Adult: Mitral Valve
Left ventricle–mitral valve ring size mismatch following ring annuloplasty for nonischemic dilated cardiomyopathy

https://doi.org/10.1016/j.jtcvs.2021.05.047Get rights and content

Abstract

Background

In patients with ischemic mitral regurgitation (MR) undergoing restrictive mitral annuloplasty (RMA), the ratio of left ventricular (LV) end-systolic dimension (LVESD) to mitral valve (MV) ring size (ie, LV–MV ring mismatch) is associated with postoperative recurrent MR. However, the impact of LV–MV ring mismatch on postoperative recurrent MR, LV function recovery, and long-term survival in patients with nonischemic dilated cardiomyopathy (DCM) remains unknown.

Methods

Sixty-six patients with nonischemic DCM (mean LVESD, 62 mm) underwent RMA (mean ring size, 26 mm) between 2003 and 2014. Recurrent MR was defined as MR grade ≥2+ at a 6-month echocardiographic evaluation.

Results

At the 6-month follow-up, 23 patients (35%) had developed recurrent MR. In univariable logistic regression analysis, larger LVESD (P = .012) and LVESD/ring size ratio (P = .008) were associated with recurrent MR. In multivariable models adjusted for age, sex, baseline LV ejection fraction, and severe MR, only LVESD/ring size ratio (odds ratio, 4.65; 95% confidence interval, 1.04-25.0; P = .048) remained significantly associated with MR recurrence. Receiver operating characteristic curve analysis demonstrated an optimal cutoff value for the LVESD/ring size ratio of 2.42. Patients with an LVESD/ring size ratio >2.42 (n = 30; mismatch) had a lower 5-year cumulative survival rate compared with those with an LVESD/ring size ratio ≤2.42 (n = 36; nonmismatch) (52% vs 71%; P = .045). Postoperatively, LV dimensions were significantly reduced in both groups; however, improvements in LVEF were only modest in the mismatched group (P = .091).

Conclusions

LV–MV ring size mismatch was associated with an increased risk of recurrent MR in our series. This finding may aid the formulation of surgical strategies for patients with nonischemic DCM.

Graphical abstract

In patients with nonischemic dilated cardiomyopathy who undergo mitral annuloplasty, the ratio of left ventricular end-systolic dimension to mitral valve ring size is independently associated with postoperative recurrent mitral regurgitation.

  1. Download : Download high-res image (261KB)
  2. Download : Download full-size image

Section snippets

Patients

We examined patients with functional MR secondary to nonischemic DCM (LV ejection fraction [LVEF] ≤40%) who underwent an RMA procedure between 2003 and 2014 and who had a complete transthoracic echocardiography study at 6 months postsurgery. All patients had LV systolic dysfunction and dilation, as well as functional moderate or severe MR caused by restricted leaflet closure (Carpentier type IIIb). Patients with degenerative MV disease and those who underwent surgical ventricular restoration

Patient Characteristics

In our surgical database, 66 patients (mean age, 63 ± 10 years) met the inclusion criteria and were included in this study. The mean body surface area was 1.6 ± 0.2 m2, and the mean size of the implanted ring was 26 ± 1 mm (range, 24-30 mm). Consequently, the mean LVESD/ring size ratio was 2.4 ± 0.4.

Notably, the size of the prosthetic mitral ring implanted during RMA was positively correlated with the patient's body surface area (ρ = 0.243; P = .049). On the other hand, neither LVEDD

Discussion

The major findings of this study can be summarized as follows: (1) in a specific cohort of patients with advanced nonischemic cardiomyopathy undergoing an RMA procedure, the LVESD/ring size ratio was significantly associated with mild or greater recurrent MR at postoperative 6 months (Figure 3); (2) in patients with an LVESD/ring size ratio >2.42 (the mismatch group), the cutoff value determined for predicting recurrent MR in the ROC analysis, had a lower survival rate compared with patients

Conclusions

In our cohort, the LV–MV ring size mismatch ratio was significantly associated with postoperative mild or greater recurrent MR in patients with functional nonischemic MR undergoing RMA. These findings may aid patient selection for MV surgery, as well as the development of surgical strategies for nonischemic DCM.

References (23)

  • D. Goldstein et al.

    Two-year outcomes of surgical treatment of severe ischemic mitral regurgitation

    N Engl J Med

    (2016)
  • Cited by (3)

    Collaborators in the OSCAR Study Group: Yasushi Yoshikawa, MD, PhD, Hiroki Hata, MD, PhD, Takuji Kawamura, MD, PhD, Ai Kawamura, MD, PhD, Takayoshi Ueno, MD, PhD, and Toru Kuratani, MD, PhD, all from the Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, and Junya Sado, MPH, PhD, from the Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine.

    View full text