Mitral valve repair in patients with end stage cardiomyopathy: who benefits?

Patients with end stage cardiomyopathy frequently present with additional severe mitral regurgitation. We analyzed the outcome of mitral valve reconstruction in this high risk patient group.

Sixty-six patients with significant mitral regurgitation and an ejection fraction (EF) below 30% (dilated cardiomyopathy=53, ischemic cardiomyopathy (ICM)=13) were retrospectively evaluated from 07/96 and 02/02. All received annuloplasty ring implantation and additional repair (n=4) if required. Mean follow-up was 28+/-18 months.

Mitral valve repair (MVR) was technically feasible in all patients. Intraoperative transesophageal echocardiography (TEE) revealed none (n=60) or only trivial (n=6) residual mitral regurgitation. Thirty day mortality was 6.1%. Actuarial survival after 1 and 5 years was 86+/-4 and 66+/-8%, respectively. During follow-up seven patients were transplanted due to lack of clinical improvement after 10+/-7 months (range 1-23). Echocardiography revealed a significant improvement in EF (25+/-10.5% pre-op, 34+/-15% post-op) and a slight decrease in left ventricular end-diastolic diameter (69+/-10 mm pre-op, 67+/-13 mm follow up). Patients were in NYHA functional -class 3 (median) preoperatively and in class 2 at long term-follow-up. Gender, left ventricular enddiastolic diameter, preoperative ejection fraction or type of surgical approach (sternotomy, right lateral minithoracotomy) had no significant influence on patient outcome. Patients with ICM or patients older than 60 years showed an increased risk for clinical events both early post-operatively and at long-term follow-up.

MVR can be performed with low perioperative morbidity and mortality even in patients with advanced heart failure, modifying selection criteria for potential candidates may further improve long term outcome.