Is It Normal To Be Short Of Breath 3 Mths After Mitral Valve Repair

In patients with mitral regurgitation, surgical intervention is intended to care for and to prevent the occurrence of congestive eye failure.ⁱ Indeed, intermediate-term studies have demonstrated marked improvement in symptoms after surgical correction.^{2 iii 4 5 vi} However, the long-term outcome afterwards surgical correction of mitral regurgitation is less well known^{vii 8} ; in particular, the incidence and impact of congestive heart failure on belatedly survival afterwards valve repair or replacement remain poorly divers. In addition to the incertitude nigh the frequency of this complication, the mechanisms of heart failure have not been fully analyzed. Although the occurrences of primary failure of valve repair^nine or replacement^{10 eleven} and of left ventricular dysfunction¹² accept been recognized, their corresponding roles in postoperative congestive heart failure are unclear. Thus, the potential predictors of this complication are undefined. Because the prognosis of heart failure is commonly poor,^{13 fourteen} it is of utmost importance to determine the long-term incidence, mechanisms, and predictors of congestive heart failure subsequently surgical correction of mitral regurgitation to appraise the potential implications for clinical decision making and management.

Therefore, nosotros examined our experience with the outcome of patients operated on betwixt January ane, 1980, and December 31, 1989, for pure mitral regurgitation and hypothesized that congestive center failure subsequently surgical correction (1) is frequent and of poor prognosis, (ii) is due more often to left ventricular dysfunction than to valvular failure, and (3) tin be predicted past the preoperative condition of the patient and should have major implications on the clinical decision-making process.

Methods

The study was based on a retrospective review of our feel with surgical correction of mitral regurgitation.

The inclusion criteria were (i) surgical correction (repair or replacement) of mitral regurgitation performed between January 1, 1980, and Dec 31, 1989; (2) acquired pure mitral regurgitation as defined by echocardiographic and surgical assessment; and (3) immediate postoperative survival assuasive for observation of long-term outcome.

Patients with associated coronary avenue bypass graft surgery were included.

The exclusion criteria were (1) previous operation for mitral regurgitation; (ii) previous or associated aortic or tricuspid valve replacement (tricuspid valve repair was non excluded); (3) operative decease, defined equally occurring during the first postoperative calendar month or within the same hospitalization; and (4) mitral regurgitation due to dilated cardiomyopathy.

During the written report flow, 2183 patients had mitral valve operations. Of these, 654 had surgical correction for pure mitral regurgitation; 577 were operative survivors, of whom 576 (99.8%) had complete follow-up to expiry or 1994, and these 576 patients stand for our study population. Some data on function of this patient population accept been published previously.^{15 xvi 17}

Of the 576 patients, the hateful age was 64±12 years, 352 (61%) were men, and 242 (42%) were in atrial fibrillation. The cause of mitral regurgitation was defined as (ane) ischemic, if information technology was documented to be due to coronary avenue illness (120 patients) and (two) organic, if intrinsic disease of the mitral valve was documented (456 patients: rheumatic, 47; endocarditic, forty; degenerative with prolapse, 353; and miscellaneous, xvi). Preoperatively, within 1 month of surgical correction, New York Heart Clan (NYHA) dyspnea course 3 was noted in 276 patients (48%) and grade Iv in 94 (16%).

The surgical procedure performed was valve repair in 288 patients and valve replacement in 288 (bioprosthesis in 137 patients and mechanical prosthesis in 151). Coronary artery bypass graft surgery was performed in 211 patients. Perioperative myocardial infarction (new Q waves) occurred in six patients.

Left Ventricular Role Assay and Coronary Angiography

Coronary angiography was performed in 477 patients and showed pregnant (≥70%) stenosis in 253 (in 120, or 100%, of the patients with ischemic mitral regurgitation and in 133, or 29%, of those with organic mitral regurgitation). Preoperative left ventricular part was analyzed with echocardiography every bit previously reported^{15 16 eighteen xix} (453 patients) or left ventricular angiography (354 patients) performed within half dozen months of surgical correction. When both techniques were performed, the ejection fraction was calculated equally the average of the two reported measurements. Therefore, preoperative ejection fraction (mean, 57±13%) was available for 545 patients.

Subsequently surgery, the ejection fraction was measured with echocardiography performed at our establishment in 410 patients with a mean delay to surgery of 1.ii±2.two years.

Congestive Middle Failure

Congestive heart failure occurring before or later on surgical correction was noted as diagnosed by the attending doc. In all cases, class Three or Iv dyspnea and show of pulmonary edema (clinical and/or radiological) and/or global heart failure were present. The cause of heart failure was considered to exist valvular failure when, in addition to the signs of heart failure, there was bear witness of severe regurgitation or stenosis (or both) of the mitral valve prosthesis or repair. Conversely, center failure was considered to be due to myocardial failure in patients who were without signs of valvular failure and in whom left ventricular dysfunction was diagnosed. The cause of heart failure was confirmed in 93% of cases with echocardiography, radionuclide angiography, catheterization, or autopsy.

Statistical Analysis

Group statistics were expressed every bit mean±SD. Group comparisons were based on standard t test or χⁱⁱ test, equally appropriate. The comparison of postoperative variables between groups divers past the presence and cause of congestive centre failure was performed by ANOVA and t test if appropriate. Grouping survival was estimated with the Kaplan-Meier method and reported equally estimated survival±1 standard fault. The observed survival of patients was compared with the expected survival of age- and sex-matched actuarial data from the 1980 U.s.a. white population and tested by the one-sample log-rank test.

The cumulative probability of congestive centre failure was estimated by the Kaplan-Meier method, with decease (without heart failure) as a censoring effect. The estimates of cumulative incidence of myocardial or valvular cause of eye failure were based on a Kaplan-Meier estimate, with the other crusade as a noncensoring upshot. Unadjusted group comparison of the time to decease or congestive heart failure was based on the two-sample log-rank test. The association of preoperative and intraoperative variables with the incidence of congestive heart failure both overall and by valvular or myocardial causes was estimated with the Cox proportional-hazards model. Multivariate analysis was performed in a sequential manner, starting with preoperative clinical variables (age, sex, cause of regurgitation, NYHA functional class, creatinine level, history of hypertension, history of congestive heart failure, and presence of coronary artery affliction) and then adding left ventricular role (ejection fraction) and operative variables (valve repair or replacement and occurrence of myocardial infarction perioperatively). For the prediction of congestive middle failure of valvular origin, the presence of posterior leaflet prolapse was added to the model. To assess the possibility that the etiologic groups would take different predictive associations between these variables and the incidence of congestive heart failure, the set up of interactions between the cause and each of the final model variables was added to the terminal model and tested for significance based on the F test. Survival afterward onset of congestive heart failure was calculated with the Kaplan-Meier method, with onset of heart failure every bit the starting time of the survival analysis of this subset of patients. The relative risk of death in patients with postoperative center failure compared with those without center failure was calculated by employ of a time-dependent proportional-hazards model, with eye failure onset as the fourth dimension-dependent variable. A value of P<.05 was considered significant.

Results

The preoperative characteristics of the overall population, the ischemic mitral regurgitation group, and the organic mitral regurgitation group are summarized in Table 1. Despite a similar incidence of NYHA class III and Four symptoms, patients with ischemic regurgitation had a markedly decreased ejection fraction compared with that of patients with organic mitral regurgitation.

Postoperative Survival

At the latest follow-up, 216 patients had died and 360 were alive. Overall survival rate was 77±2% at 5 years (93% of expected survival), 56±3% at 10 years (84% of expected survival), and 44±4% at 14 years (82% of expected survival) and was significantly decreased in comparing with expected survival (P=.0001, Fig 1). Patients with organic mitral regurgitation had a meliorate survival charge per unit (62±3% at ten years, 91% of expected rate) than those with ischemic mitral regurgitation (36±6% at 10 years, 57% of expected rate) (P=.0001) (Fig 2). The determinants of postoperative survival, and in detail the essential part of preoperative ejection fraction, have been analyzed elsewhere.¹⁶

Overall Congestive Heart Failure

Congestive center failure was diagnosed before surgery in 370 patients and after surgery in 152. The cumulative incidence of postoperative congestive heart failure was 23±2% at 5 years, 33±3% at 10 years, and 37±3% at xiv years (Fig 3). The survival rate afterwards the occurrence of heart failure was dismal, 44±iv% and 18±5% at five and 10 years, respectively, afterward the first episode of congestive heart failure (Fig iv). The relative risk of decease afterwards the occurrence of congestive eye failure compared with those without middle failure was 5.ii (95% CI, 3.9 to 6.8). With multivariate analysis, the independent clinical predictors of congestive heart failure were presence of coronary artery disease, crusade of regurgitation, preoperative symptoms, and atrial fibrillation. Historic period, sex, preoperative creatinine level, history of congestive eye failure, and hypertension were non independently predictive of the occurrence of postoperative congestive centre failure. When combined with preoperative ejection fraction and the surgical variables, the merely pregnant independent predictors of congestive heart failure were ejection fraction (P=.0001), coronary artery disease (P=.0017), and NYHA course (P=.012), with a deadline value for atrial fibrillation (P=.10) (Tabular array 2). The incidences of congestive heart failure at x years co-ordinate to the level of preoperative ejection fraction were xix±3%, 29±5%, and 70±6% in patients with preoperative ejection fraction ≥threescore%, 50% to 59%, or <50%, respectively (P=.0001) (Fig 5). The chance ratio compared with a preoperative ejection fraction ≥60% was 1.8 (95% CI, 1.ane to two.9) for ejection fraction of l% to 59% and 5.4 (three.half-dozen to 8.ii) for an ejection fraction <50% regarding late occurrence of congestive heart failure. The cumulative incidence of congestive heart failure according to the preoperative symptoms and to the presence of coronary avenue disease is shown in Figs 6 and vii, respectively. The risk ratio for postoperative congestive heart failure was one.viii (95% CI, 1.2 to 2.6) for preoperative NYHA functional course III or IV compared with course I or Ii. Compared with patients with organic mitral regurgitation without coronary artery disease, the risk ratio was 2.1 (95% CI, 1.4 to iii.2) in patients with organic mitral regurgitation with coronary artery affliction and four.v (95% CI, iii.1 to 6.half dozen) in patients with ischemic mitral regurgitation. Although preoperative congestive centre failure was non independently predictive of postoperative heart failure in multivariate analysis, it was univariately associated with a risk ratio of 1.7 (95% CI, one.two to 2.iv).

Crusade of Congestive Center Failure

The cause of middle failure was diagnosed clinically and confirmed with echocardiography, radionuclide angiography, catheterization, or autopsy performed either at our establishment or exterior in 142 of 152 patients (93%). The postoperative echocardiographic variables obtained at our institution in patients classified as without congestive center failure or with valvular or myocardial congestive heart failure are presented in Table 3. In patients with the diagnosis of myocardial congestive centre failure, there was considerable low of left ventricular function with left ventricular enlargement. In patients with valvular congestive center failure, left ventricular function was not depressed, just at that place was residual enlargement of the left atrium.

The cause of heart failure was valvular failure in 45 patients, representing an incidence of seven±1% at 5 years and 11±2% at 10 years. Valvular failure was observed in 24 repairs, 8 mechanical prostheses, and 13 bioprostheses, a distribution not unlike from the patients without postoperative center failure (224 repairs, 110 mechanical prostheses, and 90 bioprostheses; P=.34). Reoperation was performed in 28 patients. The cause of congestive heart failure was myocardial failure in 107 patients, representing an incidence of 16±2% at 5 years and 23±2% at 10 years (Fig 3).

With multivariate analysis, there was no significant predictor of congestive center failure due to valvular failure. Conversely, ejection fraction (P=.0001), coronary avenue disease (P=.0008), atrial fibrillation (P=.006), and, of more borderline value, NYHA class (P=.06) were independent predictors of eye failure due to myocardial failure.

Cause of Regurgitation

In patients with ischemic mitral regurgitation compared with those with organic mitral regurgitation, the incidence of congestive heart failure was higher (at 5 years, 45±5% versus 17±2% and at ten years, 65±7% versus 25±3%; P=.0001). However, when classified co-ordinate to the cause of middle failure, there was no significant difference in congestive heart failure due to valvular dysfunction between patients with ischemic mitral regurgitation and those with organic mitral regurgitation (at 10 years, xi±iv% versus xi±ii%; P=NS), simply patients with ischemic mitral regurgitation had a higher incidence of congestive middle failure of myocardial origin (at 8 years, 48±5% versus 14±ii%; P=.0001). However, in multivariate analysis, the caste of left ventricular dysfunction, but non the cause of regurgitation, was independently predictive of postoperative congestive heart failure (Table 3). In addition, no interaction betwixt the predictors of congestive eye failure and the cause of regurgitation was noted. The survival rate after the offset episode of congestive centre failure was significantly but moderately worse in patients with ischemic rather than organic mitral regurgitation (at seven years, 24±vii% versus 36±half-dozen%; P=.007). Overall, coronary avenue illness was a powerful predictor of postoperative congestive middle failure, and specifically in patients with organic mitral regurgitation, the incidence of congestive middle failure was significantly college in patients with associated coronary avenue disease than in those without overt coronary avenue disease (35±5% versus 21±3% at 10 years; P=.0003).

Repair Versus Replacement

With univariate analysis, there was a lower incidence of postoperative congestive heart failure after valve repair than later on valve replacement (P=.04). However, such a divergence was non detectable in patients with ischemic mitral regurgitation and was significant only in those with organic mitral regurgitation (at x years, 17±three% versus 33±4%; P=.04) and only for the myocardial failure cause (at ten years, 9±two% versus 22±four%; P=.006). Notwithstanding, with multivariate analysis, valve repair was non independently predictive of a decreased incidence of congestive heart failure when stratified for the other predictors.

Nevertheless, when a combined stop point of death and congestive middle failure was analyzed in patients with organic mitral regurgitation, repair was an independent predictor of improved outcome (P=.001) (Fig 8). The other independent predictors were ejection fraction (P=.0001), historic period (P=.0001), coronary artery disease (P=.0047), atrial fibrillation (P=.08), NYHA course (P=.025), and perioperative myocardial infarction (P=.0001). The survival rate after the kickoff episode of congestive center failure was non significantly different in patients with valve repair or valve replacement (at viii years subsequently the episode of congestive heart failure, 17±7% in the valve repair group versus 26±six% in the valve replacement grouping [P=NS] were survivors).

Give-and-take

The results of the present study testify that congestive heart failure after surgical correction of mitral regurgitation (1) is frequent but of progressively increasing incidence late afterward surgical correction, (2) is associated with a poor prognosis, (three) is most often due to left ventricular dysfunction and thus is best predicted by an already decreased preoperative ejection fraction, and (4) is more frequent in patients with coronary artery disease.

Congestive Heart Failure After Correction of Mitral Regurgitation

The occurrence of congestive centre failure later surgical correction of mitral regurgitation is particularly disturbing because the intent of the surgical intervention is to eliminate preoperative congestive heart failure or to foreclose information technology.¹ Indeed, marked improvement in symptoms after surgical relief of mitral regurgitation is quite common,^{ii 3 iv 5 6} with a very small percentage of patients remaining in NYHA functional classes III and IV.²⁰ Such an early improvement may be misleading in terms of the true long-term effect as reflected in the nowadays study. The incidence of congestive centre failure and cardiac death^{7 8 21} tends to increment progressively with time, thus emphasizing the importance of long-term follow-up for judging results. The prognosis of postoperative congestive eye failure is dismal: More than than one half of the patients who had this complexity died inside 5 years after the start episode, an incidence similar to nonvalvular causes of middle failure.^{13 14} Such an touch on on prognosis underscores the importance of determining the cause of postoperative centre failure and its predictors and because how to foreclose its occurrence.

Whereas late occurrence of congestive heart failure may be due to primary failure of valve repair,⁹ mechanical prostheses,^eleven or bioprostheses,^ten the almost common cause of heart failure in the nowadays study was left ventricular dysfunction. This complication is frequently nowadays early later surgical correction of mitral regurgitation^{15 22} and has fifty-fifty been noted with intraoperative imaging techniques.²³ The absence of symptoms early on after suppression of the valvular regurgitation may be observed even in the presence of left ventricular dysfunction every bit a upshot of previously documented normalization of left atrial force per unit area^{24 25} and is similar to what is observed in nonvalvular ventricular dysfunction.²⁶ Still, with time, overt congestive heart failure occurs in a pregnant proportion of patients. After the signs of centre failure are present, the prognosis is poor, similar to that of patients with nonvalvular left ventricular dysfunction.^{13 14}

Predictors of Postoperative Congestive Heart Failure

Postoperative congestive eye failure in nearly cases is due to left ventricular dysfunction and rarely to failure of the surgical procedure,²⁷ which cannot be predicted from preoperative variables. Intraoperative complications, such every bit myocardial infarction, may lead to left ventricular dysfunction, but these are rare.²⁸ That preoperative left ventricular ejection fraction is the most powerful predictor of postoperative center failure strongly suggests that left ventricular dysfunction is present preoperatively.^{29 30} This observation agrees with the fact that preoperative variables of left ventricular function have oft been noted to be predictors of postoperative survival^{xvi 31} and postoperative left ventricular function.^{fifteen 22 29 30} Judging normalcy of ejection fraction is complicated in patients with mitral regurgitation due to contradistinct loading atmospheric condition.^{32 33 34} However, information technology should exist noted that the incidence of congestive eye failure is very high in patients with severely depressed ventricular part (ejection fraction <50%), but it is besides increased in patients with deadline ejection fraction (50% to 59%), which indicates that these patients already take a pregnant caste of left ventricular dysfunction, which may get unnoticed until the appearance of severe symptoms at a late stage.¹

Other preoperative predictors are besides important. Astringent symptoms (NYHA classes III and Iv) and atrial fibrillation tend to be associated with an increased incidence of late congestive eye failure.³⁵ The role of atrial fibrillation suggests the demand for appropriate controlled studies to institute the need to intervene aggressively to maintain normal sinus rhythm. Associated coronary artery disease is a powerful predictor of an excess incidence of congestive eye failure and belatedly death,^{16 36} independent of ejection fraction. Such an effect emphasizes the importance of detecting coronary artery stenosis before surgery, although the dumb prognosis occurred despite bypass operation being combined with valvular correction. The survival rate after correction of ischemic mitral regurgitation was mediocre, as noted previously,³⁷ and the excess bloodshed was due primarily to the severe left ventricular dysfunction commonly present in that disease.³⁸ The suggested reward of mitral valve repair over valve replacement in this subset of patients³⁹ was not observed in the present study.

Prevention of Congestive Heart Failure

Congestive center failure due to dysfunction of the surgical correction of the mitral valve in about cases may be prevented by use of intraoperative transesophageal echocardiography.⁴⁰ Prevention of valve endocarditis and thrombosis is of import in fugitive late valvular complications that could result in congestive heart failure.^{seven 10 11} Prevention of postoperative congestive middle failure due to left ventricular dysfunction is more difficult but of considerable clinical significance.

Early Surgical Correction

Patients with a significant caste of left ventricular dysfunction (ejection fraction <threescore%) should take surgical correction without waiting for farther deterioration of their condition.^sixteen For patients in this category, surgical correction of the regurgitation should not be denied (despite a loftier incidence of postoperative congestive heart failure) for ii reasons: (1) in patients with an ejection fraction <l%, surgical correction, in comparison with medical handling, improves the prognosis^{41 42} and (2) the occurrence of congestive heart failure is often delayed, and surgical correction may provide up to several years of marked symptomatic improvement.

Patients with apparently preserved left ventricular function who have an ejection fraction ≥60% have a relatively low incidence of postoperative congestive center failure. These patients have been shown to have an excellent late survival,¹⁶ with a low incidence of postoperative left ventricular dysfunction.^{15 22} Thus, that stage of preserved left ventricular function represents the ideal indication for surgical correction of mitral regurgitation. Fifty-fifty at that phase, severe symptoms (NYHA grade III or IV) are associated with increased incidence of heart failure and increased mortality,¹⁶ suggesting that correction of mitral regurgitation in patients in NYHA class I or II with an ejection fraction ≥threescore% may be a reasonable approach under certain conditions. Such an aggressive approach is defensible simply in patients at depression operative risk and in those medical centers with documented high rates of success in repairing the mitral valve with low operative mortality.

Valve Repair every bit the Preferred Surgical Process

Although valve repair does not reduce the incidence of valve failure, information technology is univariately associated with a lower incidence of postoperative congestive heart failure due to myocardial failure. It is an independent predictor of a lower incidence of the combined end signal of congestive heart failure and death in patients with organic mitral regurgitation. Valve repair likewise has been reported to issue in decreased operative mortality and better long-term survival^{17 43} as well every bit better left ventricular role.^{17 23 44} Valve repair should be discussed in all surgical cases of mitral regurgitation.⁴⁵ The low operative risk is some other incentive to perform early surgical correction of mitral regurgitation. All the same, valve repair does not eliminate the take chances of congestive centre failure or the need for surgical correction of mitral regurgitation earlier the occurrence of left ventricular dysfunction.

Pharmacological Prevention of Congestive Centre Failure

In the present series, medical treatment of center failure was adapted to the clinical circumstances, and its consequence on outcome cannot be analyzed. Angiotensin-converting enzyme inhibitors have been used successfully to prolong survival in patients with congestive centre failure^{thirteen 14} and to improve the outcome of those with asymptomatic left ventricular dysfunction.²⁶ Although no randomized trial has studied the utilize of these medications for the prevention of congestive heart failure subsequently surgical correction of mitral regurgitation, their use in patients in whom left ventricular dysfunction has been diagnosed early afterwards surgical correction appears worthy of consideration and future analysis.

Limitations of the Study

Although heavy reliance on echocardiographic estimates of left ventricular ejection fraction may be a cause of concern, the employ of echocardiography in this setting is standard practice, and previous studies from our institution take documented the acceptable correlations to angiography and, most importantly, the high prognostic value of these estimates.^{fifteen sixteen} Withal, the importance of careful attention to quality control issues in laboratories that perform such studies needs to be emphasized.

Although all the patients in the present series were considered to have astringent mitral regurgitation, an important limitation is the lack of quantitation of the severity. This is some other important measurement that needs to be integrated in the assessment of left ventricular function and perchance may be of value in selecting patients for early intervention. Within the fourth dimension frame of the nowadays report, such quantitation was not routinely available. Yet, methods that can be used in routine clinical exercise are now bachelor for quantifying not only the regurgitant book⁴⁶ but also the effective regurgitant orifice.^{47 48} Further studies are necessary to delineate the natural history of mitral regurgitation classified co-ordinate to these variables and so equally to better define the indications for early surgical intervention.

Conclusions

Congestive heart failure is a frequent postoperative complication of surgical correction of mitral regurgitation. Information technology is rarely due to valvular failure only rather is caused most often by left ventricular dysfunction present before surgery. The poor prognosis of this complication justifies an aggressive detection of left ventricular dysfunction and prevention of heart failure, peculiarly through the use of early on valvular repair.

Reprint requests to Yard. Enriquez-Sarano, MD, Mayo Dispensary, 200 First St SW, Rochester, MN 55905.

• Download figure
• Download PowerPoint

Figure 1. Graph showing late survival in the overall population. Numbers at bottom indicate the patients at take a chance for the interval and the percentage of expected survival accomplished.

• Download effigy
• Download PowerPoint

Figure ii. Graph showing comparing of tardily survival between patients with ischemic mitral regurgitation and those with organic mitral regurgitation. Numbers at bottom point the patients at risk for the interval and the per centum of expected survival achieved.

• Download figure
• Download PowerPoint

Effigy 3. Graph showing incidence of congestive heart failure (CHF) overall and of myocardial and valvular origin in the unabridged population. Numbers at bottom indicate the patients at risk for the interval in the overall series.

• Download figure
• Download PowerPoint

Effigy 4. Graph showing survival rate subsequently the first episode of congestive heart failure in the unabridged population. Numbers at lesser signal the patients at risk for the interval.

• Download figure
• Download PowerPoint

Figure five. Graph showing incidence of congestive heart failure (CHF) according to the level of preoperative ejection fraction (EF). Numbers at bottom indicate the patients at hazard for the interval.

• Download figure
• Download PowerPoint

Effigy half-dozen. Graph showing incidence of congestive heart failure (CHF) of valvular cause in patients with New York Heart Association functional course I or II symptoms before surgery compared with those with grade III or IV symptoms before surgery. Numbers at bottom point the patients at risk for the interval.

• Download figure
• Download PowerPoint

Effigy 7. Graph showing incidence of congestive eye failure (CHF) of myocardial cause in patients with ischemic mitral regurgitation (MR) compared with those with organic MR (with [+] or without [w/o] coronary artery disease [CAD]). Numbers at lesser indicate the patients at risk for the interval.

• Download figure
• Download PowerPoint

Figure 8. Graph showing incidence of death and congestive eye failure (CHF) compared in valve repair and replacement performed in patients with organic mitral regurgitation. Numbers at bottom indicate the patients at risk for the interval.

Table 1. Preoperative Characteristics of the Study Population

	Written report Group1			P ii
	Overall (due north=576)	Ischemic MR (n=120)	Organic MR (n=456)
Age, y	64±12	67±9	64 ±12	.006
Sexual practice, % male	61	62	61	NS
Hypertension, %	29	54	23	.0001
Atrial fibrillation, %	42	23	47	.0001
Preoperative CHF, %	64	73	62	.03
CAD, %	44	100	29	.0001
NYHA class 3-IV, %	64	64	64	NS
Creatinine level, mg	1.3 ±0.5	1.5±0.6	1.2±0.5	.0001
EF, %	57±xiii	43±xiii	60 ±11	.0001
LVD, mm	61±9	sixty±8	62 ±9	NS
LVS, mm	39 ±nine	45±10	38±nine	.0001
Repair, %	fifty	47	51	NS
CABG, %	37	86	24	.0001

Table 2. Multivariate Analysis of the Determinants of Cumulative Incidence of Postoperative Congestive Heart Failure

	Overall CHF	Valvular CHF	Myocardial CHF	Survival and CHF1
Historic period	NS	NS	NS	.0001
Sex	NS	NS	NS	NS
Organic cause	NS	NS	NS	NS
NYHA	.012	NS	.06	.025
CAD	.0017	NS	.0008	.0047
Atrial fibrillation	.10	NS	.006	.08
Hypertension	NS	NS	NS	NS
Creatinine	NS	NS	NS	NS
Preoperative CHF	NS	NS	NS	NS
Postleaflet cause	…	.07	…	…
EF	.0001	NS	.0001	.0001
Repair	NS	NS	NS	.001
Postoperative MI	NS	NS	NS	.0001

Table 3. Postoperative Left Ventricular Function¹

	No CHF (n=285)	CHF Myocardial (n=82)	CHF Valvular (northward=43)
EF, %	53±12	28±92	53±123
LVD, mm	52±8	62±x2	54±8iii
LVS, mm	36 ±9	53±122	37±93
LA, mm	49±x	52±12	53 ±eleven4

Nosotros appreciate the expert data abstracting assistance of Kim Jones, information analysis of Sara Fett, and secretarial assistance of Jannett Halling.

References

• i Braunwald E. Heart Disease: A Textbook of Cardiovascular Medicine. quaternary ed. Philadelphia, Pa: WB Saunders Co; 1992:1018-1029. Google Scholar
• 2 Sand ME, Naftel DC, Blackstone EH, Kirklin JW, Karp RB. A comparing of repair and replacement for mitral valve incompetence. J Thorac Cardiovasc Surg . 1987; 94:208-219. MedlineGoogle Scholar
• 3 Galloway AC, Colvin SB, Baumann FG, Esposito R, Vohra R, Harty South, Freeberg R, Kronzon I, Spencer FC. Long-term results of mitral valve reconstruction with Carpentier techniques in 148 patients with mitral insufficiency. Circulation. 1988;78(suppl I): I-97-I-105. Google Scholar
• 4 Chaffin JS, Daggett WM. Mitral valve replacement: a nine-year follow-up of risks and survivals. Ann Thorac Surg . 1979; 27:312-319. CrossrefMedlineGoogle Scholar
• 5 Teoh KH, Ivanov J, Weisel RD. Determinants of survival and valve failure after mitral valve replacement. Ann Thorac Surg . 1990; 49:643-648. CrossrefMedlineGoogle Scholar
• 6 Thompson R, Baird J, Squire B, Hilless A, Leslie P, Easthope R. Late results of valve replacement and factors influencing survival in patients with severe chronic mitral regurgitation. Northward Z Med J . 1985; 98:944-947. MedlineGoogle Scholar
• 7 McGoon Md, Fuster V, McGoon DC, Pumphrey CW, Pluth JR, Elveback LR. Aortic and mitral valve incompetence: long-term follow-upwardly (x to xix years) of patients treated with the Starr-Edwards prosthesis. J Am Coll Cardiol . 1984; iii:930-938. CrossrefMedlineGoogle Scholar
• 8 Deloche A, Jebara VA, Relland JY, Chauvaud South, Fabiani JN, Perier P, Dreyfus G, Mihaileanu Due south, Carpentier A. Valve repair with Carpentier techniques: the 2nd decade. J Thorac Cardiovasc Surg . 1990; 99:990-1001. MedlineGoogle Scholar
• 9 Lessana A, Carbone C, Romano M, Palsky E, Quan YH, Escorsin M, Jegier B, Ruffenach A, Lutfalla G, Aime F, Guerin F. Mitral valve repair: results and the controlling process in reconstruction: written report of 275 cases. J Thorac Cardiovasc Surg . 1990; 99:622-630. MedlineGoogle Scholar
• 10 Cohn LH, Allred EN, Cohn LA, Austin JC, Sabik J, DiSesa VJ, Shemin RJ, Collins JJ Jr. Early and late risk of mitral valve replacement: a 12 twelvemonth concomitant comparison of the porcine bioprosthetic and prosthetic disc mitral valves. J Thorac Cardiovasc Surg . 1985; xc:872-881. MedlineGoogle Scholar
• eleven Miller DC, Oyer PE, Stinson EB, Reitz BA, Jamieson SW, Baumgartner WA, Mitchell RS, Shumway NE. Ten to xv year reassessment of the performance characteristics of the Starr-Edwards model 6120 mitral valve prosthesis. J Thorac Cardiovasc Surg . 1983; 85:i-xx. MedlineGoogle Scholar
• 12 Hildner FJ, Javier RP, Cohen LS, Samet P, Nathan MJ, Yahr WZ, Greenberg JJ. Myocardial dysfunction associated with valvular heart disease. Am J Cardiol . 1972; 30:319-326. CrossrefMedlineGoogle Scholar
• 13 Cohn JN, Johnson Thou, Ziesche S, Cobb F, Francis G, Tristani F, Smith R, Dunkman WB, Loeb H, Wong Grand, Bhat G, Goldman S, Fletcher RD, Doherty J, Hughes V, Carson P, Cintron K, Shabetai R, Haakenson C. A comparing of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med . 1991; 325:303-310. CrossrefMedlineGoogle Scholar
• 14 The SOLVD Investigators. Result of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med . 1991; 325:293-302. CrossrefMedlineGoogle Scholar
• 15 Enriquez-Sarano East, Tajik AJ, Schaff HV, Orszulak TA, McGoon MD, Bailey KR, Frye RL. Echocardiographic prediction of left ventricular function later correction of mitral regurgitation: results and clinical implications. J Am Coll Cardiol . 1994; 24:1536-1543. CrossrefMedlineGoogle Scholar
• xvi Enriquez-Sarano Thousand, Tajik AJ, Schaff HV, Orszulak TA, Bailey KR, Frye RL. Echocardiographic prediction of survival after surgical correction of organic mitral regurgitation. Circulation . 1994; 90:830-837. CrossrefMedlineGoogle Scholar
• 17 Enriquez-Sarano Chiliad, Schaff HV, Orszulak TA, Tajik AJ, Bailey KR, Frye RL. Valve repair improves the consequence of surgery for mitral regurgitation: a multivariate analysis. Circulation . 1995; 91:1022-1028. CrossrefMedlineGoogle Scholar
• 18 Quinones MA, Pickering E, Alexander JK. Per centum of shortening of the echocardiographic left ventricular dimension: its use in determining ejection fraction and stroke volume. Chest . 1978; 74:59-65. CrossrefMedlineGoogle Scholar
• 19 Rich South, Sheikh A, Gallastegui J, Kondos GT, Mason T, Lam Westward. Determination of left ventricular ejection fraction by visual estimation during existent-fourth dimension two-dimensional echocardiography. Am Heart J . 1982; 104:603-606. CrossrefMedlineGoogle Scholar
• 20 Salomon NW, Stinson EB, Griepp RB, Shumway NE. Patient-related risk factors as predictors of results following isolated mitral valve replacement. Ann Thorac Surg . 1977; 24:519-530. CrossrefMedlineGoogle Scholar
• 21 Fernandez J, Joyce DH, Hirschfeld KJ, Chen C, Yang SS, Laub GW, Adkins MS, Anderson WA, Mackenzie JW, McGrath LB. Valve-related events and valve-related mortality in 340 mitral valve repairs: a tardily stage follow-upwardly report. Eur J Cardiothorac Surg . 1993; 7:263-270. CrossrefMedlineGoogle Scholar
• 22 Crawford MH, Souchek J, Oprian CA, Miller DC, Rahimtoola Southward, Giacomini JC, Sethi G, Hammermeister KE. Determinants of survival and left ventricular operation later on mitral valve replacement: Department of Veterans Affairs Cooperative Report on Valvular Heart Affliction. Circulation . 1990; 81:1173-1181. CrossrefMedlineGoogle Scholar
• 23 Goldman ME, Mora F, Guarino T, Fuster V, Mindich BP. Mitral valvuloplasty is superior to valve replacement for preservation of left ventricular function: an intraoperative two-dimensional echocardiographic study. J Am Coll Cardiol . 1987; 10:568-575. CrossrefMedlineGoogle Scholar
• 24 Hultgren H, Hubis H, Shumway North. Cardiac function following mitral valve replacement. Am Heart J . 1968; 75:302-312. CrossrefMedlineGoogle Scholar
• 25 Enriquez-Sarano Thou, Hannachi G, Jais JM, Acar J. Hemodynamic and angiographic results post-obit surgical correction of mitral insufficiency: apropos of 51 repeated catheterizations. Curvation Mal Coeur Vaiss . 1983; 76:1194-1203. MedlineGoogle Scholar
• 26 The SOLVD Investigators. Result of enalapril on mortality and the development of centre failure in asymptomatic patients with reduced left ventricular ejection fractions. N Engl J Med . 1992; 327:685-691. CrossrefMedlineGoogle Scholar
• 27 Marwick TH, Stewart WJ, Currie PJ, Cosgrove DM. Mechanisms of failure of mitral valve repair: an echocardiographic study. Am Heart J . 1991; 122:149-156. CrossrefMedlineGoogle Scholar
• 28 Obarski TP, Loop FD, Cosgrove DM, Lytle BW, Stewart WJ. Frequency of acute myocardial infarction in valve repairs versus valve replacement for pure mitral regurgitation. Am J Cardiol . 1990; 65:887-890. CrossrefMedlineGoogle Scholar
• 29 Schuler G, Peterson KL, Johnson A, Francis Yard, Dennish G, Utley J, Daily PO, Ashburn Westward, Ross J Jr. Temporal response of left ventricular performance to mitral valve surgery. Circulation . 1979; 59:1218-1231. CrossrefMedlineGoogle Scholar
• 30 Zile MR, Gaasch WH, Carroll JD, Levine HJ. Chronic mitral regurgitation: predictive value of preoperative echocardiographic indexes of left ventricular office and wall stress. J Am Coll Cardiol . 1984; 3:235-242. CrossrefMedlineGoogle Scholar
• 31 Phillips HR, Levine FH, Carter JE, Boucher CA, Osbakken Doc, Okada RD, Akins CW, Daggett WM, Buckley MJ, Pohost GM. Mitral valve replacement for isolated mitral regurgitation: analysis of clinical course and late postoperative left ventricular ejection fraction. Am J Cardiol . 1981; 48:647-654.CrossrefMedlineGoogle Scholar
• 32 Wisenbaugh T. Does normal pump function belie muscle dysfunction in patients with chronic severe mitral regurgitation? Circulation . 1988; 77:515-525. CrossrefMedlineGoogle Scholar
• 33 Corin WJ, Monrad ES, Murakami T, Nonogi H, Hess OM, Krayenbuehl HP. The relationship of afterload to ejection performance in chronic mitral regurgitation. Apportionment . 1987; 76:59-67. CrossrefMedlineGoogle Scholar
• 34 Mirsky I, Corin WJ, Murakami T, Grimm J, Hess OM, Krayenbuehl HP. Correction for preload in assessment of myocardial contractility in aortic and mitral valve disease: application of the concept of systolic myocardial stiffness. Apportionment . 1988; 78:68-eighty. CrossrefMedlineGoogle Scholar
• 35 Reed D, Abbott RD, Smucker ML, Kaul Southward. Prediction of outcome afterward mitral valve replacement in patients with symptomatic chronic mitral regurgitation: the importance of left atrial size. Circulation . 1991; 84:23-34. CrossrefMedlineGoogle Scholar
• 36 van Herwerden LA, Tjan D, Tijssen JG, Quaegebeur JM, Bos E. Determinants of survival subsequently surgery for mitral valve regurgitation in patients with and without coronary artery disease. Eur J Cardiothorac Surg . 1990; iv:329-335. CrossrefMedlineGoogle Scholar
• 37 Hickey MS, Smith LR, Muhlbaier LH, Harrell FE Jr, Reves JG, Hinohara T, Califf RM, Pryor DB, Rankin JS. Current prognosis of ischemic mitral regurgitation: implications for future management. Circulation. 1988;78(suppl I):I-51-I-59. Google Scholar
• 38 Pinson CW, Cobanoglu A, Metzdorff MT, Grunkemeier GL, Kay PH, Starr A. Late surgical results for ischemic mitral regurgitation: role of wall move score and severity of regurgitation. J Thorac Cardiovasc Surg . 1984; 88:663-672. MedlineGoogle Scholar
• 39 Rankin JS, Feneley MP, Hickey MS, Muhlbaier LH, Wechsler AS, Floyd RD, Reves JG, Skelton TN, Califf RM, Lowe JE, Sabiston DC Jr. A clinical comparison of mitral valve repair versus valve replacement in ischemic mitral regurgitation. J Thorac Cardiovasc Surg . 1988; 95:165-177. CrossrefMedlineGoogle Scholar
• 40 Freeman WK, Schaff HV, Khandheria BK, Oh JK, Orszulak TA, Abel Doctor, Seward JB, Tajik AJ. Intraoperative evaluation of mitral valve regurgitation and repair past transesophageal echocardiography: incidence and significance of systolic anterior motion. J Am Coll Cardiol . 1992; xx:599-609. CrossrefMedlineGoogle Scholar
• 41 Hammermeister KE, Fisher Fifty, Kennedy W, Samuels S, Doge HT. Prediction of late survival in patients with mitral valve disease from clinical, hemodyamic, and quantitative angiographic variables. Circulation . 1978; 57:341-349. CrossrefMedlineGoogle Scholar
• 42 Hochreiter C, Niles Due north, Devereux RB, Kligfield P, Tapping JS. Mitral regurgitation: relationship of noninvasive descriptors of right and left ventricular operation to clinical and hemodynamic findings and to prognosis in medically and surgically treated patients. Circulation . 1986; 73:900-912. CrossrefMedlineGoogle Scholar
• 43 Perier P, Deloche A, Chauvaud Due south, Fabiani JN, Rossant P, Bessou JP, Relland J, Bourezak H, Gomez F, Blondeau P, d'Allaines C, Carpentier A. Comparative evaluation of mitral valve repair and replacement with Starr, Björk, and porcine valve prostheses. Circulation. 1984;seventy(suppl I):I-187-I-192. Google Scholar
• 44 Sakai K, Nakano S, Taniguchi K, Sakaki S, Hirata N, Shintani H, Shimazaki Y, Kawashima Y, Matsuda H. Global left ventricular performance and regional systolic office after suture annuloplasty for chronic mitral regurgitation. Apportionment. 1992;86(suppl 2):Ii-39-Ii-45. Google Scholar
• 45 Chavez AM, Cosgrove DM III, Lytle BW, Gill CC, Loop FD, Stewart RW, Golding LR, Taylor PC. Applicability of mitral valvuloplasty techniques in a North American population. Am J Cardiol . 1988; 62:253-256. CrossrefMedlineGoogle Scholar
• 46 Enriquez-Sarano M, Bailey KR, Seward JB, Tajik AJ, Krohn MJ, Mays JM. Quantitative Doppler cess of valvular regurgitation. Circulation . 1993; 87:841-848. CrossrefMedlineGoogle Scholar
• 47 Enriquez-Sarano M, Seward JB, Bailey KR, Tajik AJ. Effective regurgitant orifice expanse: a noninvasive Doppler development of an old hemodynamic concept. J Am Coll Cardiol . 1994; 23:443-451. CrossrefMedlineGoogle Scholar
• 48 Vandervoort PM, Rivera JM, Mele D, Palacios IF, Dinsmore RE, Weyman AE, Levine RA, Thomas JD. Application of colour Doppler flow mapping to calculate effective regurgitant orifice area: an in vitro report and initial clinical observations. Circulation . 1993; 88:1150-1156.CrossrefMedlineGoogle Scholar

Is It Normal To Be Short Of Breath 3 Mths After Mitral Valve Repair,

Source: https://www.ahajournals.org/doi/10.1161/01.cir.92.9.2496

Posted by: kileswenoboy75.blogspot.com

Share this post