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.

This article has been cited by other articles:

				R. M. Suri, H. V. Schaff, J. A. Dearani, T. M. Sundt III, R. C. Daly, C. J. Mullany, M. E. Sarano, and T. A. Orszulak Determinants of early decline in ejection fraction after surgical correction of mitral regurgitation. J. Thorac. Cardiovasc. Surg., August 1, 2008; 136(2): 442 - 447. [Abstract] [Full Text] [PDF]

				P. L. DiGiorgi, F. G. Baumann, A. M. O'Leary, C. F. Schwartz, E. A. Grossi, G. H. Ribakove, S. B. Colvin, A. C. Galloway, and J. B. Grau Mitral Valve Disease Presentation and Surgical Outcome in African-American Patients Compared With White Patients Ann. Thorac. Surg., January 1, 2008; 85(1): 89 - 93. [Abstract] [Full Text] [PDF]

				A. J. Choure, M. J. Garcia, B. Hesse, M. Sevensma, G. Maly, N. L. Greenberg, L. Borzi, S. Ellis, E. M. Tuzcu, and S. R. Kapadia In Vivo Analysis of the Anatomical Relationship of Coronary Sinus to Mitral Annulus and Left Circumflex Coronary Artery Using Cardiac Multidetector Computed Tomography: Implications for Percutaneous Coronary Sinus Mitral Annuloplasty J. Am. Coll. Cardiol., November 21, 2006; 48(10): 1938 - 1945. [Abstract] [Full Text] [PDF]

				R. O. Bonow, B. A. Carabello, K. Chatterjee, A. C. de Leon Jr, D. P. Faxon, M. D. Freed, W. H. Gaasch, B. W. Lytle, R. A. Nishimura, P. T. O'Gara, et al. ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease) Developed in Collaboration With the Society of Cardiovascular Anesthesiologists Endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons J. Am. Coll. Cardiol., August 1, 2006; 48(3): e1 - e148. [Full Text] [PDF]

				R. O. Bonow, B. A. Carabello, K. Chatterjee, A. C. de Leon Jr, D. P. Faxon, M. D. Freed, W. H. Gaasch, B. W. Lytle, R. A. Nishimura, P. T. O'Gara, et al. ACC/AHA 2006 Practice Guidelines for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease) Developed in Collaboration With the Society of Cardiovascular Anesthesiologists Endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons J. Am. Coll. Cardiol., August 1, 2006; 48(3): 598 - 675. [Full Text] [PDF]

				G Doukas, M Oc, C Alexiou, A W Sosnowski, N J Samani, and T J Spyt Mitral valve repair for active culture positive infective endocarditis Heart, March 1, 2006; 92(3): 361 - 363. [Abstract] [Full Text] [PDF]

				M. De Bonis, R. Lorusso, E. Lapenna, S. Kassem, G. De Cicco, L. Torracca, F. Maisano, G. La Canna, and O. Alfieri Similar long-term results of mitral valve repair for anterior compared with posterior leaflet prolapse J. Thorac. Cardiovasc. Surg., February 1, 2006; 131(2): 364 - 370. [Abstract] [Full Text] [PDF]

				N. Kouris, I. Ikonomidis, D. Kontogianni, P. Smith, and P. Nihoyannopoulos Mitral valve repair versus replacement for isolated non-ischemic mitral regurgitation in patients with preoperative left ventricular dysfunction. A long-term follow-up echocardiography study Eur J Echocardiogr, December 1, 2005; 6(6): 435 - 442. [Abstract] [Full Text] [PDF]

				C. Alexiou, G. Doukas, M. Oc, B. Oc, L. Hadjinikolaou, and T. J. Spyt Effect of Training in Mitral Valve Repair Surgery on the Early and Late Outcome Ann. Thorac. Surg., July 1, 2005; 80(1): 183 - 188. [Abstract] [Full Text] [PDF]

				M. A. Romano, H. J. Patel, F. D. Pagani, R. L. Prager, G. M. Deeb, and S. F. Bolling Anterior Leaflet Repair With Patch Augmentation for Mitral Regurgitation Ann. Thorac. Surg., May 1, 2005; 79(5): 1500 - 1504. [Abstract] [Full Text] [PDF]

				J. J.M. Westenberg, J. Doornbos, M. I.M. Versteegh, J. J. Bax, R. J. van der Geest, A. de Roos, R. A.E. Dion, and J. H.C. Reiber Accurate quantitation of regurgitant volume with MRI in patients selected for mitral valve repair Eur. J. Cardiothorac. Surg., March 1, 2005; 27(3): 462 - 467. [Abstract] [Full Text] [PDF]

				Y. Sakamoto, K. Hashimoto, H. Okuyama, S. Ishii, M. Hanai, T. Inoue, G. Shinohara, K. Morita, and H. Kurosawa Long-Term Assessment of Mitral Valve Reconstruction With Resection of the Leaflets: Triangular and Quadrangular Resection Ann. Thorac. Surg., February 1, 2005; 79(2): 475 - 479. [Abstract] [Full Text] [PDF]

				M. Enriquez-Sarano, H. V. Schaff, and R. L. Frye Mitral Regurgitation: What Causes the Leakage Is Fundamental to the Outcome of Valve Repair Circulation, July 22, 2003; 108(3): 253 - 256. [Full Text] [PDF]

				Zoltan. A. Szalay, A. Civelek, S. Hohe, H.-P. Brunner-LaRocca, W.-P. Klovekorn, I. Knez, P. R. Vogt, and E. P. Bauer Mitral annuloplasty in patients with ischemic versus dilated cardiomyopathy Eur. J. Cardiothorac. Surg., April 1, 2003; 23(4): 567 - 572. [Abstract] [Full Text] [PDF]

				D Pellerin, S Brecker, and C Veyrat Degenerative mitral valve disease with emphasis on mitral valve prolapse Heart, November 1, 2002; 88(90004): iv20 - 28. [Full Text] [PDF]

				E. Braunberger, A. Deloche, A. Berrebi, F. Abdallah, J.A Celestin, P. Meimoun, G. Chatellier, S. Chauvaud, J.N. Fabiani, and A. Carpentier Very Long-Term Results (More Than 20 Years) of Valve Repair With Carpentier's Techniques in Nonrheumatic Mitral Valve Insufficiency Circulation, September 18, 2001; 104(90001): I-8 - 11. [Abstract] [Full Text] [PDF]

				T. Le Tourneau, D. Grandmougin, C. Foucher, E. P. McFadden, P. de Groote, A. Prat, H. Warembourg, and G. Deklunder Anterior Chordal Transection Impairs Not Only Regional Left Ventricular Function But Also Regional Right Ventricular Function in Mitral Regurgitation Circulation, September 18, 2001; 104(90001): I-41 - 46. [Abstract] [Full Text] [PDF]

				T. Le Tourneau, P. de Groote, A. Millaire, C. Foucher, C. Savoye, P. Pigny, A. Prat, H. Warembourg, and J. M. Lablanche Effect of mitral valve surgery on exercise capacity, ventricular ejection fraction and neurohormonal activation in patients with severe mitral regurgitation J. Am. Coll. Cardiol., December 1, 2000; 36(7): 2263 - 2269. [Abstract] [Full Text] [PDF]

				E. S. Bishay, P. M. McCarthy, D. M. Cosgrove, K. J. Hoercher, N. G. Smedira, D. Mukherjee, J. White, and E. H. Blackstone Mitral valve surgery in patients with severe left ventricular dysfunction Eur. J. Cardiothorac. Surg., March 1, 2000; 17(3): 213 - 221. [Abstract] [Full Text] [PDF]

				M. R. Moon, A. DeAnda Jr, G. T. Daughters II, N. B. Ingels Jr, and D. C. Miller Effects of mitral valve replacement on regional left ventricular systolic strain Ann. Thorac. Surg., September 1, 1999; 68(3): 894 - 902. [Abstract] [Full Text] [PDF]

				R. M. Savage and D. M. Cosgrove Systematic Transesophageal Echocardiographic Examination in Mitral Valve Repair: The Evolution of a Discipline into the Twenty-First Century Anesth. Analg., June 1, 1999; 88(6): 1197 - 1197. [Full Text] [PDF]

				B. A. Carabello and F. A. Crawford Valvular Heart Disease N. Engl. J. Med., July 3, 1997; 337(1): 32 - 41. [Full Text] [PDF]

				R. J. Cerfolio, T. A. Orszulak, J. R. Pluth, W. S. Harmsen, and H. V. Schaff REOPERATION AFTER VALVE REPAIR FOR MITRAL REGURGITATION: EARLY AND INTERMEDIATE RESULTS J. Thorac. Cardiovasc. Surg., June 1, 1996; 111(6): 1177 - 1184. [Abstract] [Full Text]

				A. F. Carpentier, M. Pellerin, J.-F. Fuzellier, and J. Y. M. Relland EXTENSIVE CALCIFICATION OF THE MITRAL VALVE ANULUS: PATHOLOGY AND SURGICAL MANAGEMENT J. Thorac. Cardiovasc. Surg., April 1, 1996; 111(4): 718 - 730. [Abstract] [Full Text]

				Y. Takayama, J. W. Holmes, I. LeGrice, and J. W. Covell Enhanced Regional Deformation at the Anterior Papillary Muscle Insertion Site After Chordal Transsection Circulation, February 1, 1996; 93(3): 585 - 593. [Abstract] [Full Text]

				M. Enriquez-Sarano, H. V. Schaff, T. A. Orszulak, K. R. Bailey, A. J. Tajik, and R. L. Frye Congestive Heart Failure After Surgical Correction of Mitral Regurgitation : A Long-term Study Circulation, November 1, 1995; 92(9): 2496 - 2503. [Abstract] [Full Text]

				S. F. Bolling, G. M. Deeb, L. A. Brunsting, and D. S. Bach Early outcome of mitral valve reconstruction in patients with end-stage cardiomyopathy J. Thorac. Cardiovasc. Surg., April 1, 1995; 109(4): 676 - 683. [Abstract] [Full Text]

				M. Enriquez-Sarano, H. V. Schaff, T. A. Orszulak, A. J. Tajik, K. R. Bailey, and R. L. Frye Valve Repair Improves the Outcome of Surgery for Mitral Regurgitation : A Multivariate Analysis Circulation, February 15, 1995; 91(4): 1022 - 1028. [Abstract] [Full Text]

				Y. Suenaga, A. Io, K. Tajima, M.-H. Song, and T. Shimomura Intraoperative Evaluation of Valvular Function Using Transesophageal and Epicardial Echocardiography Vascular and Endovascular Surgery, January 1, 1995; 29(1): 1 - 14. [Abstract] [PDF]

				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] [Full Text]

				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]

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