Mitral valvuloplasty is superior to valve replacement for preservation of left ventricular function: an intraoperative two-dimensional echocardiographic study

To investigate the mechanism and time of onset of ventricular dysfunction after mitral valve replacement, 18 patients with pure, severe mitral regurgitation (of whom 10 underwent mitral valve repair and 8 standard mitral valve replacement with papillary muscle excision) were studied by intraoperative two-dimensional echocardiography immediately before and immediately after the operative procedure. No patient sustained a perioperative myocardial infarction or had any residual mitral regurgitation. Although preoperative hemodynamics were similar, postoperatively the patients with valve repair had a lower pulmonary capillary wedge pressure than did the patients with valve replacement (8.6 +/- 1.9 versus 14.4 +/- 7.5 mm Hg, p less than 0.04). Although intraoperative echocardiographic ejection fraction fell significantly after mitral valve replacement (0.64 +/- 0.11 to 0.40 +/- 0.09, p less than 0.0001), it was maintained after valve repair (0.44 +/- 0.20 to 0.49 +/- 0.16, p = NS). Additionally, regional myocardial contractile abnormalities in the anterior and posterior septum were detected immediately after the procedure by intraoperative echocardiography in the patients with valve replacement, but not in those with repair. These postoperative regional contractile abnormalities after papillary muscle resection have not been described previously. Resection of the papillary muscles may disrupt the muscle bundle alignment and induce contractile abnormalities remote from the excised muscle. This study demonstrated that significant global and regional ventricular dysfunction develops immediately after removal of the papillary muscles, whereas myocardial contractility is preserved in patients undergoing mitral valve repair. Therefore, with intraoperative echocardiography to assure minimal residual regurgitation, surgeons should attempt to preserve ventricular function by performing mitral valve reconstruction in patients with mitral regurgitation.

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				T. J. Vander Salm, L. A. Pape, and J. F. Mauser Mitral valve replacement with complete retention of native leaflets Ann. Thorac. Surg., January 1, 1995; 59(1): 52 - 55. [Abstract] [PDF]

				K.-G. Shyu, J.-J. Chen, F.-Y. Lin, C.-H. Tsai, J.-L. Lin, Y.-Z. Tseng, and W.-P. Lien Regression of left ventricular mass after mitral valve repair of pure mitral regurgitation Ann. Thorac. Surg., December 1, 1994; 58(6): 1670 - 1673. [Abstract] [PDF]

				M. Nagatsu, K. Ishihara, M. R. Zile, H. Tsutsui, H. Tagawa, G. DeFreyte, R. Tanaka, G. Cooper IV, and B. A. Carabello The effects of complete versus incomplete mitral valve repair in experimental mitral regurgitation J. Thorac. Cardiovasc. Surg., February 1, 1994; 107(2): 416 - 423. [Abstract] [Full Text]

				B. A. Carabello The changing unnatural history of valvular regurgitation Ann. Thorac. Surg., February 1, 1992; 53(2): 191 - 199. [Abstract] [PDF]

				D. H. Harpole Jr, J. S. Rankin, W. G. Wolfe, F. M. Clements, P. Van Trigt, W. G. Young, and R. H. Jones Effects of standard mitral valve replacement on left ventricular function Ann. Thorac. Surg., June 1, 1990; 49(6): 866 - 874. [Abstract] [PDF]

				W. S. Walker, K. G. Reid, E. W. J. Cameron, P. R. Walbaum, and A. H. Kitchin Comparison of Ventricular Septal Surgery and Mitral Valve Replacement for Hypertrophic Obstructive Cardiomyopathy Ann. Thorac. Surg., October 1, 1989; 48(4): 528 - 534. [Abstract] [PDF]

				M. L. Scott, C. L. Stowe, L. C. Nunnally, S. D. Spector, P. W. Moseley, P. D. Schumacher, and P. A. Thompson Mitral valve reconstruction in the elderly population Ann. Thorac. Surg., August 1, 1989; 48(2): 213 - 217. [Abstract] [PDF]

				L. H. Cohn Surgery for Mitral Regurgitation JAMA, November 18, 1988; 260(19): 2883 - 2887. [Abstract] [PDF]

				MITRAL-VALVE REPAIR SUPERIOR TO REPLACEMENT Journal Watch (General), September 18, 1987; 1987(918): 2 - 2. [Full Text]