the mitral insufficiency 27 days after the initial infarction. We performed RMA with a size 26 (instead of 30) Physioring. The patient could then be weaned from extracorporeal circulation with the same inotropic support. Postoperative TEE showed no mitral insufficiency, with a mean transvalvular gradient of 2 mm Hg and a leaflet coaptation height of 9 mm.

The postoperative course was uneventful. The IABP was removed on day 7. The patient was extubated after 20 days and was discharged after 32 days. Two months after surgery, she is in New York Heart Association functional class II, with grade 1 mitral insufficiency on echocardiography.

Discussion

Cardiogenic shock in the setting of postinfarction mitral insufficiency portends a poor prognosis, with approximately 55% in-hospital mortality in the SHOCK trial.³ Coronary revascularization with or without mitral valve surgery in that study showed a somewhat reduced but still high mortality of 40%, versus 71% in nonsurgically treated patients. Most patients who did not undergo surgery could not be stabilized and died. Thus the timing of surgery may be important in determining outcome, and early surgery before or immediately at the onset of cardiogenic shock might save lives. Our first patient underwent operation on an emergency basis. In the second case, initial stabilization allowed us to postpone surgery.

The question as to whether mitral valve repair is preferable to replacement in acute ischemic mitral insufficiency is still unanswered. Grossi and colleagues⁴ and Gillinov and associates⁵ reported similar survivals after replacement versus repair in patients with complex and acute mitral regurgitation. However, preference of the operating surgeon certainly introduced selection bias in these retrospective studies.

It has been established that preservation of the subvalvular apparatus positively influences postoperative left ventricular function. Therefore in cases where mitral valve surgery is proposed as a lifesaving procedure, we believe, as illustrated by the cases reported here, that a successful mitral valve repair is preferable, especially in the absence of papillary muscle rupture. In our hands RMA has proved its value in curing chronic ischemic mitral insufficiency by restoring an adequate height of leaflet coaptation.² Similarly, we believe that the stress in the subvalvular apparatus can also be reduced by this technique in acute cases, thereby decreasing the risk of postrepair rupture of the infarcted myocardium.

References

1. Bolling SF, Pagano FD, Deeb GM, Bach DS. Intermediate-term out-come of mitral reconstruction in cardiomyopathy. J Thorac Cardiovasc Surg. 1998;115:381–388[Abstract/Free Full Text]
   
2. Dion R, Benetis R, Elias B, Guennaoui T, Raphael D, van Dyck M, et al. Mitral valve procedures in ischemic regurgitation. J Heart Valve Dis. 1995;4(Suppl 2):S124–131
   
3. Thompson CR, Buller CE, Sleeper LA, Antonelli TA, Webb JG, Jaber WA, et al. Cardiogenic shock due to acute severe mitral regurgitation complicating acute myocardial infarction: a report from the SHOCK trial registry. J Am Coll Cardiol. 2000;36:1104–1109[Abstract/Free Full Text]
   
4. Grossi EA, Goldberg JD, LaPietra A, Ye X, Zakow P, Sussman M, et al. Ischemic mitral valve reconstruction and replacement: comparison of long-term survival and complications. J Thorac Cardiovasc Surg. 2001;122:1107–1124[Abstract/Free Full Text]
   
5. Gillinov AM, Wierup PN, Blackstone EH, Bishay ES, Cosgrove DS, White J, et al. Is repair preferable to replacement for ischemic mitral regurgitation? J Thorac Cardiovasc Surg. 2001;122:1125–1141[Abstract/Free Full Text]
   

This article has been cited by other articles:

				J. Braun, J. J. Bax, M. I.M. Versteegh, P. G. Voigt, E. R. Holman, R. J.M. Klautz, E. Boersma, and R. A.E. Dion Preoperative left ventricular dimensions predict reverse remodeling following restrictive mitral annuloplasty in ischemic mitral regurgitation Eur. J. Cardiothorac. Surg., May 1, 2005; 27(5): 847 - 853. [Abstract] [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): J. Braun Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Braun, J. Articles by Dion, R.A.E. Search for Related Content PubMed PubMed Citation Articles by Braun, J. Articles by Dion, R.A.E. Related Collections Myocardial infarction Valve disease