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• W2006348565 abstract "Acute severe mitral insufficiency after myocardial infarction usually results from rupture of a papillary muscle, which should be treated on an emergency basis with mitral valve repair or replacement. In the case of acute postinfarction mitral regurgitation with intact papillary muscle, no consensus exists, even with regard to the indication for surgery. Restrictive mitral annuloplasty (RMA) has been applied in chronic ischemic mitral insufficiency, with encouraging midterm results.1Bolling S.F. Pagano F.D. Deeb G.M. Bach D.S. Intermediate-term out-come of mitral reconstruction in cardiomyopathy.J Thorac Cardiovasc Surg. 1998; 115: 381-388Abstract Full Text Full Text PDF PubMed Scopus (579) Google Scholar, 2Dion R. Benetis R. Elias B. Guennaoui T. Raphael D. van Dyck M. et al.Mitral valve procedures in ischemic regurgitation.J Heart Valve Dis. 1995; 4: S124-131PubMed Google Scholar In this report, we describe 2 patients in whom RMA was applied as a lifesaving procedure in the presence of refractory cardiogenic shock in postinfarction mitral insufficiency with intact papillary muscle. patient 1. A 55-year-old woman had an acute inferior wall infarction with cardiogenic shock. She received an intra-aortic balloon pump (IABP) and inotropes and was intubated. Coronary angiography revealed occlusion of the right coronary and circumflex arteries. Transesophageal echocardiography (TEE) showed grade 4 mitral insufficiency resulting from systolic restrictive motion of both leaflets (Carpentier type IIIb; Figure 1, Figure 2). The regurgitation jet was slightly eccentric because of the more restrictive posterior leaflet. Because of further hemodynamic deterioration, we decided to attempt correction of the mitral regurgitation as a lifesaving procedure.Figure 2Color Doppler echocardiographic imaging demonstrating grade mitral regurgitation resulting from systolic restriction with reduced coaptation. ECG, Electrocardiogram.View Large Image Figure ViewerDownload (PPT) During the operation, a fresh infarction of the posterolateral wall involving the posterior papillary muscle was observed. The subvalvular apparatus was intact, and there was no structural anomaly of the mitral valve leaflets. RMA was performed with a size 28 Carpentier-Edwards Physioring (Baxter Healthcare Corporation CardioVascular Group, Irvine, Calif), thereby downsizing the prosthetic ring by two sizes. Tentative revascularization of the circumflex and right coronary artery territory was performed with a sequential saphenous vein graft. The patient was weaned from extracorporeal circulation with inotropic support (epinephrine at 0.22 μg/kg/min, dobutamine at 15 μg/kg/min, dopamine at 8 μg/kg/min, and enoximon at 4 μg/kg/min). Intraoperative TEE showed trivial mitral regurgitation with a mean transvalvular mitral gradient of 3 mm Hg (mitral valve surface area >2 cm2) and a leaflet coaptation height of 9 mm. Troponin T rose to 22 μg/L on day 1. The IABP was removed after 8 days. The patient was discharged after 23 days. Nine months after surgery, she is in New York Heart Association functional class I, with no mitral insufficiency on echocardiographic follow-up. patient 2. A 69-year-old woman was referred because of hemodynamic deterioration 3 days after an inferior wall infarction. Coronary angiography revealed occlusion of the right coronary artery. During balloon angioplasty, the patient went into cardiogenic shock, was resuscitated, and received an IABP. Troponin T rose to 19 μg/L. TEE showed grade 4 mitral regurgitation as a result of restrictive leaflet motion in systole (Carpentier IIIb). Initially, hemodynamic stabilization was obtained with inotropes in addition to the IABP. Three weeks later, the patient could not yet be weaned from mechanical ventilation. She acquired gram-negative sepsis, and during exchange of the IABP catheter she suffered hemodynamic collapse and was again resuscitated. Apart from nonoliguric renal insufficiency, she had neither major organ dysfunction nor neurologic complications, but she required continuous administration of epinephrine at 0.20 μg/kg/min, dobutamine at 10 μg/kg/min, and enoximon at 2 μg/kg/min. In an attempt to overcome this deadlock situation, we decided to try to correct the mitral insufficiency 27 days after the initial infarction. We performed RMA with a size 26 (instead of 30) Physioring. The patient could then be weaned from extracorporeal circulation with the same inotropic support. Postoperative TEE showed no mitral insufficiency, with a mean transvalvular gradient of 2 mm Hg and a leaflet coaptation height of 9 mm. The postoperative course was uneventful. The IABP was removed on day 7. The patient was extubated after 20 days and was discharged after 32 days. Two months after surgery, she is in New York Heart Association functional class II, with grade 1 mitral insufficiency on echocardiography. Cardiogenic shock in the setting of postinfarction mitral insufficiency portends a poor prognosis, with approximately 55% in-hospital mortality in the SHOCK trial.3Thompson C.R. Buller C.E. Sleeper L.A. Antonelli T.A. Webb J.G. Jaber W.A. et al.Cardiogenic shock due to acute severe mitral regurgitation complicating acute myocardial infarction a report from the SHOCK trial registry.J Am Coll Cardiol. 2000; 36: 1104-1109Abstract Full Text Full Text PDF PubMed Scopus (199) Google Scholar Coronary revascularization with or without mitral valve surgery in that study showed a somewhat reduced but still high mortality of 40%, versus 71% in nonsurgically treated patients. Most patients who did not undergo surgery could not be stabilized and died. Thus the timing of surgery may be important in determining outcome, and early surgery before or immediately at the onset of cardiogenic shock might save lives. Our first patient underwent operation on an emergency basis. In the second case, initial stabilization allowed us to postpone surgery. The question as to whether mitral valve repair is preferable to replacement in acute ischemic mitral insufficiency is still unanswered. Grossi and colleagues4Grossi E.A. Goldberg J.D. LaPietra A. Ye X. Zakow P. Sussman M. et al.Ischemic mitral valve reconstruction and replacement comparison of long-term survival and complications.J Thorac Cardiovasc Surg. 2001; 122: 1107-1124Abstract Full Text Full Text PDF PubMed Scopus (282) Google Scholar and Gillinov and associates5Gillinov A.M. Wierup P.N. Blackstone E.H. Bishay E.S. Cosgrove D.S. White J. et al.Is repair preferable to replacement for ischemic mitral regurgitation?.J Thorac Cardiovasc Surg. 2001; 122: 1125-1141Abstract Full Text Full Text PDF PubMed Scopus (476) Google Scholar reported similar survivals after replacement versus repair in patients with complex and acute mitral regurgitation. However, preference of the operating surgeon certainly introduced selection bias in these retrospective studies. It has been established that preservation of the subvalvular apparatus positively influences postoperative left ventricular function. Therefore in cases where mitral valve surgery is proposed as a lifesaving procedure, we believe, as illustrated by the cases reported here, that a successful mitral valve repair is preferable, especially in the absence of papillary muscle rupture. In our hands RMA has proved its value in curing chronic ischemic mitral insufficiency by restoring an adequate height of leaflet coaptation.2Dion R. Benetis R. Elias B. Guennaoui T. Raphael D. van Dyck M. et al.Mitral valve procedures in ischemic regurgitation.J Heart Valve Dis. 1995; 4: S124-131PubMed Google Scholar Similarly, we believe that the stress in the subvalvular apparatus can also be reduced by this technique in acute cases, thereby decreasing the risk of postrepair rupture of the infarcted myocardium." @default.
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• W2006348565 title "Restrictive mitral annuloplasty in refractory cardiogenic shock with acute postinfarction mitral insufficiency and intact papillary muscle" @default.
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