MITRAL-VALVE RECONSTRUCTION AND MITRAL-VALVE REPLACEMENT FOR ISCHEMICMITRAL-INSUFFICIENCY

Background: Patients with ischemic mitral incompetence have a high ope rative risk whether the valve is repaired or replaced. The advantage o f repair over replacement is unclear in this group of patients. Method s: Between April 1986 and December 1994, 232 patients underwent surger y for ischemic mitral valve insufficiency; mitral valve replacement wa s performed in 98 of them. Operative mortality was 13.3%. The actuaria l survival rate after 5 years was 73.3%. The surgical risk in patients whose left ventricular ejection fraction (LVEF) was 10%-30% (operativ e mortality 50.0%) was higher than in those whose LVEF was greater tha n 30%. Valve reconstruction was performed in 102 patients. Operative m ortality in this patient group was 14.7%. The surgical risk in patient s whose LVEF was less than or equal to 30% was higher (operative morta lity 42.9%). Results: The total actuarial survival rate of all patient s was 64.4% after 5 years. Mortality during follow-up was higher in pa tients with residual mitral valve insufficiency greater than grade I a fter mitral valve reconstruction. Twenty-four patients with severly im paired left ventricular function underwent heart transplantation. Oper ative mortality in this group was 12.5%. Eight patients received left ventricular aneurysmectomy in addition to valve surgery, three of them died early. Conclusions: We conclude that patients with highly impair ed left ventricular function and ischemic mitral insufficiency are at too great a risk for either valve reconstruction or replacement. Cardi ac transplantation should be considered for this patient group. Howeve r, patients with ischemic mitral insufficiency and moderately impaired left ventricular function can undergo valve reconstruction or replace ment with an acceptable prognosis. The goal of mitral valve reconstruc tion should be reducing mitral valve insufficiency to at least grade I . If this is not achieved, the prognosis after repair is worse than af ter valve replacement, therefore, the surgeon should replace the valve without delay.