What is the best surgical treatment for obstructive hypertrophic cardiomyopathy and degenerative mitral regurgitation?

BACKGROUND: Many prefer mitral valve replacement (MVR) for patients with obstructive hypertrophic cardiomyopathy (HCM) and concomitant degenerative mitral regurgitation (MR). We reviewed our results of septal myectomy combined with mitral valve repair (MVrep) and MVR when these problems coexist. METHODS: Between 1990 and 2006, 32 patients (56% men; mean age, 60.7 +/- 16.7 years) underwent extended septal myectomy for HCM with concomitant MVrep or MVR for degenerative MR (4% of myectomies and 3% of isolated MVrep during the same period). Preoperatively, 63% were in New York Heart Association (NHYA) functional class III/IV. Preoperative peak left ventricular outflow tract (LVOT) gradient was 63.7 +/- 37.6 mm Hg. Systolic anterior motion (SAM) was present in 94%, with severe MR in 88%. RESULTS: Extended septal myectomy included concomitant MVrep in 28 (88%) or mechanical MVR in 4 (12%). MVrep included leaflet resection in 10 (36%), edge-to-edge stitch in 6 (21%), and leaflet plication in 8 (29%). An annuloplasty ring/band was used in 19 (68%) and commissural annuloplasty in 2 (7%). There was one early death (3%). At discharge, resting LVOT gradient was reduced to 10.2 +/- 19.0 mm Hg (p < 0.005). Dismissal echocardiography in MVrep patients demonstrated chordal SAM in 6 (21%, p < 0.005). MR was absent or mild in 21 (75%) and moderate in 6 (21%; p < 0.005 vs preoperatively). At late follow-up, LVOT gradient was 2.5 +/- 5.8 mm Hg, SAM resolved in all patients, and 2 had moderate MR; 24 (83%) were in NYHA class I/II (p < 0.005). CONCLUSIONS: Concomitant MVrep with myectomy for HCM and degenerative MR can be performed with low early mortality with satisfactory relief of LVOT obstruction and MR. Most patients have significant relief of symptoms. MVR can be avoided in most patients with degenerative MR and HCM.

Management of moderate functional mitral regurgitation at the time of aortic valve replacement: is concomitant mitral valve repair necessary?

OBJECTIVE: The optimal management of moderate functional mitral regurgitation at the time of aortic valve replacement remains undefined. METHODS: We retrospectively identified 686 consecutive patients undergoing aortic valve replacement between 1993 and 2006 with at least moderate (grade 2 or more) functional mitral regurgitation. Patients with structural valve abnormalities or significant coronary artery disease were excluded, leaving 190 in the study. Analyses for predictors of residual mitral regurgitation and survival were performed. The impact of mitral regurgitation on survival was further analyzed among 91 patients case matched for age, gender, and left ventricular ejection fraction to individuals without mitral regurgitation undergoing isolated aortic valve replacement. RESULTS: The mean age of the study group was 74 +/- 11years, 45% were male, and 78% had New York Heart Association III or IV Class classification. The mean preoperative ejection fraction was 48% +/- 17%. Operative mortality was 5% (n = 9). Follow-up echocardiographic data were available for 88% of patients at discharge and 57% of patients at midterm. Mitral regurgitation was improved at discharge in 76% of patients and at mid-term follow-up in 67% of patients. Independent predictors of improved mitral regurgitation were lesser degrees of preoperative tricuspid regurgitation or prebypass mitral regurgitation, absence of cerebrovascular disease, and lower left ventricular ejection fraction. Postoperatively, 89% of patients were New York Heart Association Class I or II Symptom; No reoperations for mitral regurgitation were performed. Survival was 68% at 5 years and 42% at 10 years. Independent predictors of late mortality were increasing age, diabetes, dialysis-dependent renal failure, and increased tricuspid regurgitation severity. The survival of 91 patients from this cohort did not differ from case-matched patients without mitral regurgitation undergoing aortic valve replacement (P = .33). CONCLUSION: Moderate functional mitral regurgitation improved in most patients after aortic valve replacement. Residual mitral regurgitation did not affect survival independently of left ventricular function.