Mitral valve reconstruction in elderly, ischemic patients

The role of mitral valve reconstruction is controversial in elderly patients with concurrent ischemic heart disease owing to technical difficulty, prolonged operative times, high mortality, and possible residual mitral regurgitation. However, mitral reconstruction could be most beneficial in this age group due to preservation of left ventricular function, avoidance of anticoagulation, or repeat operation for bioprosthetic degeneration. We studied the outcome of mitral valve reconstruction in 100 consecutive elderly ischemic patients 65 years or older (mean = 73 years; range, 65 to 86 years) operated on between October 1990 and May 1995. Preoperatively all patients were New York Heart Association (NYHA) class III or IV with an ejection fraction of 32 +/- 2%. All patients underwent primary coronary bypass grafting (2.7 +/- 0.2 grafts) and had a flexible mitral annuloplasty ring inserted. Additionally, 54 patients required further complex mitral repairs. All patients had 4+ mitral regurgitation by transesophageal echocardiography prior to operation. After mitral reconstruction, no patient had more than 1+ regurgitation, while most had none and no systolic anterior leaflet motion was noted. There were 4 early (30 day) deaths (4%) and 6 late deaths (6%) at a mean follow-up of 25 months. Patient morbidity has included episodes of mild congestive heart failure (nine), transient ischemic attack (one), endocarditis (one), and respiratory failure (five). There have been one early and two late reoperations for mitral valve replacement. All remaining patients are in NYHA class I or II. While longer-term follow-up is mandatory, coronary bypass grafting and mitral valve reconstruction in the elderly can be accomplished with acceptable surgical mortality and morbidity, yielding reliable improvement in symptoms and quality of life.