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Original Articles: Cardiovascular

Recurrence of Mitral Regurgitation Parallels the Absence of Left Ventricular Reverse Remodeling After Mitral Repair in Advanced Dilated Cardiomyopathy

Department of Cardiac Surgery, San Raffaele University Hospital, Milan, Italy

Accepted for publication November 5, 2007.

^_* Address correspondence to Dr De Bonis, Cardiac Surgery Department, San Raffaele University Hospital, Via Olgettina 60, Milan, 20132, Italy (Email: michele.debonis{at}hsr.it).

Background: The aim of this study was to assess the occurrence of reverse left ventricular (LV) remodeling after effective mitral valve repair in advanced dilated cardiomyopathy and its impact on clinical outcome and repair durability.

Methods: Of 111 patients undergoing mitral valve repair in ischemic or idiopathic dilated cardiomyopathy, 79 patients with no or trivial residual mitral regurgitation (MR) at discharge and with a follow-up length of at least 6 months were included in this study. Preoperatively they had 3 to 4+ functional MR, an ejection fraction of 0.28 ± 0.055, an indexed LV end-diastolic volume of 113 ± 33.0 mL/m², an indexed LV end-systolic volume of 80.8 ± 26.3 mL/m², a tenting area of 2.7 ± 0.9 cm², and a coaptation depth of 1.1 ± 0.3 cm. Sixty-three patients (79.8%) were in New York Heart Association class III or IV. A complete, rigid or semirigid undersized ring annuloplasty (with or without "edge-to-edge") was used. Concomitant procedures were coronary artery bypass grafting (49 of 79 patients, 62%), tricuspid valve repair (11 of 79 patients, 13.9%), and ablation of permanent atrial fibrillation (13 of 79 patients, 16.4%).

Results: At a mean follow-up of 2 ± 1.3 years (median, 1.8 years), LV reverse remodeling was documented in 41 patients (51.8%), whereas in 38 patients (48.1%) LV dimensions remained unchanged or increased compared with preoperative values. The persistence or progression of LV remodeling paralleled the recurrence of MR and worsening of symptoms. Recurrence of MR of 3+ or greater was 0% in the "reverse remodeling" group and 18.4% in the "no reverse remodeling" one (p = 0.008). At 3 years, freedom from recurrence of MR of 2+ or greater was 74% ± 11.7% and 62% ± 9.2% (p = 0.004) and New York Heart Association class was 1.5 ± 0.61 and 2 ± 0.72 (p < 0.0001), respectively. Predictors of reverse remodeling were ischemic etiology (p = 0.04), concomitant coronary artery bypass grafting (p = 0.02), successful ablation of atrial fibrillation (p = 0.05), and shorter history of congestive heart failure (p = 0.06). The use of the edge-to-edge showed a trend toward favoring reverse remodeling compared with isolated annuloplasty (p = 0.08).

Conclusions: In patients with functional MR undergoing effective repair, the occurrence of reverse LV remodeling is associated with longer repair durability and a better clinical outcome compared with those with persistence or progression of the remodeling process.

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