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@# Objective To analyze the efficacy of off-pump coronary artery bypass grafting (OPCABG) in elderly patients with coronary artery disease complicated with moderate ischemic mitral regurgitation. Methods The clinical data of patients aged≥70 years with coronary artery disease complicated with moderate mitral regurgitation, and undergoing OPCABG from January 2009 to January 2020 in Beijing Anzhen Hospital were retrospectively analyzed. The echocardiographic indicators of the patients were compared preoperatively, postoperatively before discharge and during the follow-up. Results Finally 239 patients were enrolled. There were 136 males and 103 females, aged 74.1±3.2 years. Before postoperative discharge, 49 (20.5%) patients had no mitral regurgitation, 144 (60.3%) mild regurgitation, 46 (19.2%) moderate regurgitation, and 0 severe regurgitation. The area of mitral regurgitation was significantly improved (2.5±1.8 cm2 vs. 5.6±1.0 cm2, P<0.001). There were 10 (4.2%) patients of hospital death, 23 (9.6%) of low cardiac output, 3 (1.3%) of myocardial infarction, and 8 (3.3%) of nervous system injury after operation. As a result, 208 (90.8%) patients were followed up and the mean follow-up time was 3.4 years (range 1-9 years). The cumulative survival rates at postoperative 2, 4, 6, and 8 years were 95.8%, 88.0%, 78.4%, and 73.1%, respectively. Postoperative follow-up showed significant improvements compared with those before surgery in the area of mitral regurgitation, left ventricular ejection fraction, left ventricular end-diastolic and left ventricular end-systolic diameters (all P<0.05). Duirng the follow-up, the major adverse cardiac and cerebrovascular events were all cause death in 22 (10.6%) patients, including cardiac death in 17 (8.2%) patients, myocardial infarction in 7 (3.4%) patients, heart failure in 24 (11.5%) patients, cerebrovascular events in 11 (5.3%) patients, re-hospitalization due to heart disease in 23 (11.1%) patients, and none of the patients with myocardial infarction were revascularized. Conclusion The mid- and long-term outcomes of OPCABG in the treatment for elderly patients with coronary artery disease complicated with moderate ischemic mitral regurgitation is good.
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@#Objective To evaluate the papillary muscle function in patients with ischemic mitral regurgitation (IMR) before and after percutaneous coronary intervention(PCI) using two-dimensional speckle tracking imaging (2D-STI) technique. Methods Seventy-two patients with myocardial infarction were selected and divided into 2 groups, the anterior myocardial infarction group (Ant-MI group, n=33) and the inferior myocardial infarction group (Inf-MI group, n=39). The papillary muscle function was evaluated by echocardigraphy and 2D-STI technique 48 h before PCI and 3 months after PCI. Data of the left ventricular end-diastolic diameter (LVEDd), the left ventricular end-diastolic and end-systolic volume (LVEDV / LVESV), the left ventricular ejection fraction (LVEF) and the mitral regurgitation volume were measured by echocardiography. Data of the longitudinal strain (APM-S, PPM-S), the peak time (APM-T, PPM-T) and the delay time (DT=|APM-T - PPM-T|) of mitral anterior and posterior papillary muscles were measured by 2D-STI technique. Results There were no significant differences in LVEDd, LVEDV, LVESV, LVEF, and mitral regurgitation volume between two groups. Compared with the PCI opertion before, the LVEF was significantly increased, the LVESV and the mitral regurgitation volume were significantly decreased after PCI opertion in both groups (P＜0.05)，and there were no significant changes in LVEDV and LVEDd (P＞0.05). The values of |APM-S| was lower and the |PPM-S| was higher in Ant-MI group than those of Inf-MI group, neither before nor after PCI opertion (P＜0.05). After PCI operation: the |APM-S| was signigicantly increased and the DT was significantly decreased in Ant-MI group (P＜0.05). There were no signigicant changes in |PPM-S|, APM-T and PPM-T (P＞0.05). The |PPM-S| was signigicantly increased and DT was significantly decreased in Inf-MI group (P＜0.05), and there were no significant changes in |APM-S|, APM-T and PPM-T (P＞0.05). Conclusion The 2D-STI technology can be used to evaluate the function of mitral papillary muscles. PCI can significantly improve the papillary muscle function in patients with mild to moderate IMR, reduce the reflux and improve the left ventricular remodeling.
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Objective To observe the short and long term efficacy of coronary artery bypass grafting (CABG), mitral valve annuloplasty (MVP) combined operation in patients with coronary heart disease with moderate ischemic mitral regurgitation comparing with simple CABG operation, and explore the best treatment and provide reference for clinical treatment. Method 115 patients with coronary heart disease complicated with moderate ischemic mitral regurgitation, admitted from September 2010 to September 2017 in General Hospital of Northern Theater Command, of PLA, were enrolled in present study. Of the 115 patients, 69 underwent coronary artery bypass grafting surgery (CABG group), and 46 underwent coronary artery bypass grafting and mitral valve annuloplasty combined surgery (CABG+MVP group). The short and long term outcomes of the two groups were compared and analyzed. The short term outcomes included clinical indicators [left atrium diameter (LAD), left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter (LVESD), left ventricular ejection fraction (LVEF), systolic pulmonary artery pressure (sPAP), mitral regurgitation area, NYHA cardiac function classification) and the incidence of perioperative events. The long term outcomes included the cumulative survival rate and the exemption rate of cardiovascular and cerebrovascular events. Results The operation was successful in both groups. Perioperative mortality was 8 cases, including 4 cases in CABG group (5.7%) and 4 cases in CABG+MVP group (8.6%). There was no significant difference between the two groups (P>0.05). LVESD (P=0.009), mitral regurgitation (P0.05). The cumulative survival rate (P=0.205) and the exemption rate of cardiovascular and cerebrovascular events (P=0.535) had no significant difference between the two groups. Conclusions For treatment of coronary heart disease with moderate ischemic mitral regurgitation, the CABG+MVP group was superior to the CABG group, but not on long term efficacy, which can effectively improve the mitral regurgitation and NYHA cardiac function classification of patients. However, follow-up observation was still needed.
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Objective@#To discuss and evaluate the safty and outcome of the second order chordal-cutting.@*Methods@#From Aug 2015 to Mar 2017, 9 chronic IMR patients underwent chordal-cutting procedure, in addition to myocardial revascularization and undersized mitral annuloplasty. The indication was the presence of increased tethering of the anterior leaflet, with a bending angle (BA)<145° and the coaptation depth (CD) less than 10 mm. Pre- and post-procedure clinical data including left ventricular ejection fraction(LVEF), mitral regurgitation grade, New York Heart Association (NYHA) class and dimension of the left ventricle were compared.@*Results@#There was no perioperative death. No patient was lost to follow-up. MR grade decreased from 2.89 ± 0.60 preoperatively to 0.56 ± 0.70 postoperatively. The New York Heart Association class decreased from 2.78 ± 0.70 preoperatively to 1.33 ± 0.50 postoperatively. The BA increased from (136.22 ± 4.55)°preoperatively to (174.22 ± 3.15)°postoperatively. The coaptation depth decreased from (8.59 ± 0.46) mm preoperatively to (1.54 ± 0.68) mm postoperatively. LVEF increased from 0.49±0.07 preoperatively to 0.57±0.05 postoperatively. The diastolic and systolic diameters of left ventricle decreased from (62.78 ± 5.24 )mm to (53.67 ± 2.99)mm and( 44.11 ± 4.62)mm to( 37.22 ± 3.27)mm, respectively.@*Conclusion@#In selected chronic IMR patients with a BA<145° and coaptation depth less than 10 mm, second order chordal-cutting can be a good surgical option, and is related to less MR return or persistence, improved LVEF, and lower New York Heart Association class.
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Objective To discuss and evaluate the safty and outcome of the second order chordal-cutting.Methods From Aug 2015 to Mar 2017,9 chronic IMR patients underwent chordal-cutting procedure,in addition to myocardial revascularization and undersized mitral annuloplasty.The indication was the presence of increased tethering of the anterior leaflet,with a bending angle (BA) ＜ 145° and the coaptation depth (CD) less than 10 mm.Pre-and post-procedure clinical data including left ventricular ejection fraction(LVEF),mitral regurgitation grade,New York Heart Association (NYHA) class and dimension of the left ventricle were compared.Results There was no perioperative death.No patient was lost to follow-up.MR grade decreased from 2.89 ± 0.60 preoperatively to 0.56 ± 0.70 postoperatively.The New York Heart Association class decreased from 2.78 ± 0.70 preoperatively to 1.33 ± 0.50 postoperatively.The BA increased from (136.22 ± 4.55) °preoperatively to (174.22 ± 3.15) °postoperatively.The coaptation depth decreased from (8.59 ± 0.46) mm preoperatively to (1.54 ± 0.68) mm postoperatively.LVEF increased from 0.49 ± 0.07 preoperatively to 0.57 ± 0.05 postoperatively.The diastolic and systolic diameters of left ventricle decreased from (62.78 ± 5.24)mm to (53.67 ± 2.99)mm and(44.11 ± 4.62) mm to(37.22 ± 3.27) mm,respectively.Conclusion In selected chronic IMR patients with a BA ＜ 145 ° and coaptation depth less than 10 mm,second order chordal-cutting can be a good surgical option,and is related to less MR return or persistence,improved LVEF,and lower New York Heart Association class.
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@#Ischemic mitral regurgitation represents a common complication after myocardial infarction, the severity of the mitral regurgitation increases the risk of mortality. There is continuing debate regarding the management of moderate ischemic mitral regurgitation in patients undergoing surgical management. The debates lie in whether adding mitral valve surgery to coronary artery bypass grafting. So the review is about the analysis of existing evidence and expectation about it.
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Objectives: Contrary to the rest of the mitral annulus, inter‑trigonal distance is known to be relatively less dynamic during the cardiac cycle. Therefore, intertrigonal distance is considered a suitable benchmark for annuloplasty ring sizing during mitral valve (MV) surgery. The entire mitral annulus dilates and flattens in patients with ischemic mitral regurgitation (IMR). It is assumed that the fibrous trigone of the heart and the intertrigonal distance does not dilate. In this study, we sought to demonstrate the changes in mitral annular geometry in patients with IMR and specifically analyze the changes in intertrigonal distance during the cardiac cycle. Methods: Intraoperative three‑dimensional transesophageal echocardiographic data obtained from 26 patients with normal MVs undergoing nonvalvular cardiac surgery and 36 patients with IMR undergoing valve repair were dynamically analyzed using Philips Qlab® software. Results: Overall, regurgitant valves were larger in area and less dynamic than normal valves. Both normal and regurgitant groups displayed a significant change in annular area (AA) during the cardiac cycle (P < 0.01 and P < 0.05, respectively). Anteroposterior and anterolateral‑posteromedial diameters and inter‑trigonal distance increased through systole (P < 0.05 for all) in accordance with the AAs in both groups. However, inter‑trigonal distance showed the least percentage change across the cardiac cycle and its reduced dynamism was validated in both cohorts (P > 0.05). Conclusions: Annular dimensions in regurgitant valves are dynamic and can be measured feasibly and accurately using echocardiography. The echocardiographically identified inter‑trigonal distance does not change significantly during the cardiac cycle.
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Objective To evaluate the short-term-outcome of MVP in the treatment of moderate IMR patients with CABG.Methods Data from 129 patients with moderate IMR who underwent surgical treatment in our department from June 2007 to September 2011,57 patients(44.2％) underwent CABG combined with MVP,and 72 patients(55.8％) underwent CABG.Postoperative follow-up of patients with heart function NYHA grade to evaluate the clinical status of patients,with LVESD,LVEF,LVEDD to evaluate the reverse of left ventricular remodeling;The postoperative residual mitral regurgitation and major cardiac cerebral vascular events were recorded.Results There was no significant difference between two groups in the preoperative data(P ＞ 0.05).The mortality rate was 3.9％ (5 cases),2 cases (2.8 ％) died in CABG group,3 cases (5.3 ％) died in the combined surgery group.The average follow-up was 24 months,9 cases of late death (5 in CABG group,4 in CABG + MVP group),the cumulative survival rate(P =0.645) and the major cardiovascular events(P =0.761) of the two groups were not statistically different.The degree of mitral regurgitation(P ＜ 0.01) was significantly decreased in the combined surgery group.Compared with the preoperative state,the two groups of left ventricular remodeling indicators such as LVESD,LVEF,LVEDD were significantly improved(P ＜0.05),but the difference between two groups was not significant(P ＞0.05).NYHA heart function classification was significantly improved (P ＜ 0.001).Conclusion MVP can effectively improve the reverse flow of patients with moderate IMR,but CABG combined with MVP can not bring more benefits in the reversal of left ventricular remodeling,short-term survival and cardiac function.
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Caseous calcification of mitral annulus is a rare disease characterized by tumors of the mitral cusps. Operative case reports, however, are rare because this lesion seldom negatively affects hemodynamics. We encountered a 67-year-old female case of mitral regurgitation with caseous calcification of mitral posterior annulus due to ischemic heart disease and performed mitral valve replacement and CABG. The excision of the mitral thickened lesion resulted in a defect of the mitral annulus, which needed to be repaired with an autologous pericardial patch. We mainly report the intraoperative findings of this case.
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Objective To analyze effect of stem cell transplantation on the expression of smooth muscle actin (SMA), basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF) in the myocardium of dogs with ischemic mitral regurgitation.Methods 24 healthy male experiment dogs were selected, 6 were collected randondy as normal group, the others were used to construct mitral regurgitation model.After that, the modelized dogs were divided into three groups, 5 dogs in model group, 6 dogs in experiment group and 6 in control group.The experimental group were given 2 mL stem cells suspension to ischemic myocardial, control group was infused without stem cells in DMEM medium, and then the SMA, bFGF and VEGF expression levels of myocardial tissues in each groups were detected and analyzed.ResuIts Compared with control group and model group, the heart function of experiment group were improved more obviously, such as cardiac output (CO) and stroke volume (SV) increased significantly (P<0.05).Myocardialα-SMA were significantly lower (P<0.05).bFGF contents in myocardial tissue increased significantly (P<0.05).The content of VEGF in myocardial tissue significantly increased (P<0.05).ConcIusions Stem cell transplantation can inhibit the expression of SMA in myocardium of ischemic mitral regurgitation, and promote the expression of bFGF and VEGF, has a better effect on heart function.
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We report a case of redo mitral valve replacement via right thoracotomy for ischemic mitral regurgitation after coronary artery bypass grafting. An 81-year-old woman with a history of multiple coronary artery bypass grafting was admitted to our institute for treatment of severe ischemic mitral valve regurgitation. She had a history of repeated hospitalization for heart failure and complained of worsening dyspnea. Coronary angiography showed patent coronary grafts. Echocardiography revealed severe mitral regurgitation with leaflet tethering and posteroinferior wall asynergy. The patient underwent mitral valve replacement (Mosaic Bioprosthesis 27 mm) via right thoracotomy approach with ventricular fibrillation under moderate hypothermia. The ventricular fibrillation time was 57 min, and the cardiopulmonary bypass time was 126 min. The patient's postoperative recovery was uneventful. She was discharged on postoperative day 19. Right thoracotomy approach provided excellent exposure of the mitral valve and minimized the risk of repeat sternotomy, including injury of previous bypass grafts, injury of right ventricle and significant hemorrhage.
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Aims and Objectives: Mild and/or moderate ischemic mitral regurgitation (IMR) may resolve after isolated coronary artery bypass grafting (CABG). It has been shown that the loss of saddle shape of the mitral valve is associated with IMR and is determined by an increase in the nonplanarity angle (NPA). The aim of this prospective, observational study was to test the hypothesis that NPA might decrease immediately after CABG alone in patients with mild to moderate IMR. Materials and Methods: This prospective, observational study was conducted in an academic, tertiary care hospital. Twenty patients underwent 2D and 3D transoesophageal echocardiography (TEE) and mitral valve assessment before and immediately after the CABG. NPA, circularity index, and other geometric variables were obtained. They were compared using paired t test. The SPSS (Version 15.0, Chicago, IL, USA) was used for statistical analysis. P <0.05 was considered significant. Results: The NPA was similar in the pre- and post-bypass periods (148° ± 15°, 148° ± 19°, P = 0.88). Circularity index (0.93 ± 0.13, 0.97 ± 0.11, P = 0.41) also was similar. Conclusions: There was no change in the mitral valve NPA with revascularization alone in patients with mild or moderate IMR. Mitral valve does not change its planarity (NPA) with revascularization alone in patients with IMR.
Subject(s)
Coronary Artery Bypass/methods , Echocardiography, Three-Dimensional/methods , Echocardiography, Transesophageal/methods , Humans , Mitral Valve/anatomy & histology , Mitral Valve/physiopathology , Mitral Valve/diagnostic imaging , Mitral Valve Insufficiency/etiology , Mitral Valve Insufficiency/diagnostic imaging , Myocardial Revascularization/methods , Patients , Percutaneous Coronary Intervention/methodsABSTRACT
BACKGROUND: There have been controversies whether mitral valvular surgery is necessary in the patients with moderate ischemic mitral regurgitation undergoing coronary artery bypass grafting. The purpose of this study is to evaluate the long term clinical results of patients with moderate ischemic mitral regurgitation. MATERIAL AND METHOD: Between January 1992 and February 2005, 44 patients with moderate ischemic mitral regurgitation underwent coronary artery bypass grafting. Concomitant mitral valvular procedure was performed in 20 patients (group 1) and isolated coronary artery bypass grafting was performed in 24 patients (group 2). There were no significant difference between groups except cardiopulmonary bypass time (p<0.01). Postoperative follow up duration was 30.1+/-29.6 months and last follow up echocardiographic examination was performed at 21.2+/-28.0 months. RESULT: There was no difference in operative mortality between groups (group 1 vs group 2, 15.0% vs 8.3%, p=0.493). Grade of mitral regurgitation (0.81+/- 0.91 vs 1.50+/- 0.05, p=0.046) and reduction in regurgitation grade (1.75 +/-0.93 vs 0.70 +/-1.26, p=0.009) were different between two groups. But there were no significant differences in left ventricular ejection fraction (34.1+/-11.4% vs 41.6+/-12.9%), left ventricular end systolic volume (118.2+/-63.9 mL vs 85.6+/-28.1 mL), New York Heart Association functional class (2.1+/-0.2 vs 2.4+/-1.2) and 5 year survival rate (85+/-8% vs 82+/-8%). There was no risk factor for operative mortality and the only risk factor for late death was preoperative atrial fibrillation (p=0.042). There was no significant correlation between mitral valvular surgery and late death. CONCLUSION: Concomitant mitral valvular procedure in patients with moderate ischemic mitral regurgitation undergoing coronary artery bypass grafting had no significant positive effect on survival and ventricular function compared with isolated coronary artery bypass grafting. Prospective randomized study may be needed to evaluate the necessity of concomitant mitral procedure and to find more effective method for the improvement of ventricular function.
Subject(s)
Humans , Atrial Fibrillation , Cardiopulmonary Bypass , Coronary Artery Bypass , Coronary Vessels , Echocardiography , Follow-Up Studies , Heart , Mitral Valve Insufficiency , Mortality , Risk Factors , Stroke Volume , Survival Rate , Ventricular FunctionABSTRACT
BACKGROUND: There have been controversies whether mitral valvular surgery is necessary in the patients with moderate ischemic mitral regurgitation undergoing coronary artery bypass grafting. The purpose of this study is to evaluate the long term clinical results of patients with moderate ischemic mitral regurgitation. MATERIAL AND METHOD: Between January 1992 and February 2005, 44 patients with moderate ischemic mitral regurgitation underwent coronary artery bypass grafting. Concomitant mitral valvular procedure was performed in 20 patients (group 1) and isolated coronary artery bypass grafting was performed in 24 patients (group 2). There were no significant difference between groups except cardiopulmonary bypass time (p<0.01). Postoperative follow up duration was 30.1+/-29.6 months and last follow up echocardiographic examination was performed at 21.2+/-28.0 months. RESULT: There was no difference in operative mortality between groups (group 1 vs group 2, 15.0% vs 8.3%, p=0.493). Grade of mitral regurgitation (0.81+/- 0.91 vs 1.50+/- 0.05, p=0.046) and reduction in regurgitation grade (1.75 +/-0.93 vs 0.70 +/-1.26, p=0.009) were different between two groups. But there were no significant differences in left ventricular ejection fraction (34.1+/-11.4% vs 41.6+/-12.9%), left ventricular end systolic volume (118.2+/-63.9 mL vs 85.6+/-28.1 mL), New York Heart Association functional class (2.1+/-0.2 vs 2.4+/-1.2) and 5 year survival rate (85+/-8% vs 82+/-8%). There was no risk factor for operative mortality and the only risk factor for late death was preoperative atrial fibrillation (p=0.042). There was no significant correlation between mitral valvular surgery and late death. CONCLUSION: Concomitant mitral valvular procedure in patients with moderate ischemic mitral regurgitation undergoing coronary artery bypass grafting had no significant positive effect on survival and ventricular function compared with isolated coronary artery bypass grafting. Prospective randomized study may be needed to evaluate the necessity of concomitant mitral procedure and to find more effective method for the improvement of ventricular function.
Subject(s)
Humans , Atrial Fibrillation , Cardiopulmonary Bypass , Coronary Artery Bypass , Coronary Vessels , Echocardiography , Follow-Up Studies , Heart , Mitral Valve Insufficiency , Mortality , Risk Factors , Stroke Volume , Survival Rate , Ventricular FunctionABSTRACT
BACKGROUND AND OBJECTIVES: he ischemic mitral regurgitation (MR) is known as a clinically important prognostic factor of acute myocardial infarction, and it is important to understand the mechanism of ischemic MR for successful treatment of ischemic MR. However, the mechanism of ischemic MR has not been known clearly. The purposes of this study were to evaluate the role of papillary muscle ischemia and LV dysfunction in the development of ischemic MR and to relate structural and functional changes of LV with severity of ischemic MR. METHODS: Left thoracotomy was performed in ten mongrel dogs. In group 1 (n=5), first and second obtuse marginal (OM) branches were ligated, and in group 2 (n=5), second and third OM branches were ligated. Epicardial echocardiography was performed at baseline, during infusion of esmolol, and during ligation of OM branches to measure end diastolic and end systolic area, fractional area shortening of LV, incomplete leaflet closure distance and area of mitral valve, and jet area of MR. Myocardial contrast echocardiography was performed to evaluate perfusion of papillary muscle and to measure risk area during ligation of OM branches. RESULTS: 1)There was no significant difference in decrease of fractional area shortening between infusion of esmolol and ligation of OM branches, but the significant MR developed in only one dog during esmolol infusion (p=NS), and in four dogs during ligation of OM branches (p<0.05). 2)Ischemia of papillary muscle was provoked in none of group 1, but four of five dogs in group 2 (p<0.05). Ischemic MR developed in all four dogs with provocation of papillary muscle ischemia, but in none of six dogs with maintained perfusion of papillary muscle (p=0.005). 3)Only incomplete leaflet closure area was significantly related with the severity of ischemic MR (r=0.71, p<0.05). CONCLUSIONS: Ischemia of papillary muscle is the important etiologic factor in development of ischemic MR in acute posterior myocardial infarction. It will be useful to assess and restore the perfusion of papillary muscles for the treatment of ischemic MR.