Systematic reductive annuloplasty of the mitral and tricuspid valves in patients with end-stage ischemic dilated cardiomyopathy.

OBJECTIVE: Patients with ischemic dilated cardiomyopathy exhibit extensive remodeling of the left ventricle, annular dilation, and significant mitral and tricuspid regurgitation. These changes increase per operative morbidity and mortality, and emphasize patient candidacy for heart transplantation. The aim of this study is to show immediate and long-term results after reductive annuloplasty of double (mitral and tricuspid) orifices, performed at the time of coronary artery bypass grafting, as an alternative to heart transplantation. METHODS: There were 226 consecutive patients (205 males, 21 females) with ischemic dilated cardiomyopathy, mean ejection fraction below 30% [(26.6 +/- 3.1)%], and mean left ventricle end-diastolic internal diameter greater than 7.0 cm (7.3 +/- 0.3 cm). In addition to myocardial revascularization, Carpentier's mitral annuloplasty and posterior semicircular reductive annuloplasty were performed in 37 and 189 patients, respectively. In all 226 patients, a modified De Vega's tricuspid annuloplasty was performed. RESULTS: Postoperative 30-day mortality was 7.5% (17 patients). Survival rates after 5 and 10 years were (61.5 +/- 4.0)% and (38.05 +/- 8.0)%, respectively. CONCLUSION: Reductive annuloplasty of mitral and tricuspid orifices performed at the time of myocardial revascularization could be beneficial in selective patients with ischemic dilated cardiomyopathy. Results indicate that this method should not be recognized as a valve repair, but ventricular repair procedure also.

[The importance of hemodynamic monitoring in mitral and tricuspid valve surgery].

INTRODUCTION: Untreated mitral valve disease is associated with marked hemodynamic disorders, low ejection fraction (EF) and poor perfusion. The study aimed to explore the importance of hemodynamic monitoring in intraoperative evaluation and treatment of these patients. MATERIAL AND METHODS: This prospective study included 85 patients: group 1: 41 patients, EF<40%; group 11: 44 patients, EF>40%. Hemodynamic parameters were recorded after initation of anesthesia (1), after sternotomy (2), after extracorporeal circulation (ECC) (3) and before leaving the operation theatre (4). The following parameters were assessed: mean arterial pressure, mean pulmonary artery pressure, pulmonary capillary wedge pressure, pulmonary vascular resistance index, central venous pressure, cardiac index. Statistical analysis was performed using Student t-test and correlation analyses in time series. RESULTS AND DISCUSSION: Hemodynamic parameters were changed at the beginnig of surgery, but gradually improved after sternotomy and were normal at the end of the operation. Both examined groups presented with reduction of the pulmonary artery preassure, pulmonary capillary wedge pressure, pulmonary vascular resistance index (reduction more than 30%) and cardiac index (up to 100%). Strong correlation between 1/2 and 3/4 assessments pointed to the importance of intraoperative evaluation. Swan-Ganz catheter ia a valuable tool used for hemodynamic monitoring. CONCLUSION: Intraoperative medication (based on obtained hemodynamic parameters) and operative treatment led to normalization of all parameters in both groups, regardless of the preoperative values of EF.

Surgical treatment of heart failure in patients with primary and ischemic dilated cardiomyopathy.

OBJECTIVE: The aim of this study was to show hemodynamic and clinical improvement of heart failure after reductive annuloplasty of double (mitral and tricuspid) orifices (RADO) in the treatment of ischemic (IDCM) and primary (PDCM) dilated cardiomyopathy. MATERIALS AND METHODS: From November 1986 to July 15, 2002, 341 patients underwent operations for dilated cardiomyopathy. The IDCM group consisted of 231 patients (68%) with a mean ejection fraction (EF) of 23.3%. From July 1991 to July 15, 2002, the 110 patients in the PDCM group (mean EF, 22.9%) underwent such operations. RESULTS: The postoperative 30-day mortality rate was 5.9% for the entire patient population, 7.3% for the IDCM group, and 2.7% for the PDCM group. Follow-up survival rates were 61.5% +/- 4.0% at 5 years and 38.2% +/- 8.0% at 14 years for the IDCM group and 43.9% +/- 5.6% at 5 years and 21.3% +/- 8.5% at 10 years for the PDCM group. CONCLUSION: RADO corrects remodeling of the fibrous skeleton of the heart, changes the spherical geometry of the left ventricle, improves the hemodynamic action of the left and right ventricles, and slows down the progression of heart failure. We recommend the RADO procedure as an important associated procedure in the surgical treatment of IDCM and as a new surgical alternative for treating the early stage of PDCM immediately after the first decompensation.