Invited Commentary

Abstract

This article [1Hyllén S. Nozohoor S. Ingvarsson A. Meurling C. Wierup P. Sjögren J. Right ventricular performance after valve repair for chronic degenerative mitral regurgitation.Ann Thorac Surg. 2014; 98: 2023-2031Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar] shows that right ventricular (RV) dysfunction is highly prevalent (31%) in patients having mitral valve repair (MVRep) for degenerative mitral regurgitation (MR). Furthermore, while reversing pulmonary hypertension with MVRep results in improvement in RV function, RV dysfunction remains common and may be more prevalent (61%) 6 months postoperatively. This implies that patients with significant MR are at risk for not only left ventricular (LV) dysfunction, but also biventricular dysfunction, and that cardiac function, if allowed to decline, might not recover after MVRep. In this report, RV function is evaluated using two methods: conventional echocardiographic measurements (RVconv) and echocardiographic speckle tracking-derived RV longitudinal strain (RVstrain). RVconv shows RV dysfunction preoperatively (31%) and at follow-up (61%). RVstrain does not change significantly from preoperative to 6-month postoperative evaluations, but the authors note that the preoperative RVstrain is lower than reported reference values, and it is not improved 6 months postoperatively. Class 1 guidelines for MVRep for severe MR owing to leaflet prolapse are the presence of symptoms or the development of LV dysfunction (either reduced ejection fraction or LV dilatation) [2Nishimura R. Otto C.M. Bonow R.O. et al.2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease.J Am Coll Cardiol. 2014; 63: e57-e185Abstract Full Text PDF PubMed Scopus (2085) Google Scholar]. LV dysfunction related to MR is well documented and is clearly associated with reduced late survival even after MVRep (3–5). A recent review from the Mitral Registry International Database showed that initial medical management of patients with no class 1 indication for MVRep led to reduced survival compared with a propensity matched group who had early MVRep [3Suri R.S. Vanoverschelde J.-L. Grigioni F. et al.Association between early surgical intervention vs watchful waiting and outcomes for mitral regurgitation due to flail mitral valve leaflets.JAMA. 2013; 310: 609-616Crossref PubMed Scopus (248) Google Scholar]. A review from the Mayo Clinic showed reduced late survival if MVRep was performed after LVEF became less than 60% [4Ling H. Enriquez-Sarano M. Seward J.B. et al.Clinical outcome of mitral regurgitation due to flail leaflet.N Engl J Med. 1996; 335: 1417-1423Crossref PubMed Scopus (530) Google Scholar], but patients who had early MVRep had survival restored to that of a normal, matched population [5Aviernos J.F. Gersh B.J. Melton L.J. et al.Natural history of asymptomatic mitral valve prolapse in the community.Circulation. 2002; 106: 1335-1361Google Scholar]. RV dysfunction associated with severe MR may be related to secondary pulmonary hypertension, septal shift from LV volume overload, or other mechanisms. This article shows that RV dysfunction in patients coming to MVRep is common and, whereas there may be some improvement with reversible pulmonary hypertension, RV function remains reduced in many patients 6 months postoperatively. These data are another asset in the accumulating evidence that delaying MVRep is clearly detrimental to late outcome. Right Ventricular Performance After Valve Repair for Chronic Degenerative Mitral RegurgitationThe Annals of Thoracic SurgeryVol. 98Issue 6PreviewOur aim was to assess right ventricular (RV) performance after mitral valve repair by use of RV focused echocardiography and to evaluate the influence of elevated pulmonary artery systolic pressure (PASP) on RV recovery. Full-Text PDF