Downsizing of the mitral valve and coronary revascularization in severe ischemic mitral regurgitation results in reverse left ventricular and left atrial remodeling

Abstract

Data of combined mitral downsizing by restrictive prosthetic ring annuloplasty and coronary artery bypass grafting (CABG) in patients with ischemic cardiomyopathy and moderately severe to severe mitral regurgitation (MR) are rare, and little is known about the effect on reverse left ventricular (LV) and left atrial (LA) remodeling. Thirty-eight patients (70.6+/-8.3 years) with coronary artery disease, ischemic cardiomyopathy (LV ejection fraction [LVEF] 31+/-8%) and moderately severe to severe MR (grade 3.6+/-0.5) underwent CABG and mitral downsizing by 2-4 ring sizes. Clinical follow-up and serial transthoracic echocardiographic studies were performed after surgery (discharge, 3+/-0.5 months, 13+/-7 months) to assess survival, NYHA class, MR, leaflet coaptation height, LA and LV dimensions/volumes, fractional shortening (FS) and LVEF. Early mortality (<30 days) was 2.6%, survival at follow-up was 92 and 85%, respectively. NYHA class improved from 3.3+/-0.6 to 1.5+/-0.6 (P<0.001). Residual MR at discharge and at follow-up was grade 0.5 and 0.6, respectively (P<0.001). Leaflet coaptation height was 8+/-1 mm and did not change over time. LV end-diastolic, end-systolic and LA dimensions decreased from 60+/-7 to 57+/-8 mm, from 47+/-9 to 42+/-9 mm and from 51+/-5 to 45+/-4 mm, FS increased from 23+/-9 to 28+/-10% (P<0.001); LV end-diastolic and end-systolic volumes decreased from 188+/-33 to 171+/-30 ml and from 129+/-35 to 105+/-33 ml, LVEF increased from 31+/-8 to 39+/-10% (P<0.001). Combined mitral downsizing and CABG surgery was performed with excellent clinical results: only minimal residual MR, a significant reduction of LA dimension and an increase of LV contractility due to reverse remodeling were observed.