[HSF] Redo Radical Mitral Valvuloplasty

prasannasimha prasannasimha at gmail.com
Sun Jun 3 07:31:33 EDT 2007 

An MVR will always be second best as far as survival with a repair is 
concerned. At lesat therepaired pateint wil come back to you with a 
problem. Many valve patients are not so lucky.
Prasanna

/J Thorac Cardiovasc Surg/ 2006;132:1390-1397
© 2006 The American Association for Thoracic Surgery 
<http://jtcs.ctsnetjournals.org/misc/terms.shtml>


    Recurrent mitral regurgitation after repair: Should the mitral valve
    be re-repaired?

* Rakesh M. Suri, MD, DPhil^_* , Hartzell V. Schaff, MD, Joseph A. 
Dearani, MD, Thoralf M. Sundt, III, MD, Richard C. Daly, MD, Charles J. 
Mullany, MB, MS, Maurice Enriquez-Sarano, MD, Thomas A. Orszulak, MD *

Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, 
Rochester, Minn.

Read at the Eighty-sixth Annual Meeting of The American Association for 
Thoracic Surgery, Philadelphia, Pa, April 29-May 3, 2006.

Received for publication April 30, 2006; revisions received June 30, 
2006; accepted for publication July 12, 2006.

^_* Address for reprints: Rakesh M. Suri, MD, DPhil, Division of 
Cardiovascular Surgery, Mayo Clinic College of Medicine, 200 First St 
SW, Rochester, MN 55905 (Email: suri.rakesh at mayo.edu 
<mailto:suri.rakesh at mayo.edu> ).

OBJECTIVE: We sought to evaluate the clinical and echocardiographic 
outcomes^ of reoperation for failed mitral valve repair.^

METHODS: One hundred forty-five patients with recurrent mitral 
regurgitation^ after primary mitral valve repair of degenerative leaflet 
prolapse^ underwent mitral valve reoperations between January 1, 1970,^ 
and January 1, 2005. The mean age was 66 years, and 102 (70%)^ were men.^

RESULTS: The mean duration from initial repair to reoperation was 4.1^ 
years (standard deviation = ± 5.1 years). Indications^ for reoperation 
were regurgitation alone (n = 109 [75%]), hemolysis^ (n = 27 [19%]), 
obstruction from systolic anterior motion (n^ = 3 [2%]), endocarditis (n 
= 3 [2%]) and stenosis-other (n =^ 3 [2%]). New pathology was found in 
80 (55%) patients, and failure^ of the initial repair was found in 61 
(42%) patients. The mitral^ valve was re-repaired in 64 (44%) patients 
and replaced in 81^ (56%) patients. Early operative mortality was 
similar after^ re-repair and replacement (1.6% vs 4.9%, /P/ = .38). 
Independent^ predictors of improved survival on multivariate analysis 
were^ mitral re-repair (hazard ratio = 0.44, /P/ = .03), younger age^ 
(hazard ratio = 1.06, /P/ = .001), and an operative indication^ of 
mitral regurgitation alone (hazard ratio = 0.31, /P/ = .005).^ Seven 
patients had a third mitral operation (all replacements),^ 6 after 
re-repair and 1 after replacement. At last follow-up^ echocardiogram (n 
= 96), ejection fraction was greater (/P/ <^ .001) and left ventricular 
end-systolic dimension was smaller^ (/P/ = .009) in patients undergoing 
re-repair compared with values^ in those undergoing valve replacement.^

CONCLUSION: Recurrent mitral regurgitation after prior repair is 
frequently^ caused by new valve pathology. Mitral re-repair is 
performed^ in almost half of patients and is associated with superior 
survival,^ improved ejection fraction, and greater regression in 
ventricular^ dimension compared with valve replacement.

Prasanna

Tdmartin2000 wrote:
> Hal
>  while I certainly applaud your efforts and ability, why do you say that a MVR would " cloud " her future? As you know I hate coumadin and am a proponent for repair whenever possible, but most of us probably would have replaced this valve and expected good results. I am interested in the other members thoughts.
>
> Tom Martin
> U of Florida
> Gainesville
>
>
>
> In a message dated 06/02/07 00:43:57 Eastern Daylight Time, Hgrmd writes:
> Dear Members, 
>  Today's case was unusual.  About 2 years ago, I repaired a  myxomatous 
> mitral in a 38 yo lady.  I placed 4 Goretex neochords in A1 and  A2.  I closed the 
> P2-P3 interscallop leak, and performed a postero-medial  commissuroplasty.  A 
> 32 mm Physio ring was used.  She did well until a  few months ago when she 
> was noted to have a recurrent MR murmur that was  asymptomatic.  TEE revealed 
> mod-severe MR with a broad, largely central  jet.  I couldn't appreciate any 
> recurrent prolapse.  There was mod TR,  normal coronaries, and an EF of 40%.  I 
> operated this morning and found the  ring was intact and there was no prolapse. 
> I removed the ring, debrided  away the pannus, and inserted a 28 mm Physio.   
> Saline test now revealed  broad restriction of P2 and P3.  I made a radial 
> slit, 2mm from the ring,  along P2 and P3.  Gluteraldehyde treated autologous 
> pericardium was then  used for posterior leaflet extension.  This was done with 
> continuous 5-0  Cardionyl.  I also repaired the tricuspid (26mm MC3).  The 
> post-CPB  TEE showed no MR or TR with an EF of 30%.  She was extubated on the 
> table,  and did well thus far.  The main points are that rerepairing a valve is   
> quite feasible.  Certainly, with her already depressed LV function, a   
> replacement with a mechanical prosthesis would have severely clouded her  future.   
> Hopefully, this repair will hold up, though it worries me that the  posterior 
> leaflet restriction developed in the first place.  I presume it  was due to 
> adverse ventricular remodeling.  Also, Dave Adams recently had a  paper in Annals 
> in which he advocated using large rings for myxomatous  repairs.  However, I 
> think this is potentially a mistake when doing  myxomatous repairs in hearts 
> with impaired LV's.  For the myxomatous  repairs in hearts with relatively poor 
> LV function, you should probably  undersize the ring much as you would for MR 
> due to pure annular  dilatation. 
> Hal 
>
>
>
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