| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Ann Thorac Surg 2006;82:2110
© 2006 The Society of Thoracic Surgeons
Cardiothoracic Surgery, Leiden University Medical Center, Postbus 9600, Leiden, 2300 RC the Netherlands
(Email: j.braun{at}lumc.nl).
The article presented by Barletta and coworkers [1] addresses an interesting topic in heart failure surgery: how can we preoperatively identify patients who will show mitral regurgitation after surgical ventricular restoration (SVR)?
The authors have identified preoperative hemodynamic factors (mean pulmonary artery pressure and pulmonary capillary wedge pressure), but the more important findings emerge from their (laborious) analysis of left ventricular angiograms preoperatively and postoperatively.
The main results are very nicely represented graphically (especially Figs 1 and 2) to show that inferior akinesia with inferobasal normokinesia results in preoperative mitral regurgitation (MR), but inferior and inferobasal hypokinesia will result in late MR (ie, 1 year after SVR).
Although in itself this is not a new finding, this study shows that careful preoperative assessment of regional contraction abnormalities may identify late "failures" and consequently may indicate preventive measures.
Lacking in this study is an intraoperative transesophageal echocardiography (TEE) assessment of MR at the end of the Dor reconstruction, according to the authors, because of the timeframe of patient recruitment. We are also not informed on the time course of MR development; in some cases the MR might have been present at discharge and can not be qualified as an expression of late failure. In our experience, MR after finishing SVR occurs in approximately 15% of patients who did not have MR preoperatively, and necessitates the surgeon to start cardiopulmonary bypass again and to perform a restrictive (undersized) mitral annuloplasty. Therefore in patients without MR, but with minimal mitral leaflet coaptation height (< 3 mm on TEE), we tend to perform a restrictive annuloplasty.
Left ventricular angiography has been shown to be a nice technique, especially for research purposes. However, for daily practice, techniques that are easier to interpret and less invasive may be more appropriate to identify patients at risk for late MR, especially magnetic resonance imaging and (in the future) 3-dimensional contrast echocardiography, which may both become techniques of choice in this area.
The question of course is why does late MR occur? The answer will most likely be found in inadequate function of the remote myocardium. All these patients have had transmural anterior wall infarction, none had inferior infarction and the presence of right coronary artery (RCA) disease was comparable between MR, no MR, and late mitral regurgitation (LMR) groups. Patients with MR apparently had more anterior and lateral akinesia, but the LMR patients did not; however, they may have had "larger" infarctions, something that is not clear from this article. Also the higher incidence of angina in the "no MR" group could be an expression of less extensive infarction, and therefore better chances for the remote myocardium to show reverse remodeling.
This article adds to our knowledge of heart failure surgery, but also raises new questions that should stimulate further research in this field.
 |
References |
|---|
 Top References |
|---|
Related Article
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
