LETTER TO THE EDITOR
Predictors of left ventricular dysfunction following mitral valve repair for mitral regurgitation: Reply
Takayoshi Matsumura, MD,
Eiji Ohtaki, MD,
Kaoru Tanaka, MD,
Kazuhiko Misu, MD,
Tetsuya Tohbaru, MD,
Ryuta Asano, MD,
Masatoshi Nagayama, MD,
Koichi Kitahara, MD,
Jun Umemura, MD,
Tetsuya Sumiyoshi, MD,
Hitoshi Kasegawa, MD and
Saichi Hosoda, MD
Department of Cardiology, Sakakibara Heart Institute, 2-5-4 Yoyogi, Shibuya-ku, Tokyo, 151-0053, Japan
eohtaki{at}shi.heart.or.jp
We appreciate the comments by Dr. Essop regarding our recent report on left ventricular (LV) dysfunction after mitral valve repair (1).
First, as Essop points out, echocardiographic predictors of a poor outcome in our study might be similar to those previously reported for mitral valve replacement. However, to compare mitral valve repair with mitral valve replacement, we must interpret our findings carefully because our study was not designed so. Some previous data suggest that LV function is preserved better after mitral valve repair than after mitral valve replacement (2,3). Further studies are needed to compare their echocardiographic predictors of a poor outcome. And even if echocardiographic predictors are similar, we believe that mitral valve repair is the procedure of choice that brings the better quality of life whenever a complete repair is expected.
Second, we must admit that only two factors, the preoperative ejection fraction and the LV end-systolic diameter, cannot fully explain which patients will have the better postoperative ejection fraction and which patients will not. Our results showed that the LV ejection fraction decreased significantly after mitral valve repair as a whole, but that in some patients the postoperative ejection fraction can be higher than the preoperative one. In the study by Lessana et al. (4) that Essop refers to, 26 patients underwent catheterization 2 to 60 months after mitral valvuloplasty (average 14 months). Mean ejection fraction decreased from 0.58 ± 0.11 to 0.52 ± 0.11. Ejection fraction in individual patients rose in 8 and fell in 18. In the other study by Bonchek et al. (5), 10 patients were studied with catheterization one week postoperatively. Mean ejection fraction was unchanged (0.66 ± 0.1 vs. 0.62 ± 0.1). Ejection fraction in individual patients rose in three, was unchanged in one, and fell in six. Although their shorter follow-up periods and our use of recently developed surgical techniques may preclude simple comparison between their results and ours, our results are at least not inconsistent with their results (5).
The improved ejection fraction in some patients can be considered to reflect the increased LV contractility as stated in our report. Starling et al. (6) showed that contractile function is impaired in some patients with long-term mitral regurgitation and a normal ejection function, and that impaired contractile function may not be irreversible in all these patients. As Essop mentions, Wisenbaugh (7) reported that, among patients with mitral regurgitation, 10 of 14 with ejection fraction <0.60 and 4 of 13 with ejection fraction >0.60 had muscular dysfunction and that others did not. His results and ours clearly show that LV dysfunction cannot be predicted with ejection fraction alone. It may be important to us to acknowledge that ejection fraction decreases after surgery in general, but that in some patients it can increase owing to improved contractility.
Finally, among 171 patients in our analysis of LV dysfunction, 65 patients had moderate mitral regurgitation, and 106 patients had severe mitral regurgitation.
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References
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- Matsumura T, Ohtaki E, Tanaka K, et al. Echocardiographic prediction of left ventricular dysfunction after mitral valve repair for mitral regurgitation as an indicator to decide the optimal timing of repair. J Am Coll Cardiol. 2003;42:458–463[Abstract/Free Full Text]
- Akins CW, Hilgenberg AD, Buckley MJ, et al. Mitral valve reconstruction versus replacement for degenerative or ischemic mitral regurgitation. Ann Thorac Surg. 1994;58:668–675[Abstract]
- Corin WJ, Sutsch GG, Murakami T, Krogmann ON, Turina M, Hess OM. Left ventricular function in chronic mitral regurgitation: Preoperative and postoperative comparison. J Am Coll Cardiol. 1995;25:113–121[Abstract]
- Lessana A, Herreman F, Boffety C, et al. Hemodynamic and cineangiographic study before and after mitral valvuloplasty. Circulation. 1981;64(Suppl II):195–201
- Bonchek LI, Olinger GN, Siegel R, et al. Left ventricular performance after mitral reconstruction for mitral regurgitation. J Thorac Cardiovasc Surg. 1984;88:122–137[Abstract]
- Starling MR, Kirsh MM, Montgomery DG, Gross MD. Impaired left ventricular contractile function in patients with long-term mitral regurgitation and normal ejection fraction. J Am Coll Cardiol. 1993;22:239–250[Abstract]
- Wisenbaugh T. Does normal pump function belie muscle dysfunction in patients with chronic severe mitral regurgitation? Circulation. 1988;77:515–525[Abstract/Free Full Text]
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