Coaptation Height Research Articles

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

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.

Determinants of exercise-induced changes in mitral regurgitation in patients with coronary artery disease and left ventricular dysfunction

ObjectivesWe sought to examine the determinants of exercise-induced changes in ischemic mitral regurgitation (MR) in patients with left ventricular (LV) dysfunction. BackgroundIn the post-myocardial infarction (MI) phase, ischemic MR contributes to worsening of symptoms and of LV dysfunction. MethodsIn this study, 70 patients in the chronic, post-MI phase, with LV ejection fraction <45% and at least mild MR, underwent semi-supine exercise Doppler echocardiography. The effective regurgitant orifice (ERO) of MR was quantified at rest and during exercise. Exercise-induced changes in ERO were compared with changes in mitral deformation and in local and global LV remodeling. ResultsThe wide range of exercise-induced ERO changes that were observed was unrelated to the degree of MR at rest (r = 0.20). Effective regurgitant orifice changes correlated best with changes in mitral deformation (i.e., differences in systolic mitral tenting area, systolic annular area, and coaptation height) (p < 0.0001). Posterior displacement of the papillary muscles was associated with larger changes in the ERO in both infarct groups. In patients with inferior MI, a decrease in the ERO was related to improvement in wall motion (r = 0.68). The independent predictors of ERO changes during exercise were changes in systolic annular area for all infarct categories, in tenting area and wall motion score in the global population and those with inferior infarction, and in apical displacement of mitral leaflets for patients with anterior MI. ConclusionsThe degree of MR at rest is unrelated to exercise-induced changes in EROs, which are related to those in local LV remodeling and in mitral deformation but not those in global LV function.

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

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. During the operation, a fresh infarction of the posterolateral wall involving the posterior papillary muscle was observed. The subvalvular apparatus was intact, and there was no structural anomaly of the mitral valve leaflets. RMA was performed with a size 28 Carpentier-Edwards Physioring (Baxter Healthcare Corporation CardioVascular Group, Irvine, Calif), thereby downsizing the prosthetic ring by two sizes. Tentative revascularization of the circumflex and right coronary artery territory was performed with a sequential saphenous vein graft. The patient was weaned from extracorporeal circulation with inotropic support (epinephrine at 0.22 g/kg/min, dobutamine at 15 g/kg/min, dopamine at 8 g/kg/min, and enoximon at 4 g/kg/min). Intraoperative TEE showed trivial mitral regurgitation with a mean transvalvular mitral gradient of 3 mm Hg (mitral valve surface area 2c m 2 ) and

Ischemic mitral regurgitation redux—To repair or to replace?

Ischemic mitral regurgitation redux—To repair or to replace?