Mitral valve repair in patients with low left ventricular ejection fractions: early and late results.

STUDY OBJECTIVES: This retrospective study was performed to examine the outcome of mitral valve repair (ie, mitral valvuloplasty [MVP]) in relation to preoperative low left ventricular ejection fraction (LVEF). DESIGN AND SETTINGS: From our series of 338 consecutive patients who underwent MVP between 1983 and 2001, we compared the course of 302 patients with preoperative LVEF of > 35% (group I) to that of 36 patients with LVEF of

Nonresectional repair of the barlow mitral valve: importance of dynamic annular evaluation.

BACKGROUND: The most extensive form of myxomatous degeneration of the mitral valve causing severe mitral regurgitation is "Barlow disease." Surgical repair of this condition has been considered difficult because of the extent and magnitude of annular, leaflet, and chordal abnormalities and has usually involved partial resection of one or both mitral leaflets. METHODS: A surgical approach has been developed which does not involve leaflet resection. Instead, by means of precise dynamic annular sizing, a predetermined zone of leaflet apposition is achieved. The leaflets are positioned so that their large area is contained within the left ventricle. Normal annular, leaflet, and papillary muscle dynamic function is restored. RESULTS: This procedure was performed in 61 patients. The repair rate was 100%. The mean age was 57.6 +/- 12.7 years. They were 67.2% male. The preoperative anteroposterior annular dimension was 52.1 +/- 4.3 mm. The full, flexible complete ring size was 33.4 +/- 1.9 mm. There was no perioperative mortality. There was no systolic anterior leaflet motion. All patients were discharged with no or mild mitral regurgitation. At a follow-up interval of 1.2 +/- 2.1 years one patient had developed recurrent mitral regurgitation, secondary to marked remodeling to normal left ventricular function. CONCLUSIONS: Initial experience with a nonresectional approach for Barlow disease has produced good early results.

Feasibility and intermediate term outcome of repair of prolapsing anterior mitral leaflets with artificial chordal replacement in 152 patients.

BACKGROUND: Mitral valve repair of the anterior leaflet has been more difficult than at other sites. METHODS: Between February 1983 and June 2004, 607 mitral valve repairs were performed on one service. Of these, 410 patients had leaflet repair procedures: 152 were anterior leaflet repairs; isolated in 94, and combined with posterior repair in 58 patients. The results in these patients were compared with the results of posterior leaflet repair in 258 patients. All patients received flexible ring annuloplasty. RESULTS: Age and sex of the anterior leaflet and posterior leaflet patients were similar: mean age 62.5 +/- 14.3, 62.9 +/- 14.9 years; males, 50.6%, p = not significant (NS). Preoperative ejection fraction was for anterior repairs 52.6 +/- 12.8%; posterior repair, 58.2 +/- 11.8%, p = NS. Coronary artery bypass was more frequently performed with anterior leaflet repair in 18 patients (19.1%) versus 45 (6.6%) for posterior leaflet repair (p = NS). The median number of chordae was similar in the anterior leaflet and posterior leaflet patients 4 (2-8), 4 (2-6), p = NS. Perioperative mortality was similar: anterior leaflet patients, 3.3% (2/94); posterior leaflet patients, 1.1% (2/258), p = NS. Hospital stay was for anterior leaflet patients and posterior leaflet patients: 12.86 +/- 13.3 vs 11.0 +/- 12.3, p = NS. Kaplan-Meier estimates of freedom from reoperation at 3 years were: for anterior leaflet patients, 91.9%: for posterior leaflet patients, 90.7%, p = 0.77. No structural polytetrafluoroethylene (PTFE) chordal failures were observed. Late echocardiographic data were obtained in 136 patients on 222 occasions at a mean of 3.2 +/- 3.34 years. Severe mitral regurgitation was present in 10 patients (7.3%). CONCLUSIONS: Repair of the anterior leaflet is facilitated by the use of PTFE replacement. Anterior leaflet repair can be performed reproducibly with the same results as posterior leaflet repair.

Long-term results of coronary artery bypass grafting in patients with ischemic cardiomyopathy: the impact of renal insufficiency and noncardiac vascular disease.

BACKGROUND: We examined outcomes of patients with ischemic cardiomyopathy (ICMP), defined by left ventricular ejection fraction (LVEF) <35%, compared with patients with better-preserved LVEF, undergoing coronary bypass graft surgery (CABG). In addition, we examined the relative impact of a reduced LVEF in comparison with other comorbidities on long-term mortality in these patients. METHODS AND RESULTS: We evaluated 1381 patients (114 with ICMP, 1267 with better-preserved LVEF) who underwent isolated CABG at a tertiary Veterans Administration (VA) hospital between 1990 and 2000 using data from the VA Continuous Improvement in Cardiac Surgery Program and other VA databases. The 5-year survival was 74.0% in patients with ICMP and 84.4% in the group with better-preserved LVEF ( p = .005). LVEF <35% remained a significant predictor of long-term mortality in multivariable models (hazard ratio [HR] 1.55, 95% confidence interval [CI] 1.02-2.35). However, the presence of comorbidities, especially renal insufficiency, peripheral vascular disease, and cerebrovascular disease, had a similar or greater impact on long-term mortality. Renal insufficiency (serum creatinine >1.5 mg/dL) was associated with the highest risk of long-term mortality (HR 2.02, 95% CI 1.46-2.80). The use of a left internal thoracic artery graft reduced the risk of long-term mortality (HR 0.72, 95% CI 0.54-0.98). CONCLUSION: Even though severely depressed LVEF is associated with an increased risk of long-term mortality, the presence of comorbid factors, especially renal dysfunction and noncardiac vascular disease, increase the risk of long-term mortality by a similar or even larger magnitude. These comorbid factors should be given important consideration when evaluating the risks and benefits of CABG.

Participant recruitment and motivation for participation in optical technology for cervical cancer screening research trials.

In order to improve recruitment for cervical cancer screening trials, it is necessary to analyze the effectiveness of recruitment strategies used in current trials. A trial to test optical spectroscopy for the diagnosis of cervical neoplasia recruited 1000 women from the community; the trial evaluated the emerging technology against Pap smears and colposcopically directed biopsies for cervical dysplasia. We have examined women's reasons for participating as well as the effectiveness and efficiency for each recruitment strategy. Reasons for participation were identified and compared between trials. The recruitment method that resulted in the most contacts was newspaper reportorial coverage and advertising, followed by family and friends, then television news coverage. The most cost-effective method for finding eligible women who attend the research appointment is word of mouth from a family member or friend. Recommendations are given for maximizing the efficiency of recruitment for cervical cancer screening trials.