Reza Tavakoli

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The approach to mitral valve endocarditis is a surgical challenge, and the optimal procedure remains a matter of debate. In this condition, mitral valve repair appears feasible, but its long-term effects--as opposed to more often practiced valve replacement--have not yet been determined. Herein, the authors' experience of surgical treatment of infective mitral valve endocarditis is presented, with reference to surgical replacement or reconstruction. A retrospective analysis was performed of all patients with infective native mitral valve endocarditis treated surgically at the University Hospital Zurich and the City Hospital Triemli Zurich between 1980 and 1996. Of 154 patients, 97 (63%) underwent mitral valve replacement, and 57 (37%) mitral valve reconstruction. The 30-day mortality was 3.2% (5/154); 4% (4/97) after replacement and 1.7% (1/57) after reconstruction (p = 0.67). Survival (Kaplan-Meier) was 93%, 81% and 61% after one, five and 10 years, respectively. There was no significant difference between valve replacement and reconstruction in terms of long-term survival (p = 0.15), but there was a trend towards better survival after reconstruction than replacement if only cardiac deaths were considered (p = 0.1). At follow up, reconstruction patients were significantly less frequently symptomatic (NYHA class III/IV) than replacement patients (0% versus 29%; p = 0.002), had a lower incidence of atrial fibrillation and need for pacemaker implantation (29% versus 47%; p = 0.04), and tended to have less dyspnea in daily life (20% versus 38%; p = 0.07). Reoperation in patients surviving more than 30 days was more common in replacement than in reconstruction patients. The present data suggest a trend for better clinical outcome after mitral valve reconstruction than after replacement when treating mitral valve endocarditis. These results encourage mitral valve reconstruction in mitral valve endocarditis, but recommendations to clinicians undertaking surgery on mitral valve endocarditis must be made with caution.

Controversy still exists regarding the optimal surgical technique for postinfarction dyskinetic left ventricular aneurysm (LVA) repair. We compared the efficacy of two established techniques, linear vs. patch remodeling, for repair of dyskinetic LVA. From 1989 to 1998, 95 (16 women, 79 men) consecutive patients were operated on for postinfarction dyskinetic LVA. Thirty-four patients underwent patch remodeling (R) and 61 linear (L) repair. The mean age was 61.1+/-8.5 years. Indications for surgery alone or in combination included angina in 72 patients, dyspnea in 64 and ventricular tachycardia in 41. Thirty-seven patients had a history of congestive heart failure (R 13 (38%), L 24 (39%), NS). The mean ejection fraction (EF) with aneurysm was 0.29+/-0.09 in R vs. 0.35+/-0.10 in L (P<0.04), whereas the mean EF without aneurysm was 0.43+/-0.11 in R vs. 0.46+/-0.08 in L (P=0.3). Seventy-one aneurysms were anterior (R 30 (88%), L 41 (68%), P<0.05). Concomitant coronary artery bypass grafting was performed in 84 patients (R 29 (85%), L 55 (90%), NS). Follow-up ranged from 1 to 12 years (mean 5.6+/-3.4 years, median 6.1 years). Early mortality was 8% (n=8) (R 4, L 4, NS). Survival at 1, 5 and 10 years was 88, 73, and 44%, respectively. It did not differ significantly between R (1 and 5 year survival 85, 66%) and L (90, 76%, P=0.58). Preoperative risk factors for mortality were history of congestive heart failure (1 and 5 year survival 81 and 57% vs. 90 and 78%, respectively, hazard ratio (HR)=1.95, P<0.05), non-anterior localization of the aneurysm (86 and 49% vs. 86 and 77%, HR=2.06, P<0.05), history of thromboembolic events (57 and 19% vs. 89 and 74%, HR=3.27, P<0.05), and left ventricular EF (HR=0.97 per %, P=0.05). At late follow-up the mean functional class was 1.8+/-0.6 in long-term survivors (preoperative 2.9+/-0.9, P<0.001) with no difference between the groups. The technique of repair of postinfarction dyskinetic LVA should be adapted in each patient to the cavity size and extent of the scarring process into the septum and subvalvular mitral apparatus. Applying these considerations to the choice of the technique of repair, both techniques achieved satisfactory results with respect to perioperative mortality, late functional status and survival.

Moderate to severe irreversible mitral regurgitation secondary to myocardial infarction is an independent risk factor for reduced long-term survival. Late effects of correction of mitral incompetence concomitant with coronary artery bypass grafting (CABG) are less well known and the choice of mitral valve procedure is still debated. From 1988 to 1998, 93 consecutive patients (mean age 63+/-9 years) were treated for moderate to severe irreversible mitral regurgitation secondary to myocardial infarction; 84 were in NYHA functional class III-IV and 19 were in cardiogenic shock. Thirty-seven patients underwent emergency surgery. Perioperative intraaortic balloon pump (IABP) was necessary in 33 patients. Follow-up ranged from 6 months to 12 years (mean 51 months+/-41). Mitral valve was repaired in 30 patients and replaced in 63. Replacement was preferably performed in patients with major displacement of papillary muscle and in patients with acute papillary muscle rupture. CABG (3.4 distal anastomoses) was performed in all patients and was complete in 92%. Early mortality was 15% (14/93). Multivariable analysis identified need for IABP (P=0.005) and COPD (P=0.02) as risk factors for early death. Emergency surgery had only a trend (P=0.15) for increased mortality; age, low ejection fraction, repair vs. replacement had no influence. Actuarial survival rates at 1, 5 and 10 years were 81, 65 and 56%, respectively. Late survival was similar in patients with replacement or repair (P=0.46). At last follow-up, all but one patient were in NYHA functional class I or II. Combined mitral valve procedure and myocardial revascularization, as complete as possible, for moderate to severe mitral regurgitation secondary to myocardial infarction achieve satisfactory early and late outcome despite the increased operative mortality. Acute papillary muscle rupture, severe restriction of the mitral valve by major displacement of the papillary muscle are better managed by valve replacement.

Acute myocardial infarction associated with mitral papillary muscle rupture and cardiogenic shock carries a high mortality. Data relating to early and late survival after emergency mitral valve surgery and concomitant complete coronary artery revascularization in this patient population were analyzed. Between January 1988 and December 1998, 21 consecutive patients (mean age 62+/-9.7 years) underwent emergency coronary and concomitant mitral valve surgery for acute myocardial infarction and mitral papillary muscle rupture associated with cardiogenic shock. Mitral valve replacement was performed in 19 patients (90%), and mitral valve repair in two (10%). An average of 2.2 distal anastomoses per patient was performed. Revascularization was complete in 19 patients (90%). Preoperatively, intra-aortic balloon pumping was used in 11 patients (52%), and two (10%) had salvage surgery when arriving at the operating room under cardiopulmonary resuscitation. Early and late follow up was complete; mean follow up was 5+/-3 years (range: 16 months to 12 years). Thirty-day mortality was 19% (4/21), with two cardiac-related early deaths (10%). Early morbidity included perioperative stroke in 6% (1/17), myocardial infarction in 6% (1/17), and need for hemodialysis in 18% (3/17). There were three late deaths; one was cardiac-related. Actuarial survival at one, five and 10 years was 81, 68 and 56%, respectively. All survivors were in NYHA class I or II. Emergency surgery for acute post-infarction mitral papillary muscle rupture is justified, even as a salvage procedure. Concomitant mitral valve surgery and complete coronary artery revascularization achieve acceptable survival rates and satisfactory functional results.