Are recurrence of ischemic mitral regurgitation and left ventricular reverse remodeling after restrictive annuloplasty ring dependent?

https://doi.org/10.1016/j.ijcard.2020.02.068Get rights and content

Highlights

  • MR Recurrence was not influenced by the ring employed.

  • IMR-ETlogix showed the lowest MR recurrence rate.

  • LV Reverse remodeling was comparable in planar and non-planar rings.

  • Symmetric rings showed higher LV remodeling.

Abstract

Objective

This meta-analysis investigates MR recurrence and degree of left ventricular reverse remodeling (LVRR) in CIMR patients in mitral annuloplasty employing different ring designs.

Background

The deeper understanding of complex changes caused by chronic ischemic mitral regurgitation (CIMR) have led to new generations of rings that, by maintaining normal 3D annular geometry are supposed to enhance long-term repair durability.

Methods

A meta-analysis of all available reports in literature of MV repair through different ring design was conducted. Meta-regression was performed to investigate the impact of mitral ring characteristics related to flexibility, planarity, symmetry and single type utilized. Twenty studies encompassing a total of 1876 patients were included at the end of the selection process.

Results

At meta-regression recurrence of MR was not influenced by the ring employed. Nonetheless, the event rate of MR recurrence in planar rings was 19%. Vs. 11% observed with non-planar rings. Recurrence rate in patients implanted with symmetric rings was 14% whereas it was 7% in asymmetric rings. The non-planar asymmetric IMR-ETlogix showed the lowest recurrence rate (6%). Furthermore, in planar group the reduction of pre- and post-operative LVEDD was - 4%. In the non-planar group, the LVEDD was reduced by 8.6%. In patients implanted with symmetric rings LVEDD reduction was 10.8%. LVRR in the asymmetric group was −5.8%.

Conclusion

MR recurrence occurred the least with asymmetric rings with less disproportionate asymmetry. In contrast, LVRR occurred at a greater extent in symmetric rings.

Introduction

The treatment of chronic ischemic mitral regurgitation (CIMR) is still controversial [1]. The main challenges rise from its complex pathophysiology and high post-repair recurrence rate secondary to continued left ventricular remodeling [[2], [3], [4], [5]]. Complex changes involve also the mitral annulus which increases in size, flattens its 3D saddle-like shape and loses its dynamic function [[5], [6], [7]]. The deeper understanding of such pathophysiological dynamic annular modifications has led to a new generation of non-planar mitral rings for mitral repair aimed at maintaining normal 3D annular geometry and allowing for an improved surface area of coaptation [4,[8], [9], [10], [11], [12], [13], [14]]. More recently, asymmetric rings have been introduced that reduce the septal-lateral dimension greatly in the P3 region which is the site of the most extensive tethering in CIMR [15]. Nonetheless, no successfully completed randomized trials exist comparing the efficacy of different types of rings and clearly demonstrating superiority of one device over the others. Therefore, the aim of this systematic review and meta-analysis is to investigate mitral regurgitation recurrence and degree of left ventricular reverse remodeling (LVRR) after restrictive mitral annuloplasty (RMA) in CIMR patients employing different ring designs.

Section snippets

Search strategy

Literature search was conducted in accordance with the Preferred Reporting Items for Systematic Review and Metanalyses (PRISMA) and Cochrane Handbook [16,17]. Participants, interventions, comparisons, outcomes and study design were addressed following PICOS (Population or Problem-Intervention or exposure-Comparison- Outcome-Study design) [18]. For the purpose of the review, rings identified through database search are stratified to either planar or non-planar ring groups. The search strategy

Characteristics of the studies

The selection process is illustrated in the PRISMA flowchart in the Supplemental Fig. S1. The total number of studies found was 1029. After a first screening, 208 articles remained to be assessed for eligibility and final inclusion in the qualitative assessment. Among these, 18 articles satisfied the inclusion criteria. Two additional studies were included from further search conducted on the reference lists of the original sources. Therefore, a total of 20 articles were eligible [[2], [3], [4],

Discussion

Recent evidence shows that restoration of the mitral annular area and the physiological 3D saddle shape is essential for a durable mitral valve (MV) repair [[38], [39], [40]]. Furthermore, it has been shown that, in chronic ischemic mitral regurgitation (CIMR) the tethering is prevalent at the medial aspect [15]. Consequently, different ring designs have been proposed, addressing the annulus shape or the tethering asymmetry.

However, despite the great amount of literature on the topic, there is

Limitations

Our study has some limitations that have to be pointed out. Firstly, the majority of the studies included have retrospective nature because no randomized clinical trial has been found regarding this topic. Secondly, relevant variability in follow-up periods was reported among the studies. Thirdly, data on volume reduction was not widely available, therefore we used LVEDD as index of ventricular remodeling, but LV volumes have been demonstrated to be more reliable than LV diameters in assessing

Conclusions

Recurrence of MR was not influenced by the ring employed. Nonetheless, in the single analyses, the IMR-ETlogix showed the lowest rate of recurrence. In contrast, left ventricular reverse remodeling occurred at a greater extent in planar symmetric rings. The paper despite it does not gives clear-cut conclusions is the proof that a randomized trial between rings or better selection patients for single studies are needed to address the issue.

The following are the supplementary data related to this

Funding

The authors received no financial support for the research and/or authorship of this article.

CRediT authorship contribution statement

Linda Renata Micali: Investigation, Writing - original draft. Gianmarco Parise: Data curation. Amalia Ioanna Moula: Data curation, Formal analysis. Yazeed Alayed: Investigation. Orlando Parise: Formal analysis. Francesco Matteucci: Software. Monique de Jong: Data curation. Cecilia Tetta: Methodology, Writing - review & editing. Sandro Gelsomino: Writing - original draft, Writing - review & editing, Supervision.

Declaration of competing interest

The authors declare no conflicts of interest.

Acknowledgements

We kindly acknowledge Dr. Judith Wilson for the English Editing of the Manuscript.

References (53)

  • W. Bothe et al.

    Effects of different annuloplasty rings on anterior mitral leaflet dimensions

    J. Thorac. Cardiovasc. Surg.

    (2010)
  • N. D’Elia et al.

    Association between myocardial mechanics and ischemic LV remodeling

    JACC Cardiovasc. Imaging

    (2015)
  • K. Matsuzaki et al.

    Elimination of ischemic mitral regurgitation does not alter long-term left ventricular remodeling in the ovine model

    Ann. Thorac. Surg.

    (2010)
  • J.N. Cohn et al.

    Cardiac remodeling—concepts and clinical implications: a consensus paper from an international forum on cardiac remodeling

    J. Am. Coll. Cardiol.

    (2000)
  • S. Gelsomino et al.

    Left ventricular reverse remodeling after undersized mitral ring annuloplasty in patients with ischemic regurgitation

    Ann. Thorac. Surg.

    (2008)
  • E. Potter et al.

    Assessment of left ventricular function by echocardiography

    The Case for Routinely Adding Global Longitudinal Strain to Ejection Fraction

    (2018)
  • T.G. Di Salvo et al.

    Mitral valve surgery in advanced heart failure

    J. Am. Coll. Cardiol.

    (2010)
  • A.M. Calafiore et al.

    Mitral valve surgery for chronic ischemic mitral regurgitation

    Ann. Thorac. Surg.

    (2004)
  • R. Lorusso et al.

    Mitral valve repair or replacement for ischemic mitral regurgitation? The Italian Study on the Treatment of Ischemic Mitral Regurgitation (ISTIMIR)

    J. Thorac. Cardiovasc. Surg.

    (2013)
  • T.M. Sundt

    Surgery for ischemic mitral regurgitation

    N. Engl. J. Med.

    (2014)
  • S. Silberman et al.

    Repair of ischemic mitral regurgitation: comparison between flexible and rigid annuloplasty rings

    Ann. Thorac. Surg.

    (2009)
  • J. Hung et al.

    Mechanism of recurrent ischemic mitral regurgitation after annuloplasty

    Circulation

    (2004)
  • A. Hossien et al.

    A multidimensional dynamic quantification tool for the mitral valve

    Interact. Cardiovasc. Thorac. Surg.

    (2015)
  • N. Watanabe et al.

    Mitral annulus flattens in ischemic mitral regurgitation: geometric differences between inferior and anterior myocardial infarction

    Circulation

    (2005)
  • M. Daimon et al.

    Mitral valve repair with Carpentier-McCarthy-Adams IMR ETlogix annuloplasty ring for ischemic mitral regurgitation

    Circulation

    (2006)
  • A. Khamooshian et al.

    Mitral valve annuloplasty rings: review of literature and comparison of functional outcome and ventricular dimensions

    Innovations (Phila).

    (2014)
  • View full text