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European Heart Journal Advance Access originally published online on November 7, 2007
European Heart Journal 2008 29(2):231-240; doi:10.1093/eurheartj/ehm468
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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2007. For permissions please email: journals.permissions@oxfordjournals.org

Five-year echocardiographic results of combined undersized mitral ring annuloplasty and coronary artery bypass grafting for chronic ischaemic mitral regurgitation

Sandro Gelsomino1,*, Roberto Lorusso2, Giuseppe De Cicco2, Irene Capecchi1, Carlo Rostagno1, Sabina Caciolli1, Stefano Romagnoli1, Ugo Da Broi1, Pierluigi Stefàno1 and Gian Franco Gensini1

1 Experimental Surgery Unit, Department of Heart and Vessels, Careggi HospitalViale Morgagni 85, 50134 Florence, Italy
2 Cardiac Surgery Unit, Civic Hospital, Brescia, Italy

Received 30 April 2007; revised 30 August 2007; accepted 24 September 2007; online publish-ahead-of-print 7 November 2007.

* Corresponding author. Tel +39 055 794 7467, Fax: +39 055 794 7628, Email: sandro.gelsomino{at}libero.it

See page 147 for the editorial comment on this article (doi:10.1093/eurheartj/ehm531)


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Conclusions
 Acknowledgements
 References
 
Aims: We present 5-year echocardiographic results of combined undersizing mitral ring annuloplasty (UMRA) and coronary artery bypass grafting (CABG) in chronic ischaemic mitral regurgitation (CIMR).

Methods and results: Two hundred and fifty-one patients (aged 68.4 ± 8.1, 62.5% male) undergoing combined CABG and UMRA in our Institution (Cardiac Surgery, Careggi Hospital, Florence, Italy) between September 2001 and March 2007 were prospectively enrolled in the study. Median follow up was 32.9 months [interquartile range (IQR) 17.5–51.6]. Fourteen patients with significant residual mitral regurgitation (MR) needing immediate intraoperative revision (n = 3) or at discharge (n = 11) were excluded from the study. Serial echocardiograms were performed in 220 survivors at baseline, discharge, and annually thereafter. Additionally, 17 patients died (2 early and 15 late deaths) and were also excluded from the study. MR remained stable at 1 year and re-increased at 3 years (P < 0.001) and 5 years (P < 0.001). Five-year actuarial survival was 83.2 ± 4.4. Five-year freedom from re-operation for failed repair was 78.2 ± 4.9%. Mean systolic and diastolic diameters decreased significantly at discharge (P = 0.001 and P = 0.01, respectively) and at early follow up (P = 0.004 and P = 0.02) but raised at 3 years (P < 0.001) and 5 years (P < 0.001). Systolic and diastolic sphericity indexes improved at discharge (P < 0.001) remained stable at 1 year but they re-increased at 3-year control (P = 0.006 and P = 0.03, respectively) with a late raise exceeding the pre-operative value (P < 0.001). Left ventricular reverse remodelling was observed in 44.2% of the study population with 10.3% of patients showing further left ventricular dilatation. At multivariable model, end-systolic volume ≥145 mL, systolic sphericity index ≥0.7, myocardial performance index ≥0.9, and wall motion score index ≥1.5 were predictors of recurrent MR.

Conclusion: Our findings emphasize the need for improved repair technique and better patient selection to identify patients with anticipated repair failure who could benefit more from valve replacement or other procedure directly addressing ventricular tethering.

Key Words: Mitral valve • Mitral regurgitation • Mitral valve repair


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Conclusions
 Acknowledgements
 References
 
Despite of improvements in mitral reparative techniques in the recent years,1 chronic ischaemic mitral regurgitation (CIMR) still remains a challenging surgical problem. Combined coronary artery bypass grafting (CABG) and annular reduction with an annuloplasty ring (undersized mitral ring annuloplasty, UMRA) is the most common surgical technique employed to relieve ischaemic regurgitation.2 Nonetheless, conflicting data are reported in the literature about long-term effectiveness of this approach.3–7

In the present study, we present 5-year echocardiographic results after combined UMRA and CABG in terms of recurrence of mitral regurgitation (MR), global and local LV remodelling, and left ventricular reverse remodelling (LVRR). We also explore potential useful predictors of recurrence of MR following combined undersized annuloplasty and coronary artery bypass.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Conclusions
 Acknowledgements
 References
 
Patients population
CIMR was defined as the combination of mild-to-severe MR with (i) prior myocardial infarction (MI) >16 days; (ii) 75% or greater stenosis of at least one coronary vessel; (iii) a corresponding regional wall motion abnormality; (iv) type IIIb leaflet dysfunction following Carpentier’s classification8 with or without annular dilatation.

Exclusion criteria were: (i) degenerative or other non-ischaemic aetiology; (ii) ischaemic isolated type I or type II dysfunction;8 (iii) additional mitral valve repair procedures; (iv) other valvular or congenital heart diseases; (v) previous cardiac surgery/percutaneous transluminal coronary angioplasty; (vi) atrial fibrillation or sinus rhythm with heart rate at rest >100 b.p.m.

Two hundred and fifty-one patients undergoing combined CABG and UMRA in our Institution (Cardiac Surgery, Careggi Hospital, Florence, Italy) between September 2001 and March 2007 were prospectively enrolled in the study (Table 1). Clinical follow-up information was obtained from all survivors through outpatient visits and phone calls and was 100% complete. Median follow up was 32.9 months [interquartile range (IQR) 17.5–51.6].


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  		Table 1 Peri-operative data (n = 251)

 
Following the World Medical Association guidelines concerning ethical principles for medical research involving human subjects,9 the study was approved by Institutional Ethics Board. Furthermore, all patients gave their informed consent.

Surgery
All patients underwent associated CABG. For the purpose of this study, complete revascularization was accomplished when, at least, one graft was placed distal to an approximately 50% diameter narrowing in each of the three major vascular system in which arterial narrowing of this severity was noted in a vessel≥1.5 mm of diameter. It was not considered necessary to bypass all obstructed diagonal branches of the anterior descending or marginal branches of the circumflex coronary arteries for a classification of complete revascularization. Following this definition, 100% patients underwent complete revascularization.

The ring size was determined by standard measurements of the inter-trigonal distance and anterior leaflet height. A downsizing by two ring sizes was performed in all patients. After cardiopulmonary bypass (CPB), a transesophageal echocardiography (TEE) was performed to assess residual MR: leaflet co-aptation ≥0.5 cm, MR≤1, and systolic MV area >2 cm2 was assessed as successful repair. Three patients needed immediate intraoperative revision for failed repair: all underwent mitral valve replacement and were excluded from the study.

Echocardiographic measurements and calculations
The clinical echocardiographic evaluation was as follows. A transthoracic echocardiogram (TTE) and a TEE were performed within 5 days before surgery and serial TTE were performed at discharge and annually thereafter. Eleven patients (4.4%) with residual MR defined as the insufficiency ≥2+ following valve repair documented at discharge were excluded from the study. Five-year echocardiograms were available from 61 patients (27.7%). This patient dropout was independent of the disease status and totally due to the different number of patients reaching different study intervals [1 year, 187 patients (85%); 3 year, 122 (55.4%)]. Echocardiographic studies were carried out on Acuson Sequoia imaging device equipped with a 3.5 MHz ultrasound transducer (Acuson Corporation, Mountain View, CA, USA). Standard parasternal and apical views (long-axis, short-axis, 2-4-5-chamber views) were employed. The reliability of echocardiographic measurements was assessed by calculating between-observer (I.C. and C.R.) interval of agreements of main direct measures used in this study in a different group of 20 subjects (10 MR).10

Mitral regurgitation
The following quantitative measurements were simultaneously employed to grade the severity of MR and final results were averages of measured values:11–13(i) quantitative Doppler and (ii) proximal isovelocity surface area (PISA). For each measurement, minimum of three cardiac cycles were averaged. The respective thresholds for mild, moderate, and severe MR were <30, 30–59, and≥60 mL/beat for regurgitant volume (RV), <30, 30–49, and ≥50% for regurgitant fraction (RF), <20, 20–39, and≥40 mm2 for effective regurgitant orifice (ERO), respectively. In patients with no or trivial MR by colour Doppler, RV, and RF were used as calculated, and ERO was assumed as null.

The tenting area (TA) was measured by the area enclosed between the annular plane and mitral leaflets from the parasternal long-axis view at mid-systole. The distance between leaflet co-aptation and the mitral annulus plane at early and end systole measured displacement of mitral co-aptation toward the LV apex.14,15 Mitral annular areas were obtained from mitral annular dimensions in apical long-axis, four-chamber, and two-chamber views, using an ellipsoid assumption.16

Recurrent MR was the insufficiency ≥2+ at follow-up appointments in patients with no/trivial MR at discharge.

Global left ventricular remodelling
LV volumes and left ventricular ejection fraction (LVEF) were assessed by the bi-apical Simpson disk method.17 According to Stellbrink et al., 18 a decrease in LV end systolic volume >15% from baseline value was considered LVRR. The myocardial performance index (MPI) was measured using the method described by Tei et al.19 Sphericity indexes were obtained at end diastole and end systole (SID and SIS, respectively) as the volume of the left ventricle divided by the volume of a sphere with a diameter equal to the longest axis of the left ventricle measured in the apical view.20 The wall motion score index (WMSI) was calculated according to a 17-segment model.21

Local left ventricular remodelling
The displacement of papillary muscles (PMs) was quantified as distances from well-defined anatomic landmarks at early and end systole.14 Lateral and posterior displacements of anterior papillary muscles (APMs) and posterior papillary muscles (PPMs) were measured as distances from these fixed references. Separation between PMs was directly measured (from body to body of PMs). In the long-axis view, the apical displacement of the PPM was measured as the distance between the PM head and the fixed inter-valvular fibrosa (annular-papillary distance). The WMSI of the basal and mid-posterior and inferior segments for the PPM and of basal and mid-lateral and anterior segments for the APM were calculated.22

Statistical analysis
The sample size was determined by GraphPad StatMate release 2.00 (GraphPad Prism Software, Inc., San Diego, CA, USA). On the basis of preliminary data obtained by echocardiography and was determined on the basis of the following assumptions: Type I error of 0.05 (two-sided), power of 80%, difference in end systolic volume between patients with or without recurrent MR of 0.78, standard deviation of 2.4. The calculated study population was 300. However, 256 patients were recruited to allow for possible analytic problems while processing the or other eventualities potentially leading to patient attrition. Continuous variables are presented as mean and standard deviation (SD), categorical variables as n/N (%), odds ratios as OR, and pertinent 95% confidence intervals as CI. The bivariate association between the independent variables and recurrent MR was assessed by the Student’s t-test, Mann–Whitney U test, {chi}2 test, and Fisher exact test where appropriate.

Echocardiographic variables over time were analysed by means of ANOVA repeated measures followed by Tukey post hoc test and Friedman test, where appropriate to detect differences at different study points (discharge vs. baseline; 1 year vs. discharge; 3 years vs.1 year, and 5 years vs. 3 years).

Multivariable logistic regression analysis by means of a backward stepwise algorithm (cut-off for entry 0.05, for removal 0.10) was performed to select independent predictors of recurrent regurgitation. Model assumptions (linearity and additivity assumptions) were checked by piecewise cubic polynomials (spiline functions) and pooled interaction test,23 respectively, and found to be satisfied. Goodness of fit of the final logistic regression models was assessed with the Hosmer–Lemeshow statistic24 and predictive accuracy was assessed by the concordance (c) index.23 Internal validation of predictors generated by multivariable logistic regression was performed by means of bootstrapping techniques, with 1000 cycles and generation of OR and bias corrected 95% CI.23

Optimal cut-off values were determined as the rounding cut-off that gives the maximum sum of sensitivity and specificity. This value should be the shoulder at the top left of the receiver operating characteristic (ROC) curve. Bootstrapping techniques were employed to validate the results. Cumulative probability for death and re-operation were estimated by use of the Kaplan–Meier method.

SPSS 12.0 (SPSS, Chicago, IL, USA) and Stats Direct 2.5.7 (StatsDirect, Sale, UK) were used for these calculations. Significance for hypothesis testing was set at the 0.05 two-tailed level.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Conclusions
 Acknowledgements
 References
 
Overall survival
Early (30-day) mortality was 0.8% (n = 2, respiratory failure and low-output syndrome). During the follow-up 15 patients died: six of cardiac causes [heart failure (n = 3; 36, 45, and 54 months), myocardial infarction (n = 2; 31 and 42 months), and arrhythmia (n = 1; 59 months)], eight of non-cardiac causes [multi-organ failure (n = 1; 6 months), respiratory failure (n = 1; 14 months), infection (n = 2; 3 and 8 months), stroke (n = 2; 12 and 43 months), and malignancy (n = 2; 55 and 59 months)] and 1 of sudden, unexplained death (22 months). Five-year actuarial survival was 83.2 ± 4.4 (Figure 1).


Figure 1
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  		Figure 1 Five-year survival and 95% confidence interval (dotted lines) following undersized mitral ring annuloplasty and coronary artery bypass grafting in patients with ischaemic mitral regurgitation

 
Residual and recurrent mitral regurgitation
Among 220 patients surviving CABG and reductive annuloplasty (Figure 2), mean MR remained stable at 1 year and re-increased at 3-year (P < 0.001) and 5-year studies (P < 0.001, Table 2). At 5-year echocardiography, 17 patients (27.8%) had no/trivial recurrent MR, 17 (27.8%) had MR 2+, 19 (31.1%) 3+, and 8 (13.1%) 4+(Figure 3). Seventeen patients underwent re-operation for failed repair due to recurrent MR: four (3.7%) had a re-MV repair and 13 (12.1%) underwent mitral valve replacement. Freedom from re-operation for failed repair was 78.2 ± 4.9% (Figure 4).


Figure 2
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  		Figure 2 Patients selection. Abbreviations: UMRA, undersized mitral ring annuloplasty; CABG, coronary artery bypass grafting; MR, mitral regurgitation. See text for definitions

 

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  		Table 2 Mitral regurgitation

 

Figure 3
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  		Figure 3 Mitral regurgitation (%) at different echocardiographic controls (P < 001)

 

Figure 4
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  		Figure 4 Five-year freedom from re-operation for recurrent ischaemic mitral regurgitation (dotted lines, 95% confidence interval)

 
Global left ventricular remodelling and left ventricular reverse remodelling
Ventricular diameters and left atrial dimensions reduced significantly at discharge (P < 0.001, P = 0.005, P = 0.002, respectively), showing no further significant change at subsequent controls (Table 3). Mean ESV and EDV decreased significantly at discharge (P = 0.001 and P = 0.01, respectively) and at early follow up (P = 0.004 and P = 0.02), but re-increased at 3-year (P < 0.001) and 5-year (P < 0.001) studies. Furthermore, ejection fraction and MPI did not show significant changes over time. Systolic and diastolic sphericity indexes improved at discharge (P < 0.001), remained stable at 1-year (P = ns) but they increased at 3-year control (P = 0.006 and P = 0.03 for SIS and SID, respectively) with a late increase exceeding the pre-operative value (P < 0.001). Finally, WMSI reduced significantly at discharge, remained constant at 1 year, but re-increased at 3-year (P = 0.02) and 5-year (P < 0.001) echocardiograms. Sixty percent of patients (n = 132) showed reverse remodelling at discharge and percent of patients showing LVRR increased significantly at 1-year (P < 0.001), but it reduced at 3-year (P < 0.001) and 5-year (P = 0.01) studies (Figure 5).


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  		Table 3 Global left ventricular remodelling

 

Figure 5
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  		Figure 5 Left ventricular reverse remodelling (P = 0.02)

 
Local left ventricular remodelling
For local remodelling (Table 4), indexes of posterior and lateral displacement of both PMs, PM separation, PPM fibrosa, and WMSIs were reduced significantly at discharge and remained constant at 1 year; nevertheless, PPM posterior (3 years, P = 0.01; 5 years, P = 0.02), PPM lateral (3 years, P = 0.008; 5 years, P = 0.02), PMs separation (3 years, P < 0.001; 5 years, P = 0.02) and PPMs fibrosa (P < 0.001) re-increased significantly at subsequent controls. In contrast, lateral and posterior displacements of the APM as well as WMSIs did not show further significant changes.


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  		Table 4 Local left ventricular remodelling

 
Predictors of recurrent mitral regurgitation
The unadjusted relationship between recurrent MR and independent variables are shown in Table 5. Multivariable logistic regression analysis identified systolic sphericity index (OR = 4.97, 95% CI = 2.11–6.40, P < 0.001), myocardial performance index (OR = 4.66, 95% CI=2.01–5.43, P < 0.001), end systolic volume (OR=2.59, 95% CI = 1.19–3.77, P = 0.003), and wall motion score index (OR = 1.99, 95% CI = 0.88–2.37, P = 0.04) as independent predictors of the occurrence of recurrent MR internal validation of such multivariable analysis by means of bootsrapping, including the same variables of standard logistic regression model, further confirmed the significant predictive of recurrent MR (bootstrap OR = 2.3, 95% bias-corrected 95% CI = 1.1–5.2). Finally, logistic regression model was reliable (Hosmer–Lemeshow test, P = 0.7) and accurate (c-index = 0.81).


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  		Table 5 Bivariate relationship of independent variables with recurrent mitral regurgitation

 
ROC analysis showed that SIS had 100% of sensitivity and specificity with an optimal cut-off ≥0.7 (95% CI by bootstrapping 0.58–0.81) (area under curve 1; 95% CI 0.70–1; P < 0.001).

MPI with a cut-off ≥0.9 (95% CI by bootstrapping 0.75–0.96) had 85% of sensitivity and 84% of specificity (area under curve 0.94; 95% CI 0.67–1; P < 0.001). In addition, ESV ≥145 mL (95% CI by bootstrapping 134–155) had 90% of sensitivity and specificity (area under curve 0.87; 95% CI 0.80–0.94; P < 0.001). Finally, WMSI ≥1.5 (95% CI by bootstrapping 1.35–1.62) had 80% of sensitivity and 82% of specificity (area under curve 0.81; 95% CI 0.77–0.91; P = 0.002).


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Conclusions
 Acknowledgements
 References
 
An established therapeutic approach to relieve CIMR, in association with CABG, is an undersized mitral ring annuloplasty (UMRA)2 which, by reducing the septal–lateral dimensions and the valve area, brings both mitral leaflets into apposition. Nonetheless, after encouraging initial results,25 different studies have revealed a significant proportion of patients developing recurrent MR during follow-up4,7,26 which has been mainly related to continued LV remodelling and persistent leaflet tethering.5,27 We reported our experience with this technique. Patients were followed up by serial TTE over a 5-year period and recurrence of MR, local, and global LV remodelling, and LV reverse remodelling were explored. We also identified potential useful predictors of MR-recurrence following combined UMRA and CABG.

Because of unavailable complete echocardiographic data, 15 patients who died late after surgery were excluded from the study.

Recurrence of mitral regurgitation
In our report, recurrent MR significantly increased at 3-year and 5-year controls with and 27.8% of patients showing mild, 31.1%moderate, and 13.1% severe MR at latest follow-up. Five-year freedom from re-operation for failed repair was 78.2 ± 4.9%. Hung et al.5 showed 72% of patients with moderate/severe MR at late control (47 ± 27 months) after ring annuloplasty and CABG. Accordingly, Tahta et al.26 in a large single-centre surgical series reported a 29% incidence of MR ≥2 over a 3-year follow-up period. However, in these studies, annuloplasty had not been routinely performed in a restrictive fashion. In contrast with these results, Braun and coworkers4 reported that, in 87 patients undergoing restrictive ring annuloplasty (2 ring sizes, median ring size 26), no patient showing MR ≥3 and 2 with MR graded 2+ at 18-month follow-up. In addition, Geidel et al.28 reported that 15 of 29 patients having no MR (52%), nine patients with MR1+ (31%), and five patients with MR2+ (17%), 13 ± 7 months after mitral annuloplasty and CABG. Of interest, they performed mitral downsizing in a ‘dynamic fashion’ dependent on LV function (2, 3, or4 ring sizes for LVEF>30, 20–30%,<20%, respectively).

Left ventricular remodelling
In our experience, we observed a significant global remodelling late after reductive annuloplasty: LV volumes increased significantly and WMSI exceeded its pre-operative value. Furthermore, LV became more spherical with sphericity indexes exceeding their baseline values at 5-year echocardiography. Regarding local remodelling, we observed a late ‘asymmetric’ lateral and posterior displacement of PPM with APM displacement which remained constant over time. Of interest, WMSI of the segments underlying both PMs, after a transient reduction, were relatively stable and these data suggest that the late PPM displacement seems to be due to the continued global remodelling, rather than local remodelling in this area.

Left ventricular reverse remodelling
According to Stellbrink et al., 18 we considered a decrease in LV end systolic volume >15% from baseline value as LVRR. In this fashion LVRR was observed, at late control, in 44.2% of patients with 10.3% showing further increment in ESV. Braun and coworkers6 reported 60.5% of patients with significant reverse LV remodelling18 months after restrictive mitral annuloplasty. We had comparable results at 12-month follow-up (77.5%) but LVRR dramatically worsened at late controls. However, our data are not comparable because this group considered a 10% reduction in EDD as significant LVRR; however, measurements of LV volumes have been demonstrated to be more reliable than LV diameters in assessing LV remodelling, especially in enlarged ventricles.29

Predictors of recurrent mitral regurgitation
At multivariable model, ESV ≥ 145 mL, SIS ≥ 0.7, MPI ≥ 0.9, and WMSI ≥ 1.5 were predictors of recurrent MR. These results emphasize the importance of the extent of pre-operative LV global remodelling as having a central role in predicting inadequate results after UMRA. A new finding in this study is that MPI predicts the likelihood of MR, whereas LVEF was not significant. The MPI is a combined systolic and diastolic Doppler-derived index for the assessment of global LV performance which, differently from LVEF, is independent of LV loading conditions and heart rate.

Study limitation
Our study findings should be viewed in light of some inherent limitations.

  1. Evaluation of LVRR was based on volumes obtained by echocardiography; volumetry by 2D echocardiography depends on geometric assumptions and is subject to image-plane positioning errors. Hence, it is not accurate in left ventricles that are distorted in shape such as after myocardial infarction. However, this limitation belongs to most of published paper regarding this pathology.
  2. Viability testing was not performed in these patients. Therefore, lack of LVRR in non-responders might be also due to irreversible ischaemic myocardial damage (not viable myocardium). This issue deserves further investigation.
  3. Postoperative evaluation of the coronary status was not assessed. It would have been helpful to differentiate between surgical failure (valve repair and CABG) and the progress of the coronary disease.
  4. Fifteen patients with late deaths were not included in the study. They could have benefited from serial echocardiograms possibly with different results.
  5. Estimated cut-offs are known to be very susceptible to changes in the study population. We employed bootstrapping techniques to validate the results, nonetheless, it has also been documented that the sensitivity/specificity associated with these cut-offs are overly optimistic.

Strength of the study
As far as we know, this is the largest cohort reported with UMRA in CIMR patients with detailed echocardiographic follow-up. Furthermore, our patient cohort was more homogeneous than in other study:30 All patients underwent associated CABG, they had no concomitant MV procedures, and the entire cohort was uniform regarding the MV ischaemic leaflet dysfunction. Moreover, to assess results for MV repair, we studied true ‘recurrent’.

MR excluding those patients with ‘residual ‘MR in whom the insufficiency was presumably never eliminated at surgery. Additionally, we undertook valve sizing in a standardized fashion and the degree of undersizing was homogeneous over the 5-year-period of the study. Finally, we used only two rings (Carpentier’s rigid or semi-flexible rings).

Clinical implications
In our experience, UMRA does not ensure successful and durable elimination of MR in all patients. Those who can benefit from combined UMRA and CABG should be pre-operatively identified utilizing echo predictors of recurrent MR. However, restrictive annuloplasty resulted to be ineffective in a large percentage of patients and results of this study suggest the need for different approaches directly addressing ventricular tethering in most of CIMR patients.31–34 Such procedures may include LV plasty with volume reduction, chordal elongation or cutting, PM displacement, and leaflet elongation techniques as well as cardiac the employment of support devices introduced in recent years in clinical practice.35,36 Mitral valve replacement, largely employed in the past in ischaemic regurgitation, although eliminates the short-term risk of recurrent MR, it is associated with poor long-term survival.37 Thus, in our actual policy, we do not consider MV replacement as a reasonable alternative to repair.


   Conclusions
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusions
Acknowledgements
 References
 
Combined UMRA and CABG provided poor mid-term results with significant recurrent MR. Our findings emphasize the need for improved repair technique and better patient selection to identify patients with anticipated repair failure who could benefit more from valve replacement or other procedure directly addressing ventricular tethering. Long-term prospective studies on this controversial issue are encouraged.


   Acknowledgements
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusions
 Acknowledgements
References
 
We gratefully acknowledge Judith Wilson for the English revision of the manuscript and Orlando Parise for the statistical analysis.

Conflict of interest: none declared.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusions
 Acknowledgements
 References
 

  1. Miller DC. Ischemic mitral regurgitation redux-to repair or to replace? J Thorac Cardiovasc Surg (2001) 122:1059–1062.[Free Full Text]
  2. Bolling SF, Pagani FD, Deeb GM, Bach DS. Intermediate term outcome of mitral reconstruction in cardiomyopathy. J Thorac Cardiovasc Surg (1998) 115:381–386.[Abstract/Free Full Text]
  3. Bax JJ, Braun J, Somer ST, Klautz R, Holman ER, Versteegh MI, Boersma E, Schalij MJ, van der Wall EE, Dion RA. Restrictive annuloplasty and coronary revascularization in ischemic mitral regurgitation results in reverse left ventricular remodeling. Circulation (2004) 110(Suppl. II):II103–II108.[ISI][Medline]
  4. McGee EC, Gillinov AM, Blackstone EH, Rajeswaran J, Cohen G, Najam F, Shiota T, Sabik JF, Lytle BW, McCarthy PM, Cosgrove DM. Recurrent mitral regurgitation after annuloplasty for functional ischemic mitral regurgitation. J Thorac Cardiovasc Surg (2004) 128:916–924.[Abstract/Free Full Text]
  5. Hung J, Papakostas L, Tahta SA, Hardy BG, Bollen BA, Duran CM, Levine RA. Mechanism of recurrent ischemic mitral regurgitation after annuloplasty: continued LV remodeling as a moving target. Circulation (2004) 110(Suppl. II):II85–II90.[ISI][Medline]
  6. Braun J, Bax JJ, Versteegh MI, Voigt PG, Holman ER, Klautz RJ, Boersma E, Dion RA. Preoperative left ventricular dimensions predict reverse remodeling following restrictive mitral annuloplasty in ischemic mitral regurgitation. Eur J Cardiothorac Surg (2005) 27:847–853.[Abstract/Free Full Text]
  7. Serri K, Bouchard D, Demers P, Coutu M, Pellerin M, Carrier M, Perrault LP, Cartier R, Page P, Cossette M, Basmadjian AJ. Is a good perioperative echocardiographic result predictive of durability in ischemic mitral valve repair? J Thorac Cardiovasc Surg (2006) 131:523–529.[Free Full Text]
  8. Carpentier A. Cardiac valve surgery—the ‘French correction. J Thorac Cardiovasc Surg (1983) 86:326–337.
  9. World Medical Association Declaration of Helsinki: Ethical principles for medical research involving human subjects. Edinburgh, Scotland: World Medical Association. October 2000. http//www.wma.net/e/policy/17-c_3html/ (Accessed 22 June 2001).
  10. Bland MJ, Altman DJ. Statistical method for assessing agreement between two methods of clinical measurements. Lancet (1986) 1:307–310.[CrossRef][ISI][Medline]
  11. Gardin JM, Adams DB, Douglas PS, Feigenbaum H, Forst DH, Fraser AG, Grayburn PA, Katz AS, Keller AM, Kerber RE, Khandheria BK, Klein AL, Lang RM, Pierard LA, Quinones MA, Schnittger I, American Society of Echocardiography. Recommendations for a standardized report for adult transthoracic echocardiography: a report from the American Society of Echocardiography’s Nomenclature and Standards Committee and Task Force for a Standardized Echocardiography Report. J Am Soc Echocardiogr (2002) 15:275–290.[CrossRef][ISI][Medline]
  12. Zoghbi WA, Enriquez-Sarano M, Foster E, Grayburn PA, Kraft CD, Levine RA, Nihoyannopoulos P, Otto CM, Quinones MA, Rakowski H, Stewart WJ, Waggoner A, Weissman NJ, American Society of Echocardiography. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr (2003) 16:777–802.[CrossRef][ISI][Medline]
  13. Enriquez-Sarano M, Tribouilloy C. Quantitation of mitral regurgitation: rationale approach and interpretation in clinical practice. Heart (2002) 88(Suppl. IV):1–4.[Free Full Text]
  14. Yiu SF, Enriquez-Sarano M, Tribouilloy C, Seward JB, Tajik AJ. Determinants of the degree of functional mitral regurgitation in patients with systolic left ventricular dysfunction: a quantitative clinical study. Circulation (2000) 102:1400–1406.[Abstract/Free Full Text]
  15. Boltwood CM, Tei C, Wong M, Shah PM. Quantitative echocardiography of the mitral complex in dilated cardiomyopathy: the mechanism of functional mitral regurgitation. Circulation (1983) 68:498–508.[Free Full Text]
  16. Vijayaraghavan G, Boltwood CM, Tei C, Wong M, Shah PM. Simplified echocardiographic measurement of the mitral annulus. Am Heart J (1986) 112:985–991.[CrossRef][ISI][Medline]
  17. Schiller NB, Shah PM, Crawford M, DeMaria A, Devereux R, Feigenbaum H, Gutgesell H, Reicheck N, Sahn D, Schnittger I. Recommendations for quantitation of the left ventricle by two-dimensional echocardiography American Society of Echocardiography Committee on Standards, Subcommittee on Quantitation of Two-Dimensional Echocardiograms. J Am Soc Echocardiogr (1989) 2:358.[Medline]
  18. Stellbrink C, Breithardt OA, Franke A, Sack S, Bakker P, Auricchio A, Pochet T, Salo R, Kramer A, Spinelli J, PATH-CHF (Pacing Therapies in Congestive Heart Failure) Investigators; CPI Guidant Congestive Heart Failure Research Group. Impact of cardiac resynchronization therapy using hemodynamically optimized pacing on left ventricular remodeling in patients with congestive heart failure and ventricular conduction disturbances. J Am Coll Cardiol (2001) 38:1957–1965.[Abstract/Free Full Text]
  19. Tei C, Ling LH, Hodge DO, Bailey KR, Oh JK, Rodeheffer RJ, Tajik AJ, Seward JB. New index of combined systolic and diastolic myocardial performance: a simple and reproducible measure of cardiac function a study in normals and dilated cardiomyopathy. J Cardiol (1995) 26:357–366.[Medline]
  20. Kono T, Sabbah HN, Rosman H, Alam M, Jafri S, Goldstein S. Left ventricular shape is the primary determinant of functional mitral regurgitation in heart failure. J Am Coll Cardiol (1992) 20:1594–1598.[Abstract]
  21. Cerqueira MD, Weissman NJ, Dilsizian V, Jacobs AK, Kaul S, Laskey WK, Pennell DJ, Rumberger JA, Ryan T, Verani MS, American Heart Association Writing Group on Myocardial Segmentation Registration for Cardiac Imaging. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart: a statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. Circulation (2002) 105:539–542.[Free Full Text]
  22. Grigioni F, Enriquez-Sarano M, Zehr KJ, Bailey KL, Tajik AJ. Ischemic Mitral Regurgitation. Long-term outcome and prognostic implications with quantitative Doppler assessment. Circulation (2001) 103:1759–1764.[Abstract/Free Full Text]
  23. Harrel FE Jr, Lee KL, Mark DB. Multivariable Prognostic Models: Issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors. Stats Med (1996) 15:361–387.[CrossRef][ISI][Medline]
  24. Hosmer DW, Lemeshow S. Applied Logistic Regression (2000) 2nd ed. New York: Wiley-Interscience. 143–202.
  25. Bolling SF, Deeb GM, Bach DS. Mitral valve reconstruction in elderly, ischemic patients. Chest (1996) 109:35–40.[CrossRef][ISI][Medline]
  26. Tahta SA, Oury JH, Maxwell JM, Hiro SP, Duran CM. Outcome after mitral valve repair for functional ischemic mitral regurgitation. J Heart Valve Dis (2002) 11:11–18.[ISI][Medline]
  27. Kuwahara E, Otsuji Y, Iguro Y, Ueno T, Zhu F, Mizukami N, Kubota K, Nakashiki K, Yuasa T, Yu B, Uemura T, Takasaki K, Miyata M, Hamasaki S, Kisanuki A, Levine RA, Sakata R, Tei C. Mechanism of recurrent/persistent ischemic/functional mitral regurgitation in the chronic phase after surgical annuloplasty: importance of augmented posterior leaflet tethering. Circulation (2006) 114(Suppl.):I529–I534.[ISI][Medline]
  28. Geidel S, Lass M, Schneider C, Groth G, Boczor S, Kuck KH, Ostermeyer J. Downsizing of mitral valve and coronary revascularization in severe ischemic mitral regurgitation results in reverse left ventricular and left atrial remodeling. Eur J Cardiothorac Surg (2005) 27:1011–1016.[Abstract/Free Full Text]
  29. Dujardin KS, Enriquez-Sarano M, Rossi A, Bailey KR, Seward JB. Echocardiographic assessment of left ventricular remodeling: are left ventricular diameters suitable tools? J Am Coll Cardiol (1997) 30:1534–1541.[Abstract]
  30. Adams DH, Anyanwu A. Pitfalls and limitations in measuring and interpreting the outcomes of mitral valve repair. J Thorac Cardiovasc Surg (2006) 131:523–529.[Free Full Text]
  31. Batista RJ, Verde J, Nery P, Bocchino L, Takeshita N, Bhayana JN, Bergsland J, Graham S, Houck JP, Salerno TA. Partial left ventriculectomy to treat end-stage heart disease. Ann Thorac Surg (1997) 64:634–638.[Abstract/Free Full Text]
  32. Dor V, Sabatier M, Di Donato M, Montiglio F, Toso A, Maioli M. Efficacy of endoventricular patch plasty in large postinfarction akinetic scar and severe left ventricular dysfunction: comparison with a series of large dyskinetic scars. J Thorac Cardiovasc Surg (1998) 116:50–59.[Abstract/Free Full Text]
  33. Messas E, Guerrero JL, Handschumacher MD, Conrad C, Chow CM, Sullivan S, Yoganathan AP, Levine RA. Chordal cutting: a new therapeutic approach for ischemic mitral regurgitation. Circulation (2001) 104:1958–1963.[Abstract/Free Full Text]
  34. Tibayan FA, Rodriguez F, Langer F, Zasio MK, Bailey L, Liang D, Daughters GT, Ingels NB Jr, Miller DC. Does septal-lateral annular cinching work for chronic ischemic mitral regurgitation? J Thorac Cardiovasc Surg (2004) 127:654–663.[Abstract/Free Full Text]
  35. Konertz W, Rombeck B, Hotz H. Short-term safety of the Acorn cardiac support device in patients with advanced heart failure. J Am Coll Cardiol (2000) 35:182A.
  36. Fukamachi K, McCarthy PM. Initial safety and feasibility clinical trial of the myosplint device. J Card Surg (2005) 20:S43–S47.[CrossRef][ISI][Medline]
  37. Gillinov AM, Wierup PN, Blackstone EH, Bishay ES, Cosgrove DM, White J, Lytle BW, McCarthy PM. Is repair preferable to replacement for ischemic mitral regurgitation? J Thorac Cardiovasc Surg (2001) 122:1125–1141.[Abstract/Free Full Text]

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S. Gelsomino, R. Lorusso, S. Caciolli, I. Capecchi, C. Rostagno, M. Chioccioli, G. De Cicco, G. Bille, P. Stefano, and G. F. Gensini
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P. Kolh
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Eur. Heart J., January 2, 2008; 29(2): 147 - 149.
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