Management of Heart Failure by Jai Raman

Author:Jai Raman
Language: eng
Format: epub
Publisher: Springer London, London

Fig. 9.8The flexible simplicit band

Fig. 9.9Semi-rigid band – CG band

Fig. 9.10Rigid saddle-shaped ring

Unresolved Issues, Future Perspective

Despite these new insights, residual or recurrent MR and more importantly, limited LV reverse geometric remodeling have also been noted and potentially limit long term improvement [88–90]. LV remodeling is characterized by progressive LV dilatation with a change in the heart from an ellipse to a more spherical shape and is one of the strongest predictors of mortality in heart failure patients. Despite optimal surgical and/or medical therapy, heart failure is often progressive without reversal of LV remodeling. Surgical CHF treatment must, therefore, be aimed not only at MR, but more importantly, also at LV reverse remodeling [91, 92].

In a recent retrospective analysis from the University of Michigan, the effect of MV repair was compared with medical therapy in heart failure patients with severe MR. Wu et al. examined 293 patients treated medically and 126 treated with MV repair, all with severe CHF, and found that MV repair did not predict a mortality benefit [93]. In this non-randomized, but propensity-matched series, the results showed, qualitative improvement, but that there appeared to be little mortality benefit of MV repair of functional MR in advanced heart failure and severe LV dysfunction over the 10 year period of the review. Indeed, the only predictor of mortality in this study, as in every CHF trial, medical or surgical, was reverse remodeling, which did not correlate well with the abolishment of MR. CHF associated MR from LV geometric distortion does not preclude successful mitral valve repair. However, it may be inferred that reducing MR in these patients may not be “enough”, as MR is a late marker for CHF [94, 95]. Interestingly, with further analysis of the same data set, there is favorable trend upon mortality, during the last 5 years of the study, when MVR surgery evolved to include earlier surgical referral for CHF patients, and the use of rigid smaller, remodeling rings. Similarly, the recently presented ACORN trial results also showed quality of life benefit, but did not have a mortality benefit.

In this setting, when recurrent MR might prove to be the final pathway by which a patient decompensates, it might be worthwhile considering alternatives such as mitral valve replacement with complete preservation of chordal supports.

Others have found a group of patients with bad ventricles, especially with very tethered posterior leaflets or very large ventricles to have sub-optimal long-term results with tight mitral annuloplasty alone. In these patients, either as a first procedure or at redo surgery, the preference is to reconstruct the mitral valve with a chord preserving prosthetic mitral valve replacement.

Young patients tend to get mechanical mitral valve prosthesis as shown in Fig. 9.11 .

Fig. 9.11Mechanical mitral valve with preserved chords

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