Repair of anomalous origin of left coronary artery from the pulmonary artery

Patients with anomalous origin of the left coronary artery from the pulmonary artery often have mitral valve regurgitation. Although establishing dual coronary circulation is the procedure of choice, there remains controversy as to how the mitral valve is handled. Between April 1999 and August 2005, 8 patients underwent surgical correction at our institution. There were 4 males and 4 females, aged from 9 months to 13 years (mean, 6.4 years). Six patients underwent direct aortic reimplantation and 2 had a Takeuchi procedure. Simultaneous mitral annuloplasty was performed in 7 patients with moderate or severe mitral regurgitation. There were no deaths or postoperative complications. Follow-up ranged from 4 to 80 months (mean, 34 +/- 26 months). Left ventricular function improved significantly from a preoperative fractional shortening of 0.21 +/- 0.09 to 0.35 +/- 0.06. Mitral regurgitation decreased on follow-up in the 7 patients who had mitral annuloplasty. We recommend performing mitral annuloplasty at the time of operation in patients with moderate or severe mitral regurgitation and anomalous origin of the left coronary artery from the pulmonary artery.     

Surgery and critical care for anomalous coronary artery from the pulmonary artery

Anomalous origin of the left coronary artery from the pulmonary artery is a rare congenital cardiac malformation that accounts for 0.25-0.50% of children with congenital cardiac disease and can cause myocardial dysfunction in young infants. In any infant presenting with ventricular dysfunction, the diagnosis of anomalous origin of the left coronary artery from the pulmonary artery must be suspected and the origin of the coronary arteries must be confirmed. The diagnosis of anomalous origin of the left coronary artery from the pulmonary artery is an indication for surgical repair. A two-coronary arterial system is the goal and is almost always achievable. The goal of surgical therapy is the creation of a two-coronary arterial system, which appears to provide better long-term survival and protection from left ventricular dysfunction and mitral valvar regurgitation than does simple ligation of the anomalous coronary artery. Direct reimplantation of the anomalous coronary artery is the procedure of choice. It is straightforward and borrows from well-practised techniques commonly used in other procedures such as the arterial switch operation. For the rare patient in whom direct reimplantation is not possible, strategies to lengthen the anomalous coronary artery, or baffle it within the pulmonary root, are available. Mitral valvar regurgitation is common at presentation, but following the establishment of a two-coronary arterial system and satisfactory myocardial perfusion, regurgitation of the mitral valve resolves in the vast majority. Therefore, mitral valvuloplasty at the time of initial surgery for anomalous origin of the left coronary artery from the pulmonary artery is not indicated. Post-operative care requires careful manipulation of inotropic support and reduction of afterload. Mechanical support, with either extracorporeal membrane oxygenation or left ventricular assist device, should be available for use if necessary.     

Anomalous origin of left coronary artery in pulmonary artery]

We report 2 infants aged 6 months and one year with an anomalous left coronary artery origin treated surgically at our centre with direct aortic reimplantation of the anomalous coronary. Evolution has been satisfactory, with a great improvement of ventricular function. The mitral incompetence and congestive heart failure have disappeared and myocardic perfusion electrocardiographic patterns were corrected. Because of the unfavorable natural course of the disease and the improvement in techniques of coronary revascularization in infants we recommend an early surgical treatment as soon as it be diagnosed. We consider that the most adequate surgical treatment is the direct aortic reimplantation of the anomalous coronary artery.     

Results and indications of coronarography in mitral valvulopathies

Selective coronary angiography was carried out in 110 patients (68 women, 42 men; average age 57 +/- 8 years) with significant, isolated, non-ischaemic mitral valve disease. The indication for coronary angiography was angina or myocardial infarction in 42 cases and the investigation was carried out routinely in the other 68 cases. Coronary stenosis greater than 50 p. 100 was demonstrated in 25 cases (22.7 p. 100), 18 single vessel, 5 double or triple vessel disease and 2 cases of stenosis of the left main stem. The incidence of coronary artery disease was higher in patients with cardiovascular risk factors (0 factors: 13 p. 100; 1 factor: 22 p. 100, 2 or 3 factors: 45 p. 100; p less than 0.01). The coronary patients had higher mean pulmonary artery pressures (33 +/- 16 mmHg vs 25 +/- 8 mmHg, p 0.001), higher left ventricular end diastolic pressures (12.5 +/- 7 mmHg vs 9 +/- 5 mmHg, p less than 0.01) and greater left ventricular end diastolic volumes (83 + 40 ml/m2 vd 59 +/- 29 ml/m2, p less than 0.01). There was no difference in segmental wall motion between coronary and non coronary patients. 89 patients were referred for surgery, 17 of whom had coronary artery disease. 5 patients underwent coronary bypass surgery. The incidence of peroperative cardiac complications (low output, ventricular arrhythmias, myocardial infarction) was higher in the coronary patients (53 p. 100 vs 18 p. 100, p less than 0.01). The 6 year survival rate was 75 +/- 8 p. 100.(ABSTRACT TRUNCATED AT 250 WORDS)     

应用再植技术治疗起源异常左冠状动脉的效果分析

目的:分析和讨论应用冠状动脉再植技术治疗先天性起源于肺动脉的左冠状动脉异常(ALCAPA)的外科治疗效果和经验。方法:回顾分析2008年4月~2013年4月26例应用冠状动脉再植技术治疗先天性ALCAPA患儿的临床资料。其中男14例,女12例;年龄4月~6岁。术前均经超声心动图,CT和或心血管造影检查明确诊断。结果:术前左室射血分数(LVEF)20~80(48±18)%,心胸比0.54~0.77(0.64±0.07)。并发二尖瓣关闭不全(MI)轻度以上21例,其中中度以上17例。左心室心尖部室壁瘤1例,房间隔缺损1例。同期行二尖瓣成形11例,室壁瘤切除1例,房间隔缺损修补1例。本组患儿手术均顺利完成,无手术死亡。体外循环时间91~238(150±37)min,心肌阻断时间64~200(126±36)min。随访1~61(29±19)月,患儿无远期死亡。最后一次随诊LVEF35~75(64±11)%,心胸比0.48~0.65(0.57±0.05),较术前明显改善。MI中度以下24例。结论:冠状动脉再植技术手术效果良好,对于中度以上MI应积极治疗。     

The Management of the Older Adult Patient with Anomalous Left Coronary Artery from the Pulmonary Artery Syndrome: A Presentation of Two Cases and Review of the Literature

ALCAPA (anomalous left coronary artery from pulmonary artery) syndrome is a rare congenital abnormality that involves an anomalous insertion of the left coronary artery into the pulmonary artery. Ninety percent of patients present in the first year of life with signs and symptoms of heart failure or sudden cardiac death secondary to chronic myocardial ischemia. There have been an increasing number of reports of ALCAPA patients surviving to adulthood. There seems, however, to be a tendency to die suddenly in the third decade of life. Adult survivors are either asymptomatic or present with mitral regurgitation, cardiomyopathy, myocardial ischemia, or malignant arrhythmias. The management of the older patient presenting with symptoms resulting from ischemia and progressive left ventricular dysfunction remains a challenge. Treatment is largely based on guidelines for adult congenital heart disease management and an extrapolation of evidence from heart failure practice. Currently, surgical reimplantation of the anomalous coronary onto the aorta is the mainstay of treatment. The management of heart failure, sudden cardiac death, and ventricular arrhythmia present problems that are not addressed by reimplantation of the anomalous vessel alone. In this report, we present two cases with different modes of presentation and discuss treatment options.     

Pre- and post-operative echocardiographic evaluation of the anomalous origin of the left coronary artery from the pulmonary trunk

OBJECTIVE: Pre and postoperative Doppler echocardiographic assessment of the anomalous origin of the left coronary artery from the pulmonary trunk (OLCAPT). MATERIAL AND METHODS: We analyzed Doppler echocardiographic diagnostic signs, the potential for recovery of left ventricular (LV) function and mitral regurgitation (MR) in 4 patients with OL-CAPT, treated by direct aortic implantation. The age at surgery ranged from 1 to 10 years and the follow-up from 3 months to 6 years. Doppler echocardiographic diagnostic study was performed at the first examination whereas LV function and MR were studied before (3 to 8 days) and serially after surgery. RESULTS: The OLCAPT was visualized in 3 patients and the retrograde flow from the anomalous left coronary in 1. An important right coronary artery dilation was present in 2 patients, being moderate in a third patient. Before surgery, the LV shortening fraction ranged from 17 to 23% and the ejection fraction from 23 to 36%. The qualitative analysis of segmental LV wall motion showed septal akinesis and hypokinesis of the remaining segments. Nine to 12 months after surgery, global and regional indexes of LV function improved, reaching the normal range except for the interventricular septum. In 2 patients with more than 2 years of follow-up, complete normalization of LV function was obtained, as well as with the electrocardiographic features of an old myocardial infarction in one case and a marked decrease in Q wave depth in the other. A moderate to severe MR was detected in all patients which improved markedly after surgery in 3. In the other case, a mitral replacement was necessary. CONCLUSION: Doppler echocardiography allowed: 1. the anatomic diagnosis in 3 of 4 patients with OLCAPT; 2. to follow global and regional LV function and MR improvement after direct aortic implantation of the anomalous left coronary artery.     

Prediction of outcome after mitral valve replacement in patients with symptomatic chronic mitral regurgitation. The importance of left atrial size

BACKGROUND. The ability to predict outcome after mitral valve replacement remains limited in patients with symptomatic chronic mitral regurgitation. The aims of this study were to determine the preoperative predictors of postoperative cardiac-related mortality and to assess the additive prognostic value of tests performed in such patients. METHODS AND RESULTS. Accordingly, 176 patients (mean age, 57 +/- 14 years) who underwent mitral valve replacement were followed up for 3.8 +/- 0.5 years. Four categories of variables were analyzed to predict postoperative cardiac-related mortality: clinical, laboratory, two-dimensional echocardiographic (2DE), and cardiac catheterization. There were 39 cardiac-related deaths (29 due to congestive heart failure and 10 sudden). When the four categories were analyzed separately, two clinical, one laboratory, two 2DE, and one catheterization variable best predicted postoperative death. When these six variables were examined simultaneously, only three (one clinical and two 2DE) remained significant predictors of cardiac-related mortality: presence of pulmonary rales, left atrial size, and the ratio of left ventricular wall thickness to left ventricular cavity dimension in end systole. A model based on these three variables may predict cardiac-related death with considerable accuracy. Laboratory data did not add to clinical information for predicting death. 2DE variables provided significant additional information in this regard (p less than 0.001). Further addition of catheterization variables was not useful. Prognostic value did not change significantly when 50 patients with prior mitral valve surgery or 49 patients undergoing concomitant aortic valve replacement or coronary artery bypass surgery were excluded from analysis. CONCLUSIONS. We conclude that 1) measures of both left ventricular systolic function and left atrial size are equally important in predicting postoperative cardiac-related mortality in patients with symptomatic chronic mitral regurgitation undergoing mitral valve replacement; 2) left atrial size may be important because it reflects the "history" (severity and duration) of mitral regurgitation; 3) 2DE assessment of left atrial size and left ventricular function provides prognostic information that is significantly greater than that obtained from clinical and laboratory parameters alone; the addition of catheterization variables does not increase the prognostic value of the clinical and 2DE data.     

婴儿左冠状动脉异常起源于肺动脉的诊疗分析

目的 探讨左冠状动脉异常起源于肺动脉（anomalous origin of the left coronary artery from the pulmonary artery，ALCAPA）的临床特点、诊断方法、外科治疗及疗效分析。方法 2006年6月~2015年1月阜外医院诊断为ALCAPA并行手术治疗患儿29例，对这些患儿的临床资料、诊断与治疗情况及随访结果进行回顾性分析。随访结果根据包括复查结果及电话随访。结果 本组患者男性16例，女性13例，年龄2月~1（0.75±0.27）岁，体质量4.8~11.5（8.0±2.2）kg，左心室射血分数18~66(42±18)%。患儿均出现临床心功能不全症状，并通过心电图、心脏彩超及64排螺旋CT检查以明确诊断。并发二尖瓣轻度反流10例，中度反流5例，重度反流4例。手术中将左冠状动脉从肺动脉游离后，直接将左冠状动脉移植到升主动脉15例，用部分肺动脉干和主动脉壁或心包片作左冠状动脉延伸与升主动脉吻合13例，应用肺动脉内通道术（Takeuchi方法）1例。9例并发二尖瓣中度及以上反流者同期作二尖瓣成形术。术毕3例行体外膜肺氧合(extracorporeal membrane oxygenation，ECMO)辅助左心系统。无手术早期死亡。术后随访资料24例（83%，24/29），随访1~80（22±20）个月，患儿术后症状均明显改善。结论 ALCAPA的患儿应早期诊断，及早手术治疗。冠状动脉直接移植术是目前重建双冠状动脉系统的首选方案， 外科治疗效果良好。     

Anomalous origin of the left coronary artery from the pulmonary trunk: its clinical spectrum and current surgical management

An anomalous left coronary artery arising from the pulmonary artery is a rare congenital anomaly which carries a serious prognosis with a high mortality in infants. Our experience in the surgical treatment of 9 patients with this condition during the last 5 years is discussed. The majority of patients were under the age of 2 years and presented with left ventricular failure. Surgical procedures included simple ligation of the left coronary artery, left subclavian to left coronary artery anastomosis, interposition vein graft, and direct reimplantation of the left coronary artery into the aorta. Patients treated by simple ligation survived the procedure but did not show improvement. Results with the subclavian artery to left coronary artery anastomosis were disappointing. Direct reimplantation or interposition of a saphenous vein graft appears to be the method of choice.     

Anomalous left coronary artery arising from the pulmonary artery in infancy: is early operation better?

From January 1975 to January 1987, 21 consecutive infants aged less than six months (mean (SD) 2.6 (1.2] were admitted with anomalous origin of the left coronary artery from the pulmonary artery. In the first 12 patients, who were seen up to 1982, operation was performed after the age of one year (mean (SD) 29 (29) months) (group 1). The next nine infants, seen from 1983 to 1987, had their operations within a few weeks of the onset of symptoms (mean (SD) age 4.8 (1.4) months) (group 2). In group 2 the left coronary artery was relocated into the aorta, whereas in group 1 there was additional resection of the left ventricular wall or mitral valvoplasty or both. At presentation there were no differences in age, clinical condition, heart enlargement, and echocardiographic left ventricular dysfunction between groups 1 and 2. Seven of the 12 patients in group 1 died, five while they were awaiting operation (three died suddenly at home) and two at operation. The five survivors are doing well 6.4 (3.1) years after operation with normal left ventricular function which improved slowly over several months after operation. Two of the nine patients in group 2 died; both deaths occurred at or soon after operation. The seven survivors are doing well 1.8 (0.9) years after operation. In three, left ventricular function recovered within three weeks; and there was even partial or total regression of the Q waves in the supposedly necrotic areas. In the remaining four the pattern of improvement in left ventricular function resembled that in group 1. Operation should be undertaken early in infants with anomalous left coronary artery arising from the pulmonary artery because the procedure is relatively safe, prevents a high natural mortality, and offers a better chance of a faster recovery of left ventricular function.     

Anomalous left coronary artery arising from the pulmonary artery in infancy: is early operation better?

From January 1975 to January 1987, 21 consecutive infants aged less than six months (mean (SD) 2.6 (1.2] were admitted with anomalous origin of the left coronary artery from the pulmonary artery. In the first 12 patients, who were seen up to 1982, operation was performed after the age of one year (mean (SD) 29 (29) months) (group 1). The next nine infants, seen from 1983 to 1987, had their operations within a few weeks of the onset of symptoms (mean (SD) age 4.8 (1.4) months) (group 2). In group 2 the left coronary artery was relocated into the aorta, whereas in group 1 there was additional resection of the left ventricular wall or mitral valvoplasty or both. At presentation there were no differences in age, clinical condition, heart enlargement, and echocardiographic left ventricular dysfunction between groups 1 and 2. Seven of the 12 patients in group 1 died, five while they were awaiting operation (three died suddenly at home) and two at operation. The five survivors are doing well 6.4 (3.1) years after operation with normal left ventricular function which improved slowly over several months after operation. Two of the nine patients in group 2 died; both deaths occurred at or soon after operation. The seven survivors are doing well 1.8 (0.9) years after operation. In three, left ventricular function recovered within three weeks; and there was even partial or total regression of the Q waves in the supposedly necrotic areas. In the remaining four the pattern of improvement in left ventricular function resembled that in group 1. Operation should be undertaken early in infants with anomalous left coronary artery arising from the pulmonary artery because the procedure is relatively safe, prevents a high natural mortality, and offers a better chance of a faster recovery of left ventricular function.     

Repair of anomalous origin of the left coronary artery in the infant and small child

Anomalous origin of the left coronary artery from the pulmonary artery is associated with myocardial infarction, left ventricular dysfunction, mitral valve dysfunction and, occasionally, intracardiac congenital abnormalities. A technique that utilizes a flap of the anterior wall of the pulmonary artery to serve as a neocoronary artery to direct aortic flow from a created aortopulmonary window to the pulmonary artery orifice of the anomalous left coronary artery was used in five patients aged 2.5 months to 4.75 years. Two patients were less than 4 months of age at operation. There was one death 2 days after operation and one late death. The two youngest patients required mitral valve replacement. Two of the three surviving patients are well at follow-up at 7 to 44 months. One patient has been lost to follow-up study. One patient had postoperative catheterization which showed an intact repair. The pulmonary artery neocoronary procedure is applicable to infants and small patients with anomalous origin of the left coronary artery from the pulmonary artery.     

Left ventricular pseudoaneurysm after coronary artery bypass and valve replacement for post-infarction mitral regurgitation

Most left ventricular inferior wall aneurysms are classified as false, and they have a narrow neck and exhibit rapid flow. Inferior wall pseudoaneurysms that develop soon after primary percutaneous intervention and coronary artery bypass grafting for acute myocardial infarction are rare. We report the case of a 64-year-old man who had a wide-necked left ventricular inferior wall pseudoaneurysm that developed soon after surgery for an acute myocardial infarction and post-infarction mitral regurgitation that occurred as a mechanical complication. The surgery consisted of coronary artery bypass grafting and mitral valve replacement. After the surgery, congestive heart failure developed. At reoperation, we found a large pseudoaneurysm that had caused tearing of the chordae tendineae of the posterior mitral leaflet and scarring around the inferior wall defect. The inferior wall defect had formed the wide neck of the left ventricular pseudoaneurysm. We excised the pseudoaneurysm and the scar tissue and attached a small patch to the defect such that it decreased the left ventricular dimension. Our patient survived the surgery and recovered completely. In patients with acute myocardial infarction, left ventricular pseudoaneurysms can occur soon after coronary artery bypass grafting and surgery for a complication such as mitral valve regurgitation. When a large portion of the left ventricular wall is infarcted and its removal would create a smaller cavity with compromised output, we recommend ventricular reconstruction by patch placement.     

Towards an anatomically correct repair for anomalous left coronary artery arising from the pulmonary trunk

BACKGROUND: Anomalous origin of the left coronary artery from the pulmonary trunk is rare, occurring at an incidence of 1 in 300,000. If not diagnosed and treated early, it is life-threatening. Children with the anomaly usually present in infancy with congestive cardiac failure, and are occasionally referred for cardiac transplant. We investigated the medium term outcome for patients following creation of a two-coronary arterial circulation. METHODS: Between 1992 and 2007, we diagnosed 15 patients seen at our Institution as having anomalous origin of the left coronary artery from the pulmonary trunk. Over a period of 13 years, aortic reimplantation was undertaken in 12 of these patients, who form the studied cohort. RESULTS: Direct reimplantation was performed in 5 patients. In 3 cases, a tension-free anastomosis was created using a caudally based flap. In another 3 cases, an extended flap was used, while a patch arterioplasty was fashioned in the final patient. There were no deaths. Left ventricular function recovered in all but one of the patients, and all patients had a reduction in the degree of mitral regurgitation. CONCLUSIONS: Among the variety of surgical techniques, transfer of the anomalous left coronary artery to the aorta is the ideal method for long-term patency and adequate blood supply. This can be achieved by creating flaps based on the walls of the pulmonary trunk and aorta, producing a dual coronary arterial supply with no mortality and low morbidity.     

Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery: Diagnoses and Surgical Results in 12 Pediatric Patients

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital condition. It responds well to early diagnosis and treatment, but otherwise the prognosis is poor. We present our case series of 12 patients (mean age, 2 ± 2.58 yr; age range, 2 mo–8 yr), emphasizing the diagnostic process and discussing our surgical results. The diagnosis of ALCAPA should be suspected in infants who have dilated cardiomyopathy with electrocardiographic changes that suggest ischemia, and in older children who have isolated mitral regurgitation. When clinical suspicion is high, the results of 2-dimensional echocardiography combined with color-flow Doppler studies in expert hands can establish the diagnosis, thus avoiding angiography in critically ill infants. The treatment of choice in our patients was transfer and reimplantation of the left coronary artery onto the ascending aorta. There were 2 deaths: both were infants in extremis who underwent emergency surgery. An older child with severe ventricular dysfunction was given mechanical ventricular assistance and then heart transplantation. As of this report, all 10 survivors remained well and asymptomatic.     

Clinical application of amplitude processing of echocardiographic images.

In order to assess the possible clinical value of measuring regional amplitude of ultrasound reflected from intracardiac structures, two-dimensional echocardiographic images from 20 normal subjects and 70 patients with heart disease were processed by modulation of both colour and intensity to represent grey scale. Maximum echo intensity was consistently recorded from the pericardial interface behind the posterior left ventricular wall, and this was taken as 100 per cent. In the normal heart, central fibrous body reflected at 64 +/- 5 per cent, and mitral and aortic valves at 35 +/- 5 per cent and 36 +/- 8 per cent, respectively. Normal septal myocardium gave a valve of 33 +/- 8 per cent and posterior wall of 23 +/- 6 per cent. Consistent increases were recorded from prosthetic mitral valves in 20 patients, and also from the anterior cusp of the mitral valve (54 +/- 11%) in 20 patients with rheumatic heart diseases. In all of 15 patients with left ventricular involvement caused by coronary artery disease, septal echo amplitude was increased in all to 71 +/- 11 per cent, and localised increases were also noted in the posterior wall, subendocardially, or in one or both papillary muscles. Similar focal changes were noted in five, and increases in septal density in 10 of 15 patients with left ventricular hypertrophy and in 12 of those with mitral valve disease. Thus, measurement of regional echo amplitude is possible without degradation of the quality from standard two-dimensional cardiac images. Abnormalities are particularly common in left ventricular disease where their distribution corresponds to that described for fibrous tissue.     

Mitral repair in patients with a ruptured papillary muscle

BACKGROUND: The objective of this study was to evaluate the feasibility of a modified papillary muscle repair procedure for a group of patients with ischemic mitral regurgitation when ischemia/infarction has resulted in the rupture of a papillary muscle. From January 1997 to January 1999, 843 patients underwent mitral valve surgery in our hospital. Mitral reconstruction was performed in 520 (61.7%) patients, and 6 (1.2%) of these patients were found to have a rupture of a papillary muscle at initial examination. METHODS AND RESULTS: A modified papillary muscle repair procedure to reimplant the tip of the ruptured papillary muscle "height- and/or length-adjusted" into a corresponding papillary muscle, with the use of a sandwiched pericardium pledget-reinforced polytetrafluoroethylene suture, was performed in 6 patients. Although the underlying cause in this group of patients was ischemic, concomitant coronary artery bypass grafting was performed in only 3 patients, with 1.3 grafts per patient. Of these 6 patients, 3 (50%) were men; the mean age was 60.2 +/- 12.8 years. All patients had in addition to the papillary muscle repair procedure an annuloplasty with a Carpentier-Edwards Physio-Ring. There was no early death in this group of patients. Postoperative Doppler echocardiography showed satisfactory mitral valve function in all patients and a significant postoperative ventricular remodeling: The left ventricular end-diastolic diameter decreased from 72.8 +/- 3.1 mm before surgery to 54.6 +/- 9.3 mm (P <.1) after surgery; left ventricular systolic diameter also decreased (48.5 +/- 4.9 mm vs 38. 4 +/- 9.8 mm; P <.1), and a substantial reduction of left atrial diameter (58.8 +/- 1.5 mm vs 49.7 +/- 4.1 mm; P <.1) was observed. Within the short mean follow-up period of 8.6 +/- 7.5 months (2 to 26 months), there were no late deaths, reoperations, or thromboembolic or bleeding complications. All patients were in New York Heart Association functional class I or II at the time of follow-up. CONCLUSIONS: Our results indicate that our modified papillary muscle reimplantation procedure is a valuable surgical tool with good survival results in patients with ischemic mitral regurgitation caused by papillary muscle rupture.     

Long-term effects of excision of the mitral apparatus on global and regional ventricular function in humans

To evaluate the long-term sequelae of mitral valve excision on global and regional wall motion, contrast left ventriculograms from 21 patients with suspected prosthetic mitral valve dysfunction performed 10.4 +/- 2.1 years after mitral valve replacement were analyzed by a computerized radial shortening method. Patients with significant coronary artery disease (greater than 30% stenosis in any vessel) were excluded. In 8 of the 21 patients in whom preoperative ventriculograms were available, regional wall motion was normal before valve replacement. Although average radial shortening (35.6 +/- 4.8% versus 35.3 +/- 3.8%, p = NS) and left ventricular ejection fraction (62.8 +/- 4.2% versus 57.9 +/- 2.8%, p = NS) were unchanged in the preoperative and postoperative studies of these eight patients, radial shortening in the vicinity of insertion of the posteromedial papillary muscle declined significantly (38.4 +/- 6.4% to 20.8 +/- 4.4%, p less than 0.04). Postoperative radial shortening for all 21 patients at the site of insertion of the papillary muscle was also reduced to a significant degree compared with the average radial shortening (32.9 +/- 10.3% versus 17.5 +/- 2.0%, p less than 0.001). The findings demonstrate significant long-term and possibly permanent regional ventricular dysfunction after severing the chordae tendineae during mitral valve replacement.