Citations

Background The optimal timing for surgery in patients with mitral regurgitation is disputed. Because of the frequency of left ventricular dysfunction, which is difficult to predict, early surgery has been recommended, but its potential benefits have not been demonstrated. Methods and Results The outcomes of 221 patients (mean age, 65±13 years; 71% males) with flail leaflets diagnosed with two-dimensional echocardiography between 1980 and 1989 who were eligible for operation were analyzed. Group I comprised 63 patients who had early mitral valve surgery (within 1 month after diagnosis). Group II comprised 158 patients initially treated conservatively (80 of whom were operated on later). Group I patients were younger ( P =.009), had more symptoms ( P <.0001), and were more frequently in atrial fibrillation ( P =.023) than group II patients. There was no difference in ejection fraction between the groups. The early surgery strategy was followed by an improved overall survival rate ( P= .028) and a lower incidence of cardiovascular deaths ( P =.025), congestive heart failure ( P =.046), and new chronic atrial fibrillation ( P =.032), as confirmed by multivariate analysis (adjusted risk ratios of 0.31, 0.18, 0.38, and 0.05, respectively; all P< .02). Conclusions In patients with mitral regurgitation due to flail leaflets, the strategy of early surgery versus conservative management is associated with an improved long-term survival rate, decreased cardiac mortality, and decreased morbidity after diagnosis. This outcome advantage suggests that early surgery is a reasonable treatment option to be considered in low-risk candidates with repairable valves and severe mitral regurgitation.

BackgroundAortic valve replacement for aortic stenosis (AS) carries an increased risk in the presence of left ventricular (LV) systolic dysfunction. Few data are available on the outcome of such patients.Methods and ResultsBetween 1985 and 1992, 154 consecutive patients (107 men and 47 women) with LV systolic dysfunction (ejection fraction [EF] ≤35%) underwent aortic valve replacement for AS. The mean preoperative characteristics included EF, 27±6%; aortic valve mean gradient, 44±18 mm Hg; aortic valve area, 0.6±0.2 cm2; and cardiac output, 4.1±1.5 L/min. Simultaneous coronary artery bypass graft surgery was performed in 78 patients (51%). Perioperative (30-day) mortality was 9% (14 of 154 patients). Fifty patients died during follow-up. Coronary artery disease (P=.002) and a reduced preoperative cardiac output (P=.03) were significantly related to reduced overall survival rate by multivariate analysis. Postoperative improvement occurred in most patients; 88% were New York Heart Association class III or IV before surgery versus 7% after surgery. Postoperative EF was assessed in 76% of survivors; 76% of these demonstrated improvement. By multivariate analysis, change in EF was inversely related to coronary disease (P=.002) and preoperative aortic valve area (P=.03).ConclusionsDespite LV dysfunction, the risk of aortic valve replacement for AS was acceptable and related to coronary artery disease and mean aortic gradient, and long-term survival was related to coronary disease and cardiac output. Improvement in symptoms and EF occurred in most patients.

BackgroundA subgroup of patients with hypertrophic obstructive cardiomyopathy remain severely symptomatic despite optimal medical therapy. Septal myectomy reduces or eliminates left ventricular outflow obstruction and produces marked symptomatic improvement. With the recent advent of alternative methods for treatment of this disorder, such as dual-chamber pacing, it is necessary to establish the risks and benefits of septal myectomy in the modern surgical era.Methods and ResultsThe clinical, ECG, echocardiographic, cardiac catheterization, and surgical data were analyzed for 65 patients 20 to 70 years old with hypertrophic obstructive cardiomyopathy who had surgical treatment between 1986 and 1992. Specific symptoms and overall functional status were evaluated before surgery and at the end of the first postoperative year. Subsequent long-term clinical postoperative follow-up was also obtained. The extent of postoperative improvement was measured by the presence and severity of persistent symptoms, overall New York Heart Association (NYHA) functional class, and patients' self-perceptions of overall improvement. Of the patients, 95% were in NYHA functional class III or IV before surgery: 95% had dyspnea, 62% had angina, 63% had near-syncope, and 23% had syncope. The overall early mortality rate was 4.6%; there was no mortality among the 45 patients who underwent isolated septal myectomy. At the 1-year postoperative evaluation, 89% of survivors were in NYHA functional class I or II, and 47% believed that they had 100% improvement. Significant improvement (as defined) was seen in 67% of patients with dyspnea, 90% with angina, 86% with near-syncope, and 100% with syncope. The 5-year survival rate was 92%.ConclusionsThe results of the present study reaffirm the efficacy of surgical treatment of hypertrophic obstructive cardiomyopathy in patients who are severely symptomatic despite optimal medical therapy and serve as a useful reference by which the surgical approach can be compared with new and potentially promising treatment alternatives.

BackgroundIndications for surgical correction of aortic regurgitation have been established mostly in men and have not been validated in women. The outcome of this surgical correction in women is unknown.Methods and ResultsBaseline characteristics and postoperative outcomes were compared between 51 women and 198 men undergoing surgery for isolated aortic regurgitation between 1980 and 1989. Compared with men, women had surgery rarely for severe left ventricular enlargement (systolic diameter ≥55 mm in 11% versus 27%,P=.031; diastolic diameter ≥80 mm in 0% versus 16%,P<.0001) and more often for class III to IV symptoms (59% versus 32%,P<.0001). Operative mortalities were similar in women and men (3.9% and 4.5%, respectively). Among operative survivors, 10-year survival was worse for women than for men (39±9% versus 72±4%,P=.0002) and, in contrast with men, was worse than expected for women (P<.0001). Independent predictors of late survival were different for men (age and ejection fraction) and women (age and concomitant coronary bypass grafting). By multivariate analysis, female sex was an independent predictor of worse late survival (adjusted relative risk, 1.80; 95% CI, 1.04 to 3.11).ConclusionsThe generalization to women of the unadjusted left ventricular diameter surgical criteria established in men results in irrelevant criteria almost never reached in women, who often undergo surgery after developing severe symptoms. After surgery, women exhibit an excess late mortality, suggesting that surgical correction of aortic regurgitation should be considered at an earlier stage in women.

Background In patients with mitral regurgitation, surgical intervention produces immediate improvement in symptoms, but the long-term incidence and significance of postoperative congestive heart failure are unknown. Methods and Results The long-term outcome of 576 operative survivors of surgical correction of pure mitral regurgitation performed between 1980 and 1989 was analyzed. Survival was 77±2% and 56±3% at 5 and 10 years, respectively. Cumulative incidence of congestive heart failure was 23±2%, 33±3%, and 37±3% at 5, 10, and 14 years, respectively. Survival after the first episode of congestive heart failure was dismal, 44±4% at 5 years. Cause of congestive heart failure was left ventricular dysfunction in two thirds of the patients and valvular dysfunction in the other third. With multivariate analysis, the independent predictors of postoperative heart failure were preoperative ejection fraction ( P =.0001), coronary artery disease ( P =.0017), and New York Heart Association functional class ( P =.012), with borderline value for atrial fibrillation ( P =.10). The performance of valve repair was independently predictive of a lower incidence of the combined end point of death and heart failure ( P =.001), compared with valve replacement. Conclusions Congestive heart failure frequently occurs late after surgical correction of mitral regurgitation and portends dismal prognosis. This complication is due most often to left ventricular dysfunction; its main determinant is decreased left ventricular function preoperatively. These data should lead to earlier indication of surgical correction of mitral regurgitation, before left ventricular dysfunction occurs.

BackgroundIn patients with mitral valve prolapse, spontaneous changes of the effective regurgitant orifice during systole are not well documented. Such changes can now be analyzed by use of the proximal isovelocity surface area method, but the changes raise concern about the reliability of this method for assessing overall severity of regurgitation in these patients.Methods and ResultsIn a prospective study of 42 patients with mitral valve prolapse, the effective mitral regurgitant orifice was calculated at four phases of systole (early, mid, mid-late, and late) as the ratio of regurgitant flow to regurgitant velocity by use of the proximal isovelocity surface area method. Throughout systole, the effective regurgitant orifice increased significantly, from 32±27 mm2in early systole to 41±27 in midsystole, 55±30 in mid-late systole, and 107±66 mm2during late systole (P<.0001). Phasic regurgitant volume increased from early to mid-late systole but decreased in late systole. For quantitation of the overall effective regurgitant orifice, four approaches using the proximal isovelocity surface area were compared with simultaneously performed quantitative Doppler echocardiography (54±30 mm2) and quantitative two-dimensional echocardiography (51±29 mm2). All correlations were good (r>.95), but overestimation was considerable when the largest flow convergence was used (70±39 mm2; bothP<.0001), significant when the simple mean of the four phases was used (59±36 mm2;P=.005 andP=.0007, respectively), mild when a weighted mean of the four phases was used (55±33 mm2;P=.41 andP=.01, respectively), and no overestimation was observed when the effective regurgitant orifice calculated at maximum regurgitant velocity was used (54±30 mm2;P=.29 andP=.17, respectively).ConclusionsPhasic changes of mitral regurgitation are observed in patients with mitral valve prolapse. The effective regurgitant orifice increases throughout systole. Regurgitant volume also increases initially but tends to decrease in late systole. These changes can lead to overestimation of the overall degree of regurgitation, but properly timed measurements made by use of the proximal isovelocity surface area method allow an accurate estimation of the overall effective regurgitant orifice.

BackgroundMitral valve repair has been suggested as providing a better postoperative outcome than valve replacement for mitral regurgitation, but this impression has been obscured by differences in baseline characteristics and has not been confirmed in multivariate analyses.Methods and ResultsThe outcomes in 195 patients with valve repair and 214 with replacement for organic mitral regurgitation were compared using multivariate analysis. All patients had preoperative echocardiographic assessment of left ventricular function. Before surgery, patients with valve repair were less symptomatic than those with replacement (42% in New York Heart Association functional class I or II versus 24%, respectively;P=.001), had less atrial fibrillation (41% versus 53%;P=.017), and had a better ejection fraction (63±9% versus 60±12%,P=.016). After valve repair, compared with valve replacement, overall survival at 10 years was 68±6% versus 52±4% (P=.0004), overall operative mortality was 2.6% versus 10.3% (P=.002), operative mortality in patients under age 75 was 1.3% versus 5.7% (P=.036), and late survival (in operative survivors) at 10 years was 69±6% versus 58±5% (P=.018). Late survival after valve repair was not different from expected survival. After surgery, ejection fraction decreased significantly in both groups but was higher after valve repair (P=.001). Multivariate analysis indicated an independent beneficial effect of valve repair on overall survival (hazard ratio, 0.39;P=.00001), operative mortality (odds ratio, 0.27;P=.026), late survival (hazard ratio, 0.44;P=.001), and postoperative ejection fraction (P=.001).ConclusionsValve repair significantly improves postoperative outcome in patients with mitral regurgitation and should be the preferred mode of surgical correction. The low operative mortality is an incentive for early surgery before ventricular dysfunction occurs.

BACKGROUND Dilated cardiomyopathy is an important cause of morbidity and mortality among patients with congestive heart failure. Hemodynamic and prognostic characterization are critical in guiding selection of medical and surgical therapies. METHODS AND RESULTS A cohort of 102 patients with the clinical diagnosis of dilated cardiomyopathy who underwent echocardiographic examination between 1986 and 1990 was identified and followed up through July 1, 1991. Patients with moderate or severe symptoms had lower indices of systolic function and greater left atrial and right ventricular dilation. Mitral inflow Doppler signals were characterized by a restrictive left ventricular filling pattern. In multivariate logistic regression analysis, deceleration time, ejection fraction, and peak E velocity were independently associated with symptom status. Over a mean follow-up of 36 months, 35 patients died. Kaplan-Meier estimated survival at 1, 2, and 4 years was 84%, 73%, and 61%, respectively, and was significantly poorer than that of an age- and sex-matched population. The subgroup with an ejection fraction < 0.25 and deceleration time < 130 milliseconds had a 2-year survival of only 35%. The subgroup with ejection fraction < 0.25 and deceleration time > 130 milliseconds had an intermediate 2-year survival of 72%, whereas patients with an ejection fraction > or = 0.25 had 2-year survivals > or = 95% regardless of deceleration time. In multivariate analysis, ejection fraction and systolic blood pressure were independently predictive of subsequent mortality. Mitral deceleration time was significant in univariate analysis. CONCLUSIONS In patients with the clinical diagnosis of dilated cardiomyopathy, markers of diastolic dysfunction correlated strongly with congestive symptoms, whereas variables of systolic function were the strongest predictors of survival. Consideration of both ejection fraction and deceleration time allowed identification of subgroups with divergent long-term prognoses.

BACKGROUND Left ventricular dysfunction is a frequent cause of death after successful surgical repair of mitral regurgitation. The role of preoperative echocardiographic left ventricular variables in the prediction of postoperative survival and thus their clinical implications remain uncertain. METHODS AND RESULTS The survival of 409 patients operated on between 1980 and 1989 for pure, isolated, organic mitral regurgitation and with a preoperative echocardiogram (within 6 months of operation) was analyzed. The overall survival was 75% at 5 years (90% of expected), 58% at 10 years (88% of expected), and 44% at 12 years (73% of expected). Operative mortality was 6.6% and markedly improved from 1980 to 1984 (10.7%) to 1985 to 1989 (3.7%). Multivariate analysis showed that age (P = .0003), date of operation (P = .003), and functional class (P = .016) but not left ventricular function were predictors of operative mortality. In the most recent period (1985 to 1989), operative mortality was 12.3% in patients age 75 years or older and 1.1% in patients younger than 75 years. Late survival was analyzed in the operative survivors. Multivariate analysis showed that the most powerful predictor was echocardiographic ejection fraction (EF) (P = .0004), followed by age (P = .0031), creatinine level (P = .0062), systolic blood pressure (P = .0164), and presence of coronary artery disease (P = .0237). The late survival at 10 years was 32 +/- 12% for patients with EF < 50%, 53 +/- 9% for EF 50% to 60%, and 72 +/- 4% for EF > or = 60%. The hazard ratio compared with EF > or = 60% was 2.79 (95% confidence interval, 1.65 to 4.72) for EF < 50% and 1.81 (95% confidence interval, 1.11 to 2.95) for EF 50% to 60%. Echocardiographic EF remained the best predictor of late survival, even when combined with left ventricular angiographic variables. The survival of patients with EF > or = 60% was 100% of expected at 10 years but was better in patients in class I or II than in those in class III or IV (82 +/- 6% versus 59 +/- 6%, respectively, at 10 years; P = .0021). The preoperative predictors of operative and late mortality remained significant independent of the type of surgical correction performed in combined multivariate analyses. CONCLUSIONS In organic mitral regurgitation, (1) operative mortality has markedly decreased recently, being at a low 1.1% in patients younger than 75 years, and is predicted by age and symptoms and not by left ventricular function, and (2) left ventricular EF measured by echocardiography is the most powerful predictor of late survival. These results suggest that surgical treatment should be considered early, even in the absence of severe symptoms, in patients with severe mitral regurgitation, before left ventricular dysfunction occurs.

Background —Myocardial infarction (MI) can directly cause ischemic mitral regurgitation (IMR), which has been touted as an indicator of poor prognosis in acute and early phases after MI. However, in the chronic post-MI phase, prognostic implications of IMR presence and degree are poorly defined. Methods and Results —We analyzed 303 patients with previous (>16 days) Q-wave MI by ECG who underwent transthoracic echocardiography: 194 with IMR quantitatively assessed in routine practice and 109 without IMR matched for baseline age (71±11 versus 70±9 years, P =0.20), sex, and ejection fraction (EF, 33±14% versus 34±11%, P =0.14). In IMR patients, regurgitant volume (RVol) and effective regurgitant orifice (ERO) area were 36±24 mL/beat and 21±12 mm 2 , respectively. After 5 years, total mortality and cardiac mortality for patients with IMR (62±5% and 50±6%, respectively) were higher than for those without IMR (39±6% and 30±5%, respectively) (both P <0.001). In multivariate analysis, independently of all baseline characteristics, particularly age and EF, the adjusted relative risks of total and cardiac mortality associated with the presence of IMR (1.88, P =0.003 and 1.83, P =0.014, respectively) and quantified degree of IMR defined by RVol ≥30 mL (2.05, P =0.002 and 2.01, P =0.009) and by ERO ≥20 mm 2 (2.23, P =0.003 and 2.38, P =0.004) were high. Conclusions —In the chronic phase after MI, IMR presence is associated with excess mortality independently of baseline characteristics and degree of ventricular dysfunction. The mortality risk is related directly to the degree of IMR as defined by ERO and RVol. Therefore, IMR detection and quantification provide major information for risk stratification and clinical decision making in the chronic post-MI phase.