Kapoor, John R.

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Journal of the American College of Cardiology Vol. 53, No. 1, 2009
© 2009 by the American College of Cardiology Foundation ISSN 0735-1097/09/$36.00
Published by Elsevier Inc.CORRESPONDENCELetters to the Editor
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1
1ole of Mitral Valve
urgery for Secondary Mitral
egurgitation in Heart Failure
n nonischemic and ischemic cardiomyopathies, geometric pertur-
ations in the left ventricle (LV) result in dysfunction of the mitral
alve and secondary (functional) mitral regurgitation (MR). An
ncrease in interpapillary muscle distance, annular dilation, and
nhanced leaflet tethering contribute to secondary MR. Because
he MR in these patients is primarily a function of distorted LV
eometry rather than a primary valve problem, “the advantages of
orrection of secondary MR are less clear,” as discussed by
arabello (1). This prevailing concept is buttressed by the lack of
survival benefit in a retrospective analysis of 419 patients (2).
owever, this study did not report changes in patient symptoms.
arabello (1) notes that “some have questioned whether surgery in
schemic MR improves survival and/or long-term quality of life.”
hat being the case, several studies actually suggest an improve-
ent in functional status after mitral valve repair of secondary MR
n heart failure patients. Over 200 patients with cardiomyopathy
nd severe MR who underwent mitral valve repair were prospec-
ively studied over a 10-year period (3). In addition to low overall
ortality and improvements in quantitative echocardiographic
ndexes of cardiac function at 2 years, the New York Heart
ssociation (NYHA) functional class for all patients improved
rom a pre-operative mean of 3.2  0.2 to 1.8  0.4 post-
peratively. Another study of patients with severe LV dysfunction
nd MR also demonstrated improvement in NYHA functional
lass from 2.8  0.8 to 1.2  0.5 (p  0.0001) and freedom from
eadmission for heart failure of 88%, 82%, and 72% at 1, 2, and 5
ears, respectively (4). These patients were also able to tolerate
igher doses of medications after repair (4). When functional
utcomes after mitral valve repair of secondary MR were assessed
n yet another study of patients with severe dilated cardiomyopa-
hy, it was noted that, in addition to a low hospital mortality,
YHA functional class improved from 3.4  0.4 to 1.4  0.6
p  0.0001) (5). The authors of that study concluded that, “in
atients with end-stage dilated cardiomyopathy, mitral valve repair
s feasible with low hospital mortality and important symptomatic
mprovement.” These positive findings on functional status have
een reported in a number of other studies (6–10). In patients with
YHA functional class III to IV symptoms and severe MR on
aseline maximal drug therapy, operation led to improved NYHA
unctional class from 3.9  0.3 to 2.0  0.6 (6). Similar findings
ere noted in a prospective study of 125 patients with 4 MR,
evere LV dysfunction (mean ejection fraction of 14%) and NYHA
unctional class III or IV symptoms wherein NYHA functional
lass improved for all the patients from a preoperative mean of
.2  0.2 to 1.8  0.4 post-operatively (8). In patients with a
ean LV ejection fraction of 30%, NYHA functional class alsomproved significantly (3.2 to 1.6; p  0.0001) at follow-up (10).inally, a prospective, randomized, multicenter trial of 193 pa-
ients with NYHA functional class II to IV heart failure, all with
ntensive background medical therapy, demonstrated the safety
nd efficacy of mitral valve surgery after a median follow-up of 23
onths (11). Notably, there were significant improvements in
uality of life at 3, 6, 12, and 18 months as assessed with the
innesota Living with Heart Failure and the Short-Form 36
uestionnaires and improved 6-min walk tests (11). Taken to-
ether, although surgical correction of secondary MR is contro-
ersial, in part because the prognosis is thought to be related
rimarily to the underlying cardiomyopathy, physicians should
onsider offering mitral valve surgery to medically optimized yet
ymptomatic patients with severe MR and end-stage heart failure.
John R. Kapoor, MD, PhD
Division of Cardiology
tanford University
00 Pasteur Drive
tanford, California 94305
-mail: jkapoor@stanford.edu
doi:10.1016/j.jacc.2008.08.065
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Coll Cardiol 2005;45:381–7.
3. Romano MA, Bolling SF. Update on mitral repair in dilated cardio-
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5. De Bonis M, Lapenna E, La Canna G, et al. Mitral valve repair for
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1. Acker MA, Bolling S, Shemin R, et al., for the Acorn Trial Principal
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Role of Mitral Valve Surgery for Secondary Mitral Regurgitation in Heart Failure 

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Role of Mitral Valve Surgery for Secondary Mitral Regurgitation in Heart Failure

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