Management Of Ischemic Mitral Regurgitation Research Articles

Contemporary Management of Ischemic Mitral Regurgitation at Coronary Artery Bypass Grafting

BackgroundRecent guidelines for the treatment of moderate or severe ischemic mitral regurgitation (IMR) in patients undergoing coronary artery bypass grafting (CABG) have changed. This study assessed the real-world impact of changing guidelines on the management of IMR during CABG over time. We hypothesized that the utilization of mitral valve repair for IMR would decrease over time, whereas mitral valve replacement for severe IMR would increase. MethodsPatients undergoing CABG in a statewide collaborative database (2011-2020) were stratified by severity of IMR. Trends in mitral valve repair or replacement were evaluated. To account for differences of the patients, propensity score–matched analyses were used to compare patients with and without mitral intervention. ResultsA total of 11,676 patients met inclusion criteria, including 1355 (11.6%) with moderate IMR and 390 (3.3%) with severe IMR. The proportion of patients undergoing mitral intervention for moderate IMR decreased over time (2011, 17.7%; 2020, 7.5%; Ptrend = .001), whereas mitral replacement for severe IMR remained stable (2011, 11.1%; 2020, 13.3%; Ptrend = .14). Major morbidity was higher for patients with moderate IMR who underwent mitral intervention (29.1% vs 19.9%; P = .005). In a propensity analysis of 249 well-matched pairs, there was no difference in major morbidity (29.3% with mitral intervention vs 23.7% without; P = .16) or operative mortality (1.2% vs 2.4%; P = .5). ConclusionsConsistent with recent guideline updates, patients with moderate IMR were less likely to undergo mitral repair. However, the rate of replacement for severe IMR did not change. Mitral intervention during CABG did not increase operative mortality or morbidity.

MULTI-LOOP TECHNIQUE FOR PAPILLARY MUSCLE RELOCATION IN ISCHEMIC MITRAL REGURGITATION

<h3>BACKGROUND</h3> The appropriate surgical management of ischemic mitral regurgitation (IMR) is still highly debatable: valve replacement is often favoured over repair with ring annuloplasty (RA) because the former is associated with lower MR recurrence. The addition of a sub-valvular intervention, such as papillary muscle relocation (PMR), has been suggested to improve the durability of the mitral repair. Therefore, our aim was to examine the outcomes of a novel technique for PMR involving a multi-loop suture in the treatment of IMR. <h3>METHODS AND RESULTS</h3> Between 2017 and 2020, 9 patients with severe chronic IMR were enrolled into this case series: a multi-loop suture was used to address PMR in addition to ring annuloplasty. In brief, the multi-loop suture was prepared with Gore-Tex sutures, which was then anchored to the posteromedial papillary muscle, and buttressed with pledgets. The sutures attached to the loop were passed through the aspect of the annulus corresponding to the tethered segment, thus, serving as neo-chordae. Length was determined by saline test. Once regurgitation was absent on visual inspection of the saline test, the chordae were secured above the annulus with pledgets on the atrial side. Eight patients also received concomitant coronary artery bypass graft (CABG) procedure. Clinical and echocardiographic outcomes during the perioperative and follow-up periods were assessed. The mean follow-up was 15 +/- 8 months. One patient who had a pre-operative EuroSCORE of 8.25% died within the early post-operative period. The mean transmitral gradient at discharge was 3.8±1.4 mmHg. At follow-up, there was no mortality and cardiac-related readmissions, and only one patient had MR recurrence. The left ventricular end-systolic diastolic dimension was significantly lower at follow-up compared with pre-operative (6.1±4.6mm vs 5.6±0.9mm, P=0.03). A non-significant trend towards improvement was noted at follow-up compared with pre-operative for left ventricular end-diastolic volume (147.9 ± 61.2 ml vs 161.1 ± 46.6 ml, p=0.74), and left ventricular end-systolic volume (84.8 ± 42.6 ml vs 87.3 ± 35.9 ml, p=0.78). Despite the use of an undersized RA, mitral stenosis was not noted at latest follow-up, and the mean transmitral gradient of 3.6 ± 1.4 mmHg. <h3>CONCLUSION</h3> In patients with severe IMR, PMR with a multi-loop suture adjunctive to RA appears to offer excellent clinical and echocardiographic outcomes during follow-up of up to 2 years post-operatively. Nevertheless, these preliminary findings warrant further validation in a larger series of patients.

Ischemic mitral regurgitation: when should one intervene?

Optimal timing of intervention for ischemic mitral regurgitation remains to be elucidated. This review summarizes the data on the management of ischemic mitral regurgitation, and their implications on current practice and future research. Mechanistically, ischemic mitral regurgitation can present as Type I, Type IIIb or mixed Type I and IIIb disease. Severity of mitral regurgitation is typically quantified with echocardiography, either transthoracic or transesophageal echocardiography, but may also be assessed via cardiac MRI. In patients with moderate ischemic mitral regurgitation, revascularization can lead to left ventricular reverse remodeling in some. In patients with severe ischemic mitral regurgitation, mitral valve replacement may be associated with fewer adverse events related to heart failure and cardiovascular readmissions, compared with valve repair, although reverse remodeling may be better in patients following successful mitral repair. Transcatheter edge-to-edge repair also further complements the treatment of ischemic mitral regurgitation. A tailored approach to patients should be considered for each patient presenting with ischemic mitral regurgitation.

Ischemic Mitral Regurgitation: A Multifaceted Syndrome with Evolving Therapies.

Dysfunction of the left ventricle (LV) with impaired contractility following chronic ischemia or acute myocardial infarction (AMI) is the main cause of ischemic mitral regurgitation (IMR), leading to moderate and moderate-to-severe mitral regurgitation (MR). The site of AMI exerts a specific influence determining different patterns of adverse LV remodeling. In general, inferior-posterior AMI is more frequently associated with regional structural changes than the anterolateral one, which is associated with global adverse LV remodeling, ultimately leading to different phenotypes of IMR. In this narrative review, starting from the aforementioned categorization, we proceed to describe current knowledge regarding surgical approaches in the management of IMR.

Multicenter experience: early outcome of mitral valve repair in patients with ischemic mitral regurgitation

Ischemic mitral regurgitation is associated with poor outcomes. The optimal surgical strategy for management of ischemic mitral regurgitation is still debated. The objective of this study was to evaluate the early mortality and morbidity of mitral valve repair in patients with ischemic mitral regurgitation undergoing coronary artery bypass grafting. We performed a retrospective, observational, cohort study on prospectively collected data on 136 consecutive coronary artery bypass graft patients with ischemic mitral regurgitation undergoing mitral valve repair between January 2016 and January 2020. Perioperative echocardiogram findings, operative procedures, and outcomes were analyzed. The overall mortality rate was 4.4%. Mitral valve repair with a low ejection fraction had a 4-fold increase in the risk of death compared to mitral valve repair with preserved ejection fraction > 30%. However, after adjusting for preoperative risk factors, the number of grafts was not an independent risk factor for mortality (odds ratio = 0.18, 95% confidence interval: 0.03-2.81, p = 0.84). Multivariable analysis showed that preoperative ejection fraction (odds ratio = 1.14, 95% confidence interval: 0.82-4.86, p < 0.01), preoperative left ventricular end-systolic dimension (odds ratio = 1.03, 95% confidence interval: 0.65-3.51, p < 0.01) and preoperative left ventricular end-diastolic dimension (odds ratio = 0.99, 95% confidence interval: 0.64-3.28, p = 0.04) were independent risk factors for mortality. Mitral valve repair can be performed safely concomitantly with coronary artery bypass grafting in patients with moderate, moderately severe, and severe ischemic mitral regurgitation.

Ischemic Mitral Regurgitation: Current Understanding and Surgical Options.

Secondary, or functional, mitral regurgitation (MR) occurs with impaired coaptation of structurally normal valve leaflets due to abnormal structure and/or function of the left ventricle (LV). A leading cause of functional mitral regurgitation is ischemic cardiomyopathy, resulting in left ventricular dysfunction and subsequent congestive heart failure (CHF) and ischemic mitral regurgitation (IMR). The value of surgical or transcatheter correction of IMR remains controversial, since the underlying pathology of IMR is attributed to a dysfunctional left ventricle. However, even mild IMR has been shown to be harmful to CHF patients, as IMR is both a surrogate of advanced CHF and an independent contributor to CHF morbidity and mortality. While observational and randomized studies have examined surgical treatment of IMR with conflicting outcomes, additional well-designed randomized controlled trials should be performed to further clarify the optimal treatment for IMR. Additionally, close attention should be paid to the quality of interventions performed, as durable reduction in IMR provides the best hope of a positive clinical outcome. This review focuses on the pathophysiology of IMR, current evidence regarding surgical and transcatheter interventions, and future directions in management of IMR.

RF86 THE TREATMENT OF ISCHEMIC MITRAL REGURGITATION WITH THE USE OF INCOMPLETE C RING ANNULOPLASTY: LONG-TERM RESULTS

Background and Aim: Surgical management of ischemic mitral regurgitation (IMR) is controversial, and in the setting of mitral valve repair (MVRep) the choice of the ring is still debated. We evaluate the results of MVRep with a semirigid incomplete C-ring in IMR. Methods: Between January 2006 and May 2014, 105 consecutive patients (mean age 69 ± 8 years, 75% males) underwent MVRep using an undersized C-ring during coronary artery bypass grafting to treat IMR. Mean logistic EuroSCORE was 14 ± 12%. Preoperative left ventricular ejection fraction was 43 ± 11%. Mean follow-up was 57 ± 35 months. Results: In-hospital mortality was 6.6% (7 patients). Predictor of in-hospital mortality was the duration of cardiopulmonary bypass (p &lt; 0.05). Echocardiography performed at discharge showed a significant reduction of left ventricle end-diastolic diameter (p &lt; 0.0001) and mitral regurgitation grade (p &lt; 0.0001). Eight-year late death was 26% (26 patients), cardiac death 12%. Eight-year freedom from all-cause and cardiac death was 62 ± 7% and 83 ± 4%, respectively. In 7 patients (7%) recurrence of mitral regurgitation (&gt;2 + ) was found. Freedom from recurrence of mitral regurgitation ≥ 2 and NYHA class &gt; II were 89 ± 5% and 76 ± 9%, respectively. No patients underwent reoperation. Instable angina (p &lt; 0.05), moderate-severe pulmonary hypertension (p &lt; 0.0001) and left ventricle end-systolic diameter (p &lt; 0.001) were independent predictors of long-term mortality. Conclusions: Despite the adverse prognosis of IMR, MVRep with semirigid C-ringassociated with coronary artery bypass showed satisfactory long-term survival, and low recurrence of mitral regurgitation/redo operation.

Mitral valve repair versus replacement in patients with ischemic mitral regurgitation.

The optimal management of ischemic mitral regurgitation (IMR) is controversial. The aim of this study was to examine our eight years' experience of surgical treatment in patients with IMR, and to compare outcomes of mitral valve repair versus replacement with concomitant coronary artery bypass grafting (CABG). A retrospective, observational, cohort study was undertaken to collect data on consecutive patients with IMR and coronary artery disease who received CABG and mitral valve surgery in our hospital between January 2008 and December 2015. Basic patient characteristics, operative data, and postoperative clinical outcomes were examined. The series included 22 consecutive patients (21 male; 1 female). The mean age was 62.1±11.4 years old. The mean preoperative left ventricular ejection fraction (LVEF) was 33.4%±15.4%. The mean cardiopulmonary bypass (CPB) time was 165.4±38.4 minutes, and the mean aortic cross clamp time was 113.8±33.6 minutes. Eighteen patients underwent CABG plus mitral valve repair, and four patients underwent CABG plus mitral valve replacement (MVR). There were three early in-hospital mortalities: two in the mitral valve repair group, and one in the replacement group. The follow-up was complete in all patients, with a mean follow-up duration of 3.1±2.3 years. The mean last LVEF was 35.3%±17.7%. There were 2 late mortalities. Both were from the repair group. The overall late survival rate was 81.6%, with 83.0% in the repair group and 75.0% in the replacement group. In patients with echocardiography follow-up of more than or equal to 1 year duration, the residual or recurrent mitral regurgitation rates were 0.0% in the replacement group and 57.1% in the repair group. One patient in the repair group later underwent MVR due to severe regurgitation postoperatively. Our preliminary findings showed that the surgical outcome of mitral valve repair might be comparable to that of MVR in terms of early mortality and long-term survival. However, mitral valve repair was associated with a higher residual or recurrent mitral regurgitation rate. According to the latest literature, the role of MVR can justifiably be indicated for severe IMR. As for moderate IMR, CABG alone without mitral valve intervention may provide similar clinical outcomes.

Comparison of Surgical Options in the Management of Ischaemic Mitral Regurgitation With Concurrent Coronary Artery Bypass Grafting

Comparison of Surgical Options in the Management of Ischaemic Mitral Regurgitation With Concurrent Coronary Artery Bypass Grafting

Diagnosis and Management of Ischemic Mitral Regurgitation: Evidence-Based Clinical Decision Making at the Point of Care.

Anatomical, functional, and pathophysiologic mechanisms of ischemic mitral regurgitation (IMR) are markedly different from the primary mitral regurgitation. The older and ubiquitous cutoff of EROA (effective regurgitant orifice area) and Rvol (regurgitant volume) for IMR has been reinstated in the new guideline after a brief hiatus. There had always been a lack of good-quality evidence for its introduction for guiding IMR severity in the previous guideline, and we still do not have quality evidences that could justify its reintroduction. Unlike primary MR, IMR is usually associated with reduced ejection fraction. Therefore, it appears unrealistic to keep the similar cutoff for primary MR and IMR. The cutoff of severity can be modified according to projected values of Rvol normalized to ejection fraction and EROA normalized to Rvol. In addition, the treatment outcome in these patients is determined by factors (left ventricular dyssynchrony, annular dilatation, tenting area, tenting height, tenting volume, and myocardial viability) other than the simple grading. In this review article, a series of graph have been constructed from the numerical data derived from the literatures on IMR to depict the relationship between EROA, Rvol, left ventricular end diastolic volume, and ejection fraction in order to obtain a reasonable projection formula for EROA and Rvol. Furthermore, a management algorithm has been proposed for patients with IMR undergoing coronary artery bypass grafting based on echocardiographic predictors that influence the postoperative outcome.

Surgical management of ischemic mitral regurgitation

Ischemic mitral regurgitation (IMR) portends a dismal survival rate for the afflicted irrespective of the type of surgical intervention. The treatment of moderate IMR has been a subject of debate with recent evidence citing similar survival statistics with revascularisation alone/revascularisation with mitral valve surgery approaches. The recognition of left ventricular (LV) reverse remodelling as the key factor determining the progression of IMR has resulted in a paradigm shift in the surgical management of IMR. Literature review was done in Pubmed and Scopus to identify relevant articles pertaining to the pathophysiology, diagnosis and treatment of IMR with the view of writing a narrative review on the subject. The similar long-term outcomes following mitral valve repair/replacement strategies for IMR has led to a resurgence of interest in primarily replacing the valve employing chordal preservation techniques especially in the setting of high probability of repair failure. Although mitral valve annuloplasty remains the most utilised surgical technique in IMR correction, several ingenious techniques tackling the various components of the valve apparatus continue to evolve. From the current understanding, IMR is primarily a valvular manifestation of ischemic ventricular disease and hence, myocardial revascularisation forms the key element in the surgical treatment of IMR with or without adjunctive mitral valve repair/replacement.

Low-dose dobutamine stress echocardiography cannot predict mitral regurgitation reversibility after coronary artery bypass grafting

The ideal management of ischemic mitral regurgitation (MR) remains a clinical dilemma because of the suboptimal available therapeutic options. Recently, new concepts have emerged, pointing to the benefits of a patient selection approach when debating the management of moderate ischemic MR. We investigated the predictability of low-dose dobutamine stress echocardiography (DSE) in selecting candidates for CABG with moderate MR for valve repair. From November 2002 to May 2010, 110 candidates for first-time CABG, who were admitted to the cardiac surgery department in Day General Hospital (Tehran, Iran), were enrolled in the present cross-sectional study. DSE was performed for each case before CABG. Those with positive findings underwent CABG alone and those with negative results underwent concomitant CABG and mitral valve repair. The patients were followed up for a minimum of 60 months. Of the 110 patients, 47 (42.72%) had positive test results and underwent CABG alone and 63 (57.28%) had negative DSE results and underwent concomitant CABG and mitral valve repair. The MR degree had decreased from 2.8±0.3 preoperatively to 1.46±0.6 early during the hospital stay and 1.9±0.7 during late follow-up in the CABG group. It had decreased from 2.84±0.4 preoperatively to 0.93±0.65 postoperatively but then increased to 1.41±0.9 during late follow-up, for a significant decrease in the combined group (P<.05). Despite its utility in selecting CABG patients with moderate ischemic MR for valve repair from a short-term perspective, the use of DSE cannot predict the long-term outcomes of these patients.

When to repair ischemic mitral valve regurgitation? An algorithmic approach

Background Despite huge progress in the surgical management of ischemic mitral regurgitation, there is still controversy regarding the ideal treatment option.

Concomitant Off-Pump Coronary Artery Bypass Grafting Results in Improved In-Hospital Outcomes for Patients with Ischemic Mitral Regurgitation Undergoing Surgery

Surgical management of ischemic mitral regurgitation (IMR) has primarily consisted of revascularization with or without the addition of mitral valve repair or replacement. We hypothesize that performing off-pump coronary artery bypass (OPCAB) grafting before fixing MR improves in-hospital outcomes for patients with IMR undergoing surgery. From January 2000 through December 2010, a total of 96 consecutive patients with moderate or severe IMR, as determined by preoperative echocardiography, underwent on-pump coronary artery bypass grafting (CABG) (n = 66) or OPCAB (n = 30) revascularization with concomitant mitral valve repair or replacement. A retrospective analysis of a prospectively collected cardiac surgery database (PATS; Dendrite Clinical Systems, Oxford, UK) was performed. In addition, medical notes and charts were reviewed for all study patients. The 2 groups had similar preoperative demographic and EuroSCORE risk-stratification characteristics. The operative mortality rate for the entire cohort was 9.4%. Patients who underwent OPCAB grafting had a lower operative mortality than those who underwent CABG (3.3% versus 12.1%; P = .006). The mean ±SD cardiopulmonary bypass time (82.7 ± 34.7 minutes versus 160.7 ± 45.2 minutes; P < .001) and cross-clamp time (49.0 ± 22.4 minutes versus 103.4 ± 39.5 minutes; P < .001) were significantly shorter in the off-pump group than in the on-pump group. The OPCAB group also had significantly less in-hospital morbidity and shorter stays in the intensive care unit and the hospital. Our analysis shows that OPCAB grafting (compared with conventional CABG) before repairing MR is associated with favorable in-hospital outcomes for patients undergoing surgery for IMR.

Surgical Management of Ischemic Mitral Regurgitation: Relearning Our Lessons

Surgical Management of Ischemic Mitral Regurgitation: Relearning Our Lessons

Surgery for chronic ischemic mitral regurgitation – which mitral intervention?

Surgical management of ischemic mitral regurgitation is associated with higher operative mortality, increased morbidity and poorer long-term survival. Selection of the most appropriate surgical treatment to maximize survival could be challenging due to factors such as inconsistent usage of contemporary surgical techniques, inconsistent classification schemes for the entity, paucity of long-term data in order to compare alternatives and an absence of randomized trials of valve repair versus valve replacement. In addition, there is a lack of patient-reported outcome measures and functional data parameters that take into consideration the patient’s perspective in refining the decision making of the therapeutic strategy. In fact, such trials are difficult and if they were to be conducted there would be a high risk of dubious conclusions owing to clustering of outcomes with surgical expertise. This article aims to review the options for surgical management of chronic ischemic mitral regurgitation. It also attempts to identify areas of future research in order to clarify which of these are of priority and will realistically seek for relevant answers. Mitral intervention in this patient group seems to improve survival, although it is dependent on producing a competent mitral apparatus. There is no convincing evidence that repair is superior to replacement, and there is the possibility that the literature has been biased against replacement as the treatment of choice.

Long-Term Echocardiographic Follow-up after Posterior Mitral Annuloplasty Using a Vascular Strip for Ischemic Mitral Regurgitation: Ten-Years of Experience at a Single Center

Management of ischemic mitral regurgitation (MR) is challenging. The aim of this study was to investigate long-term clinical and echocardiographic results of restrictive mitral annuloplasty for ischemic MR. From 2001 through 2010, 96 patients who underwent myocardial revascularization with restrictive mitral annuloplasty using a vascular strip for ischemic MR were analyzed. Patients were stratified into two groups based on left ventricular ejection fraction (LVEF): group I, n = 50, with LVEF > 35% and group II, n = 46, with LVEF ≤ 35%. The early mortality rate was 2.1% (2/96) and the late cardiac mortality rate was 11.5% (11/96). MR grade was reduced at discharge (0.8 ± 0.7) but increased during follow-up (1.1 ± 0.8, P = 0.001). There was no intergroup difference in terms of freedom from recurrent MR ≥ moderate eight years after surgery (94.1% ± 5.7%, group I vs 87.8% ± 7.2%, group II; P = 0.575). NYHA functional class (odds ratio [OR], 2.2; P = 0.044) and early postoperative residual MR ≥ mild (OR, 25.4; P < 0.001) were independent predictors of recurrent MR. Restrictive mitral annuloplasty using a vascular strip is effective in ischemic MR. It is important to avoid early postoperative residual MR.

Meta-analysis of short-term and long-term survival following repair versus replacement for ischemic mitral regurgitation

The optimal surgical strategy for the management of ischemic mitral regurgitation (IMR) is still debated. The purpose of this study was to perform a meta-analysis summarizing the evidence favoring one technique over another (repair vs replacement). A search of the English literature in PubMed was performed using 'ischemic mitral regurgitation' and 'repair or replacement or annuloplasty' in the title/abstract field. Articles were excluded if they lacked a direct comparison of repair versus replacement, or used Teflon/pericardial strip or suture annuloplasty in >10% of the repairs. Nine articles were selected for the final analysis. All studies except one were relatively recent (2004-2009). The patient characteristics between treatment groups were similar across studies. All studies excluded patients with degenerative etiology and used a rigorous definition of IMR. Most patients had concomitant coronary artery bypass graft. In the patients with mitral valve replacement, at least the posterior and, in many cases, the entire subvalvular apparatus were preserved. Mean ejection fraction and proportion of patients with severe ventricular dysfunction were similar between the repair and replacement groups. The odds ratios for the studies, comparing replacement to repair, ranged from 0.884 to 17.241 for short-term mortality and the hazard ratios ranged from 0.677 to 3.205 for long-term mortality. There was a significantly increased likelihood of both short-term mortality (summary odds ratio 2.667 (95% confidence interval (CI) 1.859-3.817)) and long-term mortality (summary hazard ratio 1.352 (95% CI 1.131-1.618)) for the replacement group compared to the repair group. Based on the meta-analysis of the current relevant literature, mitral valve repair for IMR is associated with better short-term and long-term survival compared to mitral valve replacement. Our conclusion should be interpreted in the context of the inherent limitations of a meta-analysis of retrospective studies including heterogeneity of patient characteristics, which may have influenced the physician's decision to perform mitral valve repair or replacement. In the absence of any published randomized studies, mitral procedure selection should be individualized.

Editor's Note

HomeCirculationVol. 120, No. 13Editor's Note Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBEditor's Note Samuel Z. Goldhaber, MD and Joseph Loscalzo, MD, PhD Samuel Z. GoldhaberSamuel Z. Goldhaber Search for more papers by this author and Joseph LoscalzoJoseph Loscalzo Search for more papers by this author Originally published29 Sep 2009https://doi.org/10.1161/CIRCULATIONAHA.109.899757Circulation. 2009;120:1168Editor’s NoteThe Editors of Circulation wish to remind our readers about 2 special sections of our journal: Clinician Update and the Patient Page. Clinician Update serves as case-based learning of important topics in cardiology geared to readers who are not specialists in that particular area. The section is especially pertinent for general cardiologists and for those cardiovascular medicine specialists who wish to retain overall familiarity with cardiovascular medicine. Recent contributions to this section have included a broad range of topics: clopidogrel resistance, coronary artery spasm, ventricular assist devices, coronary stents, and health literacy. Articles in Clinician Update are always published in the Print Edition of Circulation and are also posted on our Web site under the journal’s Special Sections (http://circ.ahajournals.org/misc/special.shtml). For an example of a recent Clinician Update, please see the one in this issue by Badiwala et al, titled “Surgical Management of Ischemic Mitral Regurgitation.”The Patient Page is geared to nonprofessionals, especially to patients and their families. Articles are written with a minimum of medical jargon and are focused on providing the same type of “take-home message” that a cardiovascular specialist might provide to a patient and family during an outpatient office visit or family meeting during a hospitalization. Recent topics have included the following: venous thromboembolism prevention, warfarin anticoagulation, implantable cardioverter-defibrillator recalls, aortic dissection, and hospital quality of care. Articles in the Patient Page section are posted on our Web site (http://circ.ahajournals.org/misc/special.shtml) and are available for downloading at no charge and without any restriction.The Editors welcome submissions to either section of Circulation. Instructions to authors are posted on our Web site (http://circ.ahajournals.org/misc/ifora.shtml). Previous Back to top Next FiguresReferencesRelatedDetailsCited By Huang Q, Zhang J, Liang L, Lan Z, Huo T and Li S (2015) The Significance of Neuregulin-1/ErbB Expression in Autogenous Vein Grafts in a Diabetic Rat Model, Journal of Cardiovascular Pharmacology, 10.1097/FJC.0000000000000279, 66:3, (300-306), Online publication date: 1-Sep-2015. September 29, 2009Vol 120, Issue 13 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.109.899757 Originally publishedSeptember 29, 2009 PDF download Advertisement SubjectsAcute Coronary Syndromes

LVOTO following mitral prosthetic insertion with full retention of the native valve apparatus

Background: Mitral repair rather than mitral replacement appears to provide a survival benefit for management of ischaemic mitral regurgitation despite a 30% recurrence of clinically significant MR by 5 years postoperatively. It is considered that resection of the anterior leaflet at the time of valve replacement contributes to increased mortality. However, retention of the anterior leaflet carries a risk of left ventricular outflow tract obstruction (LVOTO).