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J Thorac Cardiovasc Surg 2008;135:1252-1253
© 2008 The American Association for Thoracic Surgery
Invited Commentary |
Mitral insufficiency and heart failure are often very dynamic, and these patients were not that sick. Were these patients really optimized on standard advanced medical therapy before you attempted to operate? How long were they followed before making the decision to operate?
Dr Jerry Braun (Leiden, The Netherlands). All patients were on a good medical treatment strategy. All patients had at least had diuretics.
Dr Acker. Were they all on beta-blockers and angiotensin-converting enzyme inhibitors? If not, what percentage?
Dr Braun. All patients were receiving angiotensin-converting enzyme inhibitors, and the majority were receiving beta-blockers (
80% or 90%), this was continued after surgery.
Dr Acker. I saw that there was a bit of residual MR at your follow-up (0.6±), suggesting that some patients had up to 2+ MR. If you ever do see that, can you give us a hint on what preoperative characteristics of the patients, the ventricle, or the actual mitral valve might indicate late failure of your repair with a small annuloplasty ring?
Dr Braun. In this group, none of the patients had grade 2 MR. We know from our studies in ischemic patients, after 4 years about 85% has no grade 2 MR, while 15% has. In that patient group we tried to relate it to preoperative variables, but were not able to find a relation. It occurs both in the larger ventricle group as well as in the smaller ventricle group.
Dr Acker. Nothing about the degree of coaptation depth or annular size or whether it's an eccentric jet or central jet would indicate?
Dr Braun. No, not at all.
Dr Acker. Two of your patients died. At death—I don't know if they were censored from your results or not—did they have return of MR and did you see a lack of reverse remodeling in these 2 patients who died of progressive heart failure?
Dr Braun. Two patients died. One patient died several months after surgery, suddenly, probably because of ventricular arrhythmias. The other died shortly after emergent surgery for a vascular problem. The last echo several months before death showed a competent mitral valve and no progression of LV dilatation.
Dr Acker. You've demonstrated that there is reverse modeling in moderate heart failure. Do you have any evidence that you can share with us for patients with advanced heart failure secondary to idiopathic myopathy, such as these, and for patients with ischemic cardiomyopathy?
Dr Braun. We're working on our complete series of nonischemic patients. Unfortunately, we're not able to follow them with MRI, but with echocardiography. We're still working on that. I should say that currently we treat these patients with the CorCap cardiac support device (Acorn Cardiovascular; St. Paul, Minn, USA) device if they have an LV end-diastolic dimension exceeding 65 mm; we don't only do a restrictive mitral annuloplasty.
I should say that we treat these patients currently, if they have a left ventricular end diastolic dimension exceeding 65 mm, not only by a restrictive mitral annuloplasty, but we also add a CorCap cardiac support device (Acorn Cardiovascular; St. Paul, Minn, USA). In the ischemic patients, that we presented at the STS meeting in San Diego earlier this year we obtained results that are quite promising, as I said. Maybe I can show a discussion slide.
Dr Starnes. I don't think we have time.
Dr Braun. The results are very promising.
Dr Hormoz Azar (Norfolk, Va). There will be a certain amount of remodeling just by inserting the ring. Did you measure the midventricular diameter and did that show diminution in time, or how much of it was related just to cinching the ventricle by the ring?
Dr Braun. Of course, that difference is difficult to make. We measured the volumes in this series, so we get an overall impression of the ventricle. By echocardiography, we measure the end-diastolic dimension at the level where the tips of the mitral leaflets close, or at least where the tips of the papillary muscles are located, and we see a decrease at that level as well. But that is not a way to discern whether this is why MR is observed.
Related Article
J. Thorac. Cardiovasc. Surg. 2008 135: 1247-1253.
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