End-stage cardiomyopathy and secondary mitral insufficiency surgical alternative with prosthesis implant and left ventricular restoration.

ABSTRACT

BACKGROUND: Secondary mitral insufficiency is a strong risk factor for death in end-stage cardiomyopathy. The possible correction of mitral regurgitation has now been accepted as an alternative to cardiac transplantation in a special subset of patients. We propose a new surgical approach that consists of implantation of a mitral prosthesis that is smaller than the annulus, and preservation and traction of the papillary muscles to reduce sphericity of the left ventricle. METHODS: Between December 1995 and September 2005, 116 patients with dilated cardiomyopathy underwent this procedure, with the following etiologic factors ischemic (68), idiopathic (43), Chagas disease (3), viral (1), and postpartum (1). The patients were analyzed according to clinical criteria, echocardiographic findings, and morphology of left ventricle. RESULTS: All patients were in an end-stage phase, requiring >2 hospital admissions over the past 3 months, despite receiving full medication. Furthermore, seven were in intensive care unit receiving intravenous drugs or intra-aortic balloon counterpulsation, and one was in cardiogenic shock. Hospital mortality was 16.3% (19/116), yet midterm follow-up showed a relatively flat late survival curve, with evidence of improved clinical status, better echocardiographic parameters, and reduction in ventricular sphericity. CONCLUSIONS: The high early mortality rate related to other clinical conditions at the time of surgery. However, the resultant flat survival after this early interval offers a promising long-term therapeutic alternative for the treatment of patients in refractory heart failure with cardiomyopathy that is associated with moderate or severe secondary mitral regurgitation.