Abstract
There is an increasing number of patients with mitral regurgitation secondary to dilated cardiomyopathy. Recent data suggest that mitral regurgitation (MR) can be surgically corrected in heart failure with symptomatic improvements and favourable reverse left ventricular remodeling. However, several questions remain to be answered, regarding the optimal management of functional mitral regurgitation, the correct timing of surgery and the choice of the surgical technique to perform in patients affected by dilated cardiomyopathy. In the setting of ischemic chronic cardiomyopathy, data derived from the recent literature suggest that concomitant severe ischemic MR should be addressed during CABG to improve survival and quality of life. Most surgeons perform concomitant CABG and mitral valve surgery in patients with ischemic chronic cardiomyopathy and moderate to severe MR. In the setting of chronic dilated cardiomyopathy, most clinicians would agree that correction of severe MR in heart failure is warranted, mostly due to a symptomatic benefit and reduction of number of re-hospitalizations. Moreover, reverse ventricular remodeling has been demonstrated with undersized annuloplasty rings and correction of MR: this could lead to improved contractility, reduction in left ventricular end-diastolic and end-systolic volumes, and finally to improved NYHA functional class. Recent large studies suggest that patients undergoing mitral valve repair had improved perioperative survival, shorter length of stay, and improved long-term survival than those undergoing mitral valve replacement because the preservation of the subvalvular apparatus seems to result in superior left ventricular remodelling and in greater improvement in NYHA class. In the near future, data from multi-institutional, randomized prospective trials will help to elucidate many of the questions and concerns regarding repair of severe functional mitral regurgitation. Finally, technology applied to heart surgery is continually evolving and will allow more exciting cellular and novel device therapies for the treatment of functional mitral regurgitation secondary to dilated cardiomyopathy.
Highlights
In the setting of ischemic chronic cardiomyopathy, data derived from the recent literature suggest that concomitant severe ischemic mitral regurgitation (MR) should be addressed during coronary artery bypass grafting (CABG) to improve survival and quality of life
Reverse ventricular remodeling has been demonstrated with undersized annuloplasty rings and correction of MR: this could lead to improved contractility, reduction in left ventricular end-diastolic and end-systolic volumes, and to improved NYHA functional class
Recent large studies suggest that patients undergoing mitral valve repair had improved perioperative survival, shorter length of stay, and improved long-term survival than those undergoing mitral valve replacement because the preservation of the subvalvular apparatus seems to result in superior left ventricular remodelling and in greater improvement in NYHA class
Summary
6 million Americans suffer from heart failure [1] and many of these patients have a dilated cardiomyopathy based on either ischemic or idiopathic dilated etiology. Functional MR worsens the symptoms of chronic heart failure and it has been well demonstrated that it is a significant factor for increased mortality in the natural history of these patients [2]. In the setting of chronic ischemic cardiomyopathy, the optimal management of patients with concomitant functional MR remains to be established [6,7,8,9]. F. Nicolini et al / World Journal of Cardiovascular Diseases 3 (2013) 100-107 regurgitation (MR), but such an advantage remains controversial in the presence of chronic ischemic MR [6,7,8,9,10,11,12,13,14], in case of concurrent left ventricular dysfunction [15,16]. In consideration of several studies reporting high recurrence of MR, it appears mandatory to discuss the correct indications for the optimal surgical management of functional MR in dilated cardiomyopathies
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