Circulation, Vol 89, 191-197, Copyright © 1994 by American Heart Association
T Wisenbaugh, D Skudicky and P Sareli
BACKGROUND: Noninvasive predictors of important outcomes after valve
replacement for mitral regurgitation have not been examined in a rheumatic
population (in whom the results of valve repair are suboptimal) in the era
of chordal preservation. Timing of valve replacement thus remains a
difficult question in rheumatic mitral regurgitation. METHODS AND RESULTS:
Of 278 patients followed after valve replacement, 66 had pure or
predominant mitral regurgitation, and in 61 of these the etiology was
rheumatic. The mean age was 24 years. After a mean follow-up of 24 +/- 10
months, the ability of preoperative clinical and echocardiographic data to
predict outcome was assessed prospectively, and the possible impact of
chordal preservation (n = 35) on survival and post-operative left
ventricular function was examined retrospectively. There were no
perioperative deaths. There were six postoperative deaths, all the result
of heart failure and all related to left ventricular dysfunction. The mean
probability of survival was .90 at 16 months. In a stepwise Cox
proportional hazards regression analysis, the only independent predictor of
postoperative death was preoperative end-systolic diameter. According to a
logistic model, the probabilities of death (n = 6) and death or severe
heart failure (n = 7) increased abruptly at a preoperative end-systolic
diameter of 51 mm (probabilities, .23 and .31, respectively), and the
accuracy of this cut point for predicting outcomes was 97% and 98%,
respectively. Multiple linear regression analysis identified a large
preoperative end- systolic diameter and the need to use tricuspid
annuloplasty as significant independent predictors of postoperative
fractional shortening; the use of chordal preservation (n = 35) was not a
predictor of postoperative fractional shortening. A good outcome was
predicted at a preoperative end-systolic diameter of 40 mm: probability of
death or heart failure was .0001, and predicted mean postoperative
fractional shortening was 0.27 after mitral valve replacement without
tricuspid annuloplasty. CONCLUSIONS: When preoperative end-systolic
diameter is more than 50 mm, a poor postoperative outcome is predicted
despite chordal preservation in relatively young patients with rheumatic
mitral regurgitation, and alternative strategies should therefore be
considered. When preoperative end-systolic diameter is 40 mm or less, an
excellent outcome is predicted, and close observation without surgery would
appear to be reasonable in the absence of symptoms.
ARTICLES
Prediction of outcome after valve replacement for rheumatic mitral regurgitation in the era of chordal preservation
Cardiology Department, Baragwanath Hospital, Johannesburg, South Africa.
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