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13. Is Good Perioperative Echocardiographic Result Predictive of Mid-Term Durability in Ischemic Mitral Valve Repair?
Denis Bouchard, Karim Serri, Arsène J. Basmadjian, Marianne Coutu, Philippe Demers, Raymond Cartier, Pierre Pagé, Louis P. Perrault, Michel Carrier, Michel Pellerin; Montreal, PQ, Canada

Background: Mitral regurgitation (MR) of ischemic etiology must frequently be addressed at the time of coronary bypass surgery. It is associated with poor long-term survival. Despite the increasing popularity of valve repair techniques over replacement procedures, the durability and long-term outcome of valve repair for ischemic mitral regurgitation (IMR) have recently been questioned.
Methods: Seventy-eight patients had undergone mitral valve repair for IMR between 1996 and 2002 at our institution. Excluding the early postoperative death, 73 patients had complete clinical and echocardiographic follow-up. The repair technique consisted exclusively of ring annuloplasty. The ring types were: semi-rigid and complete in 88%, flexible posterior band in 12%. The average number of grafts used per patient was 2.6, with 89% of patients having complete revascularization. Preoperative, intraoperative and postoperative clinical data were abstracted from charts and results of echocardiograms were reviewed to assess the state of the mitral valve immediately postop as well as the rate of recurrence of MR following repair.
Results: Mean preoperative MR grade, NYHA class and LV ejection fraction were 2.72, 2.65 and 39.4% respectively. Mortality was 5.1% at 30 days and 24.7% at a mean follow-up of 29 months. Early postoperative echocardiography (within the first week) showed mild or trivial MR in 89.4% and moderate MR in 10.6%. Freedom from reoperation was 93.2%. Recurrent moderate MR (2/4) was present in 36.7% of patients and severe MR (3-4/4) in 20% during follow-up. In a multiple linear regression model, only age (p=0.0336) and more severe tethering of the posterior mitral leaflet (p= 0.0362) were predictive of recurrent MR. Neither the type of ring (complete rigid ring or flexible posterior band), annuloplasty ring size, operating surgeon, completeness of revascularization, preoperative ejection fraction, preoperative functional class were predictive of recurrent MR. The impact of the recurrence of MR in the clinical evolution of these patients in the long term is unknown. In this study, NYHA class at follow-up was not associated with the severity of MR.
Conclusions: Despite good postoperative echo results following ischemic mitral valve repair, 56% of patients had at least moderate MR at an average follow-up of 29 months. These findings raise questions about the durability of repair as well as the reliability of perioperative echocardiographic evaluation. These results challenge our approach to the mitral valve when severe posterior leaflet tethering - or Carpentier type IIIb - is present. Whether MVR with total chordal preservation is a better option is still debatable.

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