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November 18, 1988, Vol 260, No. 19 >
ARTICLE | November 18, 1988

Surgery for Mitral Regurgitation FREE

Lawrence H. Cohn, MD
[+] Author Affiliations

Reprint requests to Division of Cardiac Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115 (Dr Cohn).


JAMA. 1988;260(19):2883-2887. doi:10.1001/jama.1988.03410190131036
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Article
References

Mitral regurgitation is a valvular heart lesion that is difficult to diagnose accurately; thus, it is difficult to determine the appropriate timing for surgical correction. With increasing use of reparative techniques, including local resection of valve pathology and placement of an annuloplasty ring, and the realization that chronic atrial fibrillation leads to decreased long-term survival, the timing of surgery has changed. In addition, serial noninvasive studies have indicated that despite the absence of symptoms, patients may progress to a myopathic condition if the regurgitation progresses over a long period and surgery is not performed when signs of left ventricular dysfunction are evident. Preservation of the papillary muscle is also extremely important for late postoperative function in patients with mitral regurgitation, and reparative surgery that preserves both anterior and posterior papillary muscle complexes and continuity with the anulus appears to satisfy this assumption. Worldwide experience is reviewed and I present conclusions related to the appropriate indications for mitral valve repair or replacement in patients with mitral regurgitation.

(JAMA 1988;260:2883-2887)

REFERENCES

1 +
Lillehei CW, Gott VL, De Wall RA, et al:  Surgical correction of pure mitral insufficiency by annuloplasty under direct vision . Lancet 1957;;2:446-449.
2 +
Merendino KA, Bruce RA:  One hundred seventeen surgically treated cases of valvular rheumatic heart disease with preliminary report of two cases of mitral regurgitation treated under direct vision with aid of a pump-oxygenator . JAMA 1957;; 164:749-754.
3 +
Wooler GH, Nixon PGF, Crunshaw VA, et al:  Experience with the repair of the mitral valve in mitral incompetence . Thorax 1962;;17:49-55.
4 +
Reed GE, Tice DA, Clauss RH:  Asymmetric exaggerated mitral annuloplasty: Repair of mitral insufficiency with hemodynamic predictability . J Thorac Cardiovasc Surg 1965;;49:752-761.
5 +
Kay JH, Tsuji HK, Reddington JV:  Surgical treatment of mitral insufficiency asociated with torn chordae tendinae . Ann Thorac Surg 1965;; 1:269-274.
6 +
McGoon DC:  Repair of mitral valve insufficiency due to ruptured chordae tendinae . J Thorac Cardiovasc Surg 1960;;39:357-362.
7 +
Cohn LH, Allred EN, Cohn LA, et al:  Early and late risk of mitral valve replacement . J Thorac Cardiovasc Surg 1985;;90:872-881.
8 +
Angell WW, Oury JH, Shah P:  A comparison of replacement and reconstruction in patients with mitral regurgitation . J Thorac Cardiovasc Surg 1987;;93:665.
9 +
Perier P, Deloche A, Chauvaud S, et al:  Comparative evaluation of mitral valve repair and replacement with Starr, Bjork and porcine valve prostheses . Circulation 1984;;70( (suppl 2) ):187-192.
10 +
Carpentier A, Chauvaud S, Fabiani JN, et al:  Reconstructive surgery of mitral incompetence: Ten-year appraisal . J Thorac Cardiovasc Surg 1980;;79:338-348.
11 +
Duran CG, Pomer JL, Revuelta JM, et al:  Conservative operation for mitral insufficiency: Critical analysis supported by postoperative hemodynamic studies in 72 patients . J Thorac Cardiovasc Surg 1980;;79:326-337.
12 +
Murphy JP Jr, Sweeney MS, Cooley DA:  The Puig-Massana-Shiley annuloplasty ring for mitral valve repair: Experience in 126 patients . Ann Thorac Surg 1987;;43:52-58.
13 +
Bonchek LI, Olienger GN, Siegel RD, et al:  Left ventricular performance after mitral reconstruction for mitral regurgitation . J Thorac Cardiovasc Surg 1984;;88:122-127.
14 +
David TE, Ho WC:  The effect of preservation of chordae tendinae on mitral valve replacement for postinfarction mitral regurgitation . Circulation 1986;;74( (suppl 1) ):116-120.
15 +
David TE, Uden DE, Strauss HD:  The importance of the mitral apparatus in left ventricular function after correction of mitral regurgitation . Circulation 1983;;68( (suppl 2) ):76-82.
16 +
Hansen DE, Cahill PD, Derby GC, et al:  Relative contributions of the anterior and posterior mitral chordae tendinae to canine global left ventricular systolic function . J Thorac Cardiovasc Surg 1987;;93:45-55.
17 +
Salter DR, Pellom GL, Murphy CE, et al:  Papillary-annular continuity and left ventricular systolic function after mitral valve replacement . Circulation 1986;;74( (suppl 1) ):121-129.
18 +
Hansen DE, Cahill PD, DeCampli WM, et al:  Valvular-ventricular interaction: Importance of the mitral apparatus in canine left ventricular systolic performance . Circulation 1986;;73:1310-1320.
19 +
Spence PA, Peniston CM, David TE, et al:  Toward a better understanding of the etiology of left ventricular dysfunction after mitral valve replacement: An experimental study with possible clinical implications . Ann Thorac Surg 1986;;41:363-371.
20 +
Roberts AJ: Myocardial Protection in Cardiac Surgery . New York, Marcel Dekker Inc, 1987;.
21 +
Lillehei CW, Levy MJ, Bonnabeau RC:  Mitral valve replacement with preservation of papillary muscles and chordae tendinae . J Thorac Cardiovasc Surg 1964;;47:532-543.
22 +
Cohn LH, Reis RL, Morrow AG:  Left ventricular function following mitral valve replacement: The effect of excision of the chordae tendinae and papillary muscles . J Thorac Cardiovasc Surg 1968;;56:11-15.
23 +
Rastelli GC, Tsakinis AG, Bonchero N, et al:  Cardiac performance after replacement of the dog mitral valve with Starr-Edwards prosthesis with and without preservation of the chordae tendinae . Surg Forum 1966;;17:178-179.
24 +
Kirklin JW:  Replacement of the mitral valve for mitral valve incompetence . Surgery 1972;; 72:827-836.
25 +
Goldman ME, Mora F, Guarino T, et al:  Mitral valvuloplasty is superior to valve replacement for preservation of left ventricular function: An intraoperative two-dimensional echocardiographic study . J Am Coll Cardiol 1987;;10:568-575.
26 +
Cohn LH, Kowalker W, Bhatia S, et al:  Comparative morbidity of mitral valve repair vs. replacement of mitral regurgitation with and without coronary artery disease . Ann Thorac Surg 1988;;45:284-290.
27 +
Grossman W:  Aortic and mitral regurgitation . JAMA 1984;;252:2447-2449.
28 +
Gaasch WH, Levine HJ, Zile MR:  Chronic aortic and mitral regurgitation: Mechanical consequences of the lesion and the results of surgical correction , in The Ventricle: Basic and Clinical Aspects . Boston, Martinus Nijhoff, 1985;, pp 237-258.
29 +
Hickey AJ, Wilcken DEL, Wright JS, et al:  Primary spontaneous chordal rupture: Relation to myxomatous valve disease and mitral valve prolapse . J Am Coll Cardiol 1985;;5:1341-1346.
30 +
Nishimura RA, McGoon MD, Shub C, et al:  Echocardiographically documented mitral-valve prolapse . N Engl J Med 1985;;313:1305-1309.
31 +
Gajewski J, Singer RB:  Mortality in an insured  population with atrial fibrillation. JAMA 1981; 245:1540-1544.
32 +
Kannel WB, Abbott RD, Savage DO, et al:  Epidemiologic features of chronic atrial fibrillation . N Engl J Med 1982;;306-310:
33 +
Betrin A, Chaitman BR, Aleazan A, et al:  Preoperative determinants of return to sinus rhythm after valve replacement , in Cohn LH, Gallucci V (eds): Cardiac Bioprosthesis . New York, Yorke Medical Books, 1982;, pp 184-191.
34 +
Yacoub M, Halim M, Radley-Smith R, et al:  Surgical treatment of mitral regurgitation caused by floppy valves: Repair versus replacement . Circulation 1981;;64( (suppl 2) ):210-216.
35 +
Buda AJ, Zotz RJ, LeMire MS, et al:  Prognostic significance of vegetations detected by two-dimensional echocardiography in infective endocarditis . Am Heart J 1986;;112:1291-1296.
36 +
Cosgrove DM, Chavez AM, Lytle BW:  Results of mitral valve reconstruction . Circulation 1986;; 74( (suppl 1) ):82-87.
37 +
Spencer FC, Colvin SG, Collifort AT, et al:  Experiences with the Carpentier technique of mitral valve reconstruction in 103 patients . J Thorac Cardiovasc Surg 1985;;90:341-350.
38 +
Sand ME, Naftel DC, Blackstone EH, et al:  A comparison of repair and replacement for mitral valve incompetence . J Thorac Cardiovasc Surg 1987;;94:208-219.
39 +
Angell WW, Oury JH, Shah P:  A comparison of replacement and reconstruction in patients with mitral regurgitation . J Thorac Cardiovasc Surg 1987;;93:665-674.
40 +
Antunes MJ, Colsen PR, Kinsley RH:  Mitral valvuloplasty: A learning curve . Circulation 1983;;68( (suppl 2) ):70-75.
41 +
Kriendel MS, Schiavone WA, Lever HM, et al:  Systolic anterior motion of the mitral valve after Carpentier ring valvuloplasty for mitral valve prolapse . Am J Cardiol 1986;;57:408-412.
42 +
Galler M, Kronzon I, Slater J, et al:  Long-term followup after mitral valve reconstruction: incidence of postoperative left ventricular outflow obstruction . Circulation 1986;;74( (suppl 1) ):99-103.
43 +
Chauvaud SM, Deleuze P, Perier PM, et al:  Failures in reconstructive mitral valve surgery, abstracted . Circulation 1986;;74( (suppl 2) ):393.
44 +
Kenny J, Cohn LH, Collins JJ, et al:  Noninvasive assessment of mitral valvuloplasty . Cardiol Board Rev 1987;;4:75-82.
45 +
Oury JH, Grehl TM, Lamberti JJ, et al:  Mitral valve regurgitation . J Cardiac Surg 1986;;1:217-231.

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1 +
Lillehei CW, Gott VL, De Wall RA, et al:  Surgical correction of pure mitral insufficiency by annuloplasty under direct vision . Lancet 1957;;2:446-449.
2 +
Merendino KA, Bruce RA:  One hundred seventeen surgically treated cases of valvular rheumatic heart disease with preliminary report of two cases of mitral regurgitation treated under direct vision with aid of a pump-oxygenator . JAMA 1957;; 164:749-754.
3 +
Wooler GH, Nixon PGF, Crunshaw VA, et al:  Experience with the repair of the mitral valve in mitral incompetence . Thorax 1962;;17:49-55.
4 +
Reed GE, Tice DA, Clauss RH:  Asymmetric exaggerated mitral annuloplasty: Repair of mitral insufficiency with hemodynamic predictability . J Thorac Cardiovasc Surg 1965;;49:752-761.
5 +
Kay JH, Tsuji HK, Reddington JV:  Surgical treatment of mitral insufficiency asociated with torn chordae tendinae . Ann Thorac Surg 1965;; 1:269-274.
6 +
McGoon DC:  Repair of mitral valve insufficiency due to ruptured chordae tendinae . J Thorac Cardiovasc Surg 1960;;39:357-362.
7 +
Cohn LH, Allred EN, Cohn LA, et al:  Early and late risk of mitral valve replacement . J Thorac Cardiovasc Surg 1985;;90:872-881.
8 +
Angell WW, Oury JH, Shah P:  A comparison of replacement and reconstruction in patients with mitral regurgitation . J Thorac Cardiovasc Surg 1987;;93:665.
9 +
Perier P, Deloche A, Chauvaud S, et al:  Comparative evaluation of mitral valve repair and replacement with Starr, Bjork and porcine valve prostheses . Circulation 1984;;70( (suppl 2) ):187-192.
10 +
Carpentier A, Chauvaud S, Fabiani JN, et al:  Reconstructive surgery of mitral incompetence: Ten-year appraisal . J Thorac Cardiovasc Surg 1980;;79:338-348.
11 +
Duran CG, Pomer JL, Revuelta JM, et al:  Conservative operation for mitral insufficiency: Critical analysis supported by postoperative hemodynamic studies in 72 patients . J Thorac Cardiovasc Surg 1980;;79:326-337.
12 +
Murphy JP Jr, Sweeney MS, Cooley DA:  The Puig-Massana-Shiley annuloplasty ring for mitral valve repair: Experience in 126 patients . Ann Thorac Surg 1987;;43:52-58.
13 +
Bonchek LI, Olienger GN, Siegel RD, et al:  Left ventricular performance after mitral reconstruction for mitral regurgitation . J Thorac Cardiovasc Surg 1984;;88:122-127.
14 +
David TE, Ho WC:  The effect of preservation of chordae tendinae on mitral valve replacement for postinfarction mitral regurgitation . Circulation 1986;;74( (suppl 1) ):116-120.
15 +
David TE, Uden DE, Strauss HD:  The importance of the mitral apparatus in left ventricular function after correction of mitral regurgitation . Circulation 1983;;68( (suppl 2) ):76-82.
16 +
Hansen DE, Cahill PD, Derby GC, et al:  Relative contributions of the anterior and posterior mitral chordae tendinae to canine global left ventricular systolic function . J Thorac Cardiovasc Surg 1987;;93:45-55.
17 +
Salter DR, Pellom GL, Murphy CE, et al:  Papillary-annular continuity and left ventricular systolic function after mitral valve replacement . Circulation 1986;;74( (suppl 1) ):121-129.
18 +
Hansen DE, Cahill PD, DeCampli WM, et al:  Valvular-ventricular interaction: Importance of the mitral apparatus in canine left ventricular systolic performance . Circulation 1986;;73:1310-1320.
19 +
Spence PA, Peniston CM, David TE, et al:  Toward a better understanding of the etiology of left ventricular dysfunction after mitral valve replacement: An experimental study with possible clinical implications . Ann Thorac Surg 1986;;41:363-371.
20 +
Roberts AJ: Myocardial Protection in Cardiac Surgery . New York, Marcel Dekker Inc, 1987;.
21 +
Lillehei CW, Levy MJ, Bonnabeau RC:  Mitral valve replacement with preservation of papillary muscles and chordae tendinae . J Thorac Cardiovasc Surg 1964;;47:532-543.
22 +
Cohn LH, Reis RL, Morrow AG:  Left ventricular function following mitral valve replacement: The effect of excision of the chordae tendinae and papillary muscles . J Thorac Cardiovasc Surg 1968;;56:11-15.
23 +
Rastelli GC, Tsakinis AG, Bonchero N, et al:  Cardiac performance after replacement of the dog mitral valve with Starr-Edwards prosthesis with and without preservation of the chordae tendinae . Surg Forum 1966;;17:178-179.
24 +
Kirklin JW:  Replacement of the mitral valve for mitral valve incompetence . Surgery 1972;; 72:827-836.
25 +
Goldman ME, Mora F, Guarino T, et al:  Mitral valvuloplasty is superior to valve replacement for preservation of left ventricular function: An intraoperative two-dimensional echocardiographic study . J Am Coll Cardiol 1987;;10:568-575.
26 +
Cohn LH, Kowalker W, Bhatia S, et al:  Comparative morbidity of mitral valve repair vs. replacement of mitral regurgitation with and without coronary artery disease . Ann Thorac Surg 1988;;45:284-290.
27 +
Grossman W:  Aortic and mitral regurgitation . JAMA 1984;;252:2447-2449.
28 +
Gaasch WH, Levine HJ, Zile MR:  Chronic aortic and mitral regurgitation: Mechanical consequences of the lesion and the results of surgical correction , in The Ventricle: Basic and Clinical Aspects . Boston, Martinus Nijhoff, 1985;, pp 237-258.
29 +
Hickey AJ, Wilcken DEL, Wright JS, et al:  Primary spontaneous chordal rupture: Relation to myxomatous valve disease and mitral valve prolapse . J Am Coll Cardiol 1985;;5:1341-1346.
30 +
Nishimura RA, McGoon MD, Shub C, et al:  Echocardiographically documented mitral-valve prolapse . N Engl J Med 1985;;313:1305-1309.
31 +
Gajewski J, Singer RB:  Mortality in an insured  population with atrial fibrillation. JAMA 1981; 245:1540-1544.
32 +
Kannel WB, Abbott RD, Savage DO, et al:  Epidemiologic features of chronic atrial fibrillation . N Engl J Med 1982;;306-310:
33 +
Betrin A, Chaitman BR, Aleazan A, et al:  Preoperative determinants of return to sinus rhythm after valve replacement , in Cohn LH, Gallucci V (eds): Cardiac Bioprosthesis . New York, Yorke Medical Books, 1982;, pp 184-191.
34 +
Yacoub M, Halim M, Radley-Smith R, et al:  Surgical treatment of mitral regurgitation caused by floppy valves: Repair versus replacement . Circulation 1981;;64( (suppl 2) ):210-216.
35 +
Buda AJ, Zotz RJ, LeMire MS, et al:  Prognostic significance of vegetations detected by two-dimensional echocardiography in infective endocarditis . Am Heart J 1986;;112:1291-1296.
36 +
Cosgrove DM, Chavez AM, Lytle BW:  Results of mitral valve reconstruction . Circulation 1986;; 74( (suppl 1) ):82-87.
37 +
Spencer FC, Colvin SG, Collifort AT, et al:  Experiences with the Carpentier technique of mitral valve reconstruction in 103 patients . J Thorac Cardiovasc Surg 1985;;90:341-350.
38 +
Sand ME, Naftel DC, Blackstone EH, et al:  A comparison of repair and replacement for mitral valve incompetence . J Thorac Cardiovasc Surg 1987;;94:208-219.
39 +
Angell WW, Oury JH, Shah P:  A comparison of replacement and reconstruction in patients with mitral regurgitation . J Thorac Cardiovasc Surg 1987;;93:665-674.
40 +
Antunes MJ, Colsen PR, Kinsley RH:  Mitral valvuloplasty: A learning curve . Circulation 1983;;68( (suppl 2) ):70-75.
41 +
Kriendel MS, Schiavone WA, Lever HM, et al:  Systolic anterior motion of the mitral valve after Carpentier ring valvuloplasty for mitral valve prolapse . Am J Cardiol 1986;;57:408-412.
42 +
Galler M, Kronzon I, Slater J, et al:  Long-term followup after mitral valve reconstruction: incidence of postoperative left ventricular outflow obstruction . Circulation 1986;;74( (suppl 1) ):99-103.
43 +
Chauvaud SM, Deleuze P, Perier PM, et al:  Failures in reconstructive mitral valve surgery, abstracted . Circulation 1986;;74( (suppl 2) ):393.
44 +
Kenny J, Cohn LH, Collins JJ, et al:  Noninvasive assessment of mitral valvuloplasty . Cardiol Board Rev 1987;;4:75-82.
45 +
Oury JH, Grehl TM, Lamberti JJ, et al:  Mitral valve regurgitation . J Cardiac Surg 1986;;1:217-231.

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