Circulation, Vol 86, 1718-1726, Copyright © 1992 by American Heart Association
JD Rozich, BA Carabello, BW Usher, JM Kratz, AE Bell and MR Zile
BACKGROUND. Standard mitral valve replacement (MVR) in patients with
chronic mitral regurgitation consistently results in a decrease in
postoperative left ventricular (LV) ejection performance. This fall in
ejection performance has been attributed, at least in part, to unfavorable
loading conditions imposed by the elimination of the low- impedance pathway
for LV emptying into the left atrium. In contrast to standard MVR in which
the chordae tendineae are severed, however, MVR with chordal preservation
(MVR-CP) does not usually decrease LV ejection performance despite similar
removal of the low-impedance pathway. The purpose of the present study was
to define the mechanisms responsible for this discordance in postoperative
ejection performance between MVR with and without chordal preservation.
METHODS AND RESULTS. Echocardiography and sphygmomanometer blood pressures
were obtained in 15 patients with pure chronic mitral regurgitation before
and 7-10 days after mitral valve surgery. These measurements were used to
calculate ventricular volume, wall stress, and ejection fraction. Seven
patients underwent MVR with chordal transection (MVR-CT), and eight
patients underwent MVR-CP. MVR-CT resulted in no postoperative change in LV
end- diastolic volume, a significant increase in LV end-systolic volume, a
significant increase in end-systolic stress, from 89 +/- 9 to 111 +/- 12
g/cm2 (p < 0.05), and a significant decrease in ejection fraction, from
0.60 +/- 0.02 to 36 +/- 0.02 (p < 0.05). In contrast, patients who
underwent MVR-CP had a significant decrease in LV end-diastolic and end-
systolic volumes. End-systolic wall stress actually fell from 95 +/- 6 to
66 +/- 6 g/cm2 (p < 0.05), and ejection fraction was unchanged (0.63 +/-
0.01 before and 0.61 +/- 0.02 after mitral valve surgery) instead of
reduced. CONCLUSIONS. MVR-CT resulted in a decrease in ejection performance
caused in part by an increase in end-systolic stress, which in turn
increased end-systolic volume. Conversely, MVR-CP resulted in a smaller LV
size, allowing a reduced end-systolic stress and preservation of ejection
performance despite closure of the low- impedance left atrial ejection
pathway.
ARTICLES
Mitral valve replacement with and without chordal preservation in patients with chronic mitral regurgitation. Mechanisms for differences in postoperative ejection performance
Department of Medicine, Medical University of South Carolina, Charleston 29525.
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