HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Roberto Lorusso Sandro Gelsomino Cesare Beghi Claudio Russo Michele De Bonis Andrea Colli Andrea Sala Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lorusso, R. Articles by Sala, A. Search for Related Content PubMed PubMed Citation Articles by Lorusso, R. Articles by Sala, A. Related Collections Valve disease

Mitral valve surgery in emergency for severe acute regurgitation: analysis of postoperative results from a multicentre study

^a Cardiac Surgery Units of Civic Hospital, Brescia, Italy
^b Ospedale Niguarda, Centro De Gasperis, Milan, Italy
^c Ospedale Maggiore, University of Parma, Italy
^d San Raffaele Hospital, Milan, Italy
^e University of Insubria, Varese, Italy
^f Experimental Surgery, Careggi Hospital, Florence, Italy
^g Department of Cardiovascular Surgery, Hospital Clinic, Barcelona, Spain

Received 6 September 2007; received in revised form 17 December 2007; accepted 19 December 2007.

^_* Corresponding author. Address: Cardiac Surgery Unit, Civic Hospital, Piazzale Spedali Civili, 1, 25123 Brescia, Italy. Tel.: +39 030 3995636; fax: +39 030 3995004. (Email: roberto_lorusso{at}iol.it).

	Abstract

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusions Appendix A Appendix B References

 
Objective: To evaluate postoperative outcome of emergency surgery for acute severe mitral regurgitation (ASMR) from a multicentre experience. Methods: In six centres, 279 patients (mean age 62 ± 14 years, 62% female) undergoing emergency surgery for ASMR from December 1986 to March 2007 were analysed and followed up. Aetiology included acute myocardial infarction (AMI) in 126 patients (group 1, 45%), degenerative mitral valve disease in 74 (group 2, 26%), and acute endocarditis (AE) in 79 (group 3, 28%). Preoperatively, all patients were in haemodynamic instability, with 185 patients in cardiogenic shock (66%), 184 (66%) intubated, and 61 (22%) on IABP, respectively. Valve repair was performed in 76 (27%), whereas 203 (73%) underwent valve replacement. Median follow-up (98% complete) was 70.8 months (inter-quartile range 59.8–86.66 months). Results: Overall 30-day mortality was 22.5% (63/279). Early death was significantly lower in group 2 (p < 0.001 and p = 0.005 vs group 1 and 3, respectively) whereas no difference was detected between group 1 and 3. At logistic regression analysis AMI, AE, shock, left ventricular dysfunction, and coronary artery disease were predictors of early death. Overall 15-year survival was 67 ± 10%. Survival was lower in group 1 (39 ± 11%) than in group 2 (75 ± 9%) and group 3 (77 ± 10%). Cox regression found AMI, and associated coronary artery disease to be predictors of late death. Overall 15-year actuarial and actual freedom from cardiac-related events were 44 ± 9% and 28 ± 10%, respectively, with the worst outcome in the presence of AE. Associated coronary artery disease, AE, AMI, preoperative atrial fibrillation, and chronic renal failure were independent predictors of cardiac-related events. Conclusions: Emergency surgery for ASMR remains a surgical challenge for high incidence of early and late cardiac-related events, particularly in patients with associated coronary artery disease and acute endocarditis. Apparently, type of mitral valve surgical approaches (repair or replacement) did not provide any influence on postoperative outcome.

Key Words: Mitral valve regurgitation • Emergency cardiac surgery • Cardiogenic shock • Acute endocarditis • Acute myocardial infarction

	1. Introduction

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusions Appendix A Appendix B References

 
Acute severe mitral regurgitation (ASMR) is a rather uncommon form of mitral valve (MV) dysfunction. Acute myocardial infarction (AMI) and acute endocarditis (AE) are the most frequent causes of ASMR, although degenerative valve disease, trauma, or interventional procedures may also contribute to its occurrence [1]. Despite the advances in modern cardiac care, management of the patient with ASMR remains a clinical challenge [1,2]. Acute pulmonary venous congestion and left ventricular (LV) overload represent the immediate pathophysiological consequences following sudden and severe valve dysfunction, often poorly tolerated, thereby leading to left or bi-ventricular failure, and to multiorgan dysfunction. Surgery represents, in the majority of the cases, the only effective treatment to correct ASMR and counteract progressive and sometimes refractory compromise of the cardiovascular and pulmonary conditions strictly related to uncontrollable mitral regurgitation (MR). A few reports, characterised by small patient cohorts, are available in the literature regarding results of emergency surgery in such a setting [2–12], whereas limited or no information has been published in relation to peculiar subgroups of ASMR, like degenerative MV disease. The aim of this study, therefore, was to perform a retrospective multicentre evaluation in a large patient cohort with different aetiology of ASMR operated on in emergency, and analyse early and long-term postoperative results.

	2. Methods

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusions Appendix A Appendix B References

 
This study was authorised by the local ethical committees and followed the rules of the Helsinki Declaration for patient data use and evaluation. Informed consent for the use of personal data for scientific purposes was given by patients or by relatives.

All hospital survivors were followed up at outpatient clinics or contacted by telephone. All post-discharge echocardiographic information was obtained by transthoracic echocardiography carried out at the outpatient clinic of each individual centre or by copies or echo reports performed in other locations and transmitted by the patient. Information about modality of patient's death and their previous clinical conditions at long-term was obtained by telephone contact with relatives, or by hospital records.

2.1 Patient population and surgical techniques
From December 1986 to March 2007, in six different centres, 279 patients undergoing emergency surgery for ASMR were identified and followed up. All patients had diagnosis of severe MR by transthoracic or transoesophageal echocardiography. Emergency surgery was considered when performed immediately after diagnosis had been made, or carried out within a few hours (6–8 h) because of refractory deterioration of clinical or cardio circulatory conditions, with overt signs of venous pulmonary congestion (pulmonary rales or frank oedema), cardiogenic shock (systemic arterial systolic blood pressure <90 mmHg with inotropes, with or without intra-aortic balloon counterpulsation, oligoanuria), mono or biventricular failure, or in cardiac arrest. Patients previously submitted to any cardiac operation were excluded from the study. Preoperative patients characteristics are shown in Table 1 .

2.2 Surgery
Surgical data are displayed in Table 2 . Mitral valve replacement was performed in almost two thirds of the patients, and the majority of these cases had preservation of the valve leaflet (predominantly mono-leaflet preservation). A mechanical valve was implanted more frequently than a bioprosthesis. Contrastingly, almost 30% of the patients underwent mitral valve repair which comprised several techniques of MV reconstruction. Annuloplasty was performed in the majority of these patients, and mainly with a complete ring.

2.3 Statistical analysis
A formal sample size estimate was not performed, due to the retrospective nature of the study. However, the power analysis was determined by Power Analysis software (Stat Soft, Tulsa, OK). With an F statistic of 14.02 at one-way ANOVA, the calculated statistical power was 0.90.

Continuous variables are presented as mean and standard deviation (SD), categorical variables as n/N and non-normally distributed variables as median and interquartile [IRQ] range. Comparison of echocardiographic continuous variables were analysed using one-way analysis of variance (Tukey post-hoc test.). The Friedman test was used when variables were not normally distributed and the Dunn post-hoc test was employed for multiple comparisons.

Proportions were compared using ² test and Fisher's exact test, where appropriate.

Thirty-nine demographic, clinical, and anatomical parameters were investigated for their predictive value of early and late death and cardiac events. Categorical variables with more than two levels in the regression model were converted into dummy variables. To enhance the accuracy of the model, the number of variables was reduced using variable clustering [13] until the number of variables to use as candidates in the regression analysis was m/10 where m is the number of uncensored event times (e.g. deaths) in the sampling used in fitting the model. For binary outcomes m is the number of patients in the less frequent outcome category [13].

Multivariable logistic regression analysis by means of a backward stepwise algorithm (cut-off for entry 0.05, for removal 0.10) was performed to select independent predictors of early death and cardiac events. Model assumptions (linearity and additivity assumptions) were checked by piecewise cubic polynomials (spiline functions) and pooled interaction test [14], respectively, and found to be satisfied. Goodness of fit of the final logistic regression models was assessed with the Hosmer–Lemeshow statistic [15,16], and predictive accuracy was assessed by the concordance (c) index [14]. Internal validation of predictors generated by multivariable logistic regression was performed by means of bootstrapping techniques, with 1000 cycles and generation of OR and bias corrected 95% [14].

Cumulative probability for death and reoperation were estimated by use of the Kaplan–Meier method and log-rank was employed to detect differences between curves. Finally, freedom from cardiac events was calculated employing the actual method [17]. Cox regression analysis was employed to detect predictors of late death.

SPSS 12.0 (SPSS, Chicago, IL, USA) and Stats Direct 2.5.7 (StatsDirect, Sale, UK) were used for these calculations. Significance for hypothesis testing was set at the 0.05 two-tailed level.

	3. Results

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusions Appendix A Appendix B References

 
3.1 Early outcome
Overall 30-day mortality was 22.5% (63/279); early death was significantly lower in group 2 (14.8%) than in group 1 [26.9%, p < 0.001] and 3 [22.7% p = 0.005] whereas no difference was detected between group 1 and 3 (p = .4). Within the post-AMI Group, early mortality did not differ between patient undergoing or not associated CABG (27.3% [20/73] vs 26.4% [14/53], p > 0.9).

At logistic regression analysis, AMI, AE, shock, LV dysfunction, and coronary artery disease were predictors of early death, as shown in Table 3 . Early complications were significantly higher in patients belonging to group 1 (p < 0.001) who also showed a significantly longer intensive care unit length of stay (p = 0.004), need for inotropes (p = 0.003) and intra-aortic balloon pump (p < 0.001) in the postoperative period.

View larger version (8K): [in this window] [in a new window]   Fig. 1. Early postoperative mortality adjusted by patient groups and by period of surgery. AMI: acute myocardial infarction. p = significance over time; * p 0.05 at post-hoc Dunn test.

View larger version (12K): [in this window] [in a new window]   Fig. 2. Fifteen-year actuarial survival by groups in patients operated in emergency for acute severe mitral regurgitation.

View larger version (10K): [in this window] [in a new window]   Fig. 3. Fifteen-year actuarial survival in patients with ASMR due to acute myocardial infarction. Patients undergoing associated CABG showed a better 15-year survival.

Overall 15-year actuarial and actual freedom from cardiac-related events is shown in Fig. 4 . AE showed the least favourable freedom from major cardiac-related events. At logistic regression analysis AE, AMI, coronary artery disease, preoperative atrial fibrillation, and chronic renal failure were independent predictors of cardiac events (Table 4 ).

View larger version (16K): [in this window] [in a new window]   Fig. 4. Overall and aetiology-related actuarial (A) and actual (B) freedom from cardiac-related events after mitral valve surgery in emergency for acute severe insufficiency.

One patient in group 1 (1.6%), two in group 2 (3.7%), and two in group 3 (3.6%, p = 0.45 [NS]) showed prosthetic valve dysfunction and underwent redo mitral valve replacement. Furthermore, one patient in group 1 (1.6%) and two in group 2 (3.7%) underwent reoperation due to mitral repair failure (p = 0.06 [NS]).

In addition, among survivors, in group 3, 29/55 (52.7%) experienced cardiac-related events (heart failure, n = 10 [16.1%]; AMI, n = 5 [8%]; arrhythmias, n = 7 [11.2%]; thromboembolism, n = 3 [4.8%]; anticoagulation-related events, n = 1 [1.6%]; endocarditis, n = 3 [4.8%]). In contrast, 18.5% (10/54, myocardial infarction, n = 2 [3.7%]; arrhythmias, n = 2 [3.7%]; thromboembolism, n = 3 [4.8%]; endocarditis, n = 3 [5.5%]) and 22.5% (14/62, heart failure, n = 6 [10.9%]; myocardial infarction, n = 1 [1.8%]; arrhythmias, n = 7 [12.7%]) showed cardiac-related events during the follow-up period in group 2 and 1, respectively (p < 0.001).

	4. Discussion

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusions Appendix A Appendix B References

 
Acute severe mitral regurgitation occurs rarely, may be secondary to several aetiologies, and is often characterised by haemodynamic instability, cardiogenic shock and pulmonary oedema, ultimately leading to multiorgan failure and death. Chordal rupture, complete or partial rupture of the papillary muscle, leaflet perforation, leaflet disruption, and acute left ventricular wall dysfunction are all mechanisms which may, isolated or in combination, variably affect the structural or functional integrity of the MV apparatus leading to ASMR. Horskotte and colleagues reviewed 42 consecutive patients admitted in intensive care unit with severe mitral insufficiency and pulmonary oedema. In this series, 50% of the cases were due to post-AMI MR, 25% to AE, and 5% to degenerative MV disease. These data are in accordance with our study cohorts except for the degenerative MV subgroup. The relatively high prevalence of emergency surgery for ASMR secondary to degenerative MV disease is an interesting and peculiar finding of our study, representing, to our knowledge, the largest series ever reported of emergency surgery in such a setting. This finding remains difficult to explain, although an increase in the prevalence of MR due to degenerative MV disease appears a common finding in patients with MR [18].

Because of the poor results obtained by non-surgical approaches [5], surgery represents the only effective therapeutic option in case of ASMR. Comprehensive information about surgical results in ASMR, however, is lacking. Several reports, although characterised by limited patient cohorts, have described the surgical outcome in post-AMI ASMR [2–12]. Thompson and colleagues [5] showed 40% in-hospital mortality in 43 patients undergoing surgery for post-AMI ASMR in the Shock Trial Registry experience. More recently, Tavakoli and Chevalier have independently shown slightly better results in surgical correction of ASMR in post-AMI patients with an early mortality of 22% and 24%, respectively. These dismal outcomes are in accordance to our experience, which showed a 26% of early mortality in post-AMI group of ASMR. The higher prevalence of shock before surgery in this subgroup of ASMR, as also indicated by the higher prevalence of preoperative mechanical cardio-circulatory assistance, explain such a finding. Acar and colleagues [19] indicated that cardiogenic shock was the only determinant of unfavourable in-hospital outcome in a series of 102 patients operated for ischaemic MR. In post-AMI MR, the impact of coronary revascularisation in patients with MV disease has been extensively investigated [3,4,6–8]. Chevalier and co-workers [3] have shown that the absence of myocardial revascularisation exerts an additional negative impact on early survival in patients undergoing surgery for post-AMI MR. In our experience, associated CABG conferred a protective role, but only in terms of long-term survival.

As mentioned, additional aetiologies may consistently contribute to occurrence of ASMR. Infective MV disease represents a well-established factor in the development of acute MR and the need for surgical correction. Mortality and morbidity remains high also in this setting, as confirmed by our data. In particular, patients afflicted by ASMR for infective MV disease showed poor long-term freedom from cardiac-related events. Several authors advocate the extensive use of mitral valve repair also for the treatment of AE [20]. In our experience, no discrepancy was observed between patients submitted to MV reconstruction or replacement in relation to early or late outcome, but the obvious and extensive varieties of structural damages encountered in MV AE make this search, in our opinion, extremely unreliable.

Postoperative results of patients with ASMR because of degenerative MV disease, have been poorly addressed in the literature. In our experience, emergency surgery in such a setting appears to have a more favourable outcome, in comparison with other ASMR aetiologies, although in-hospital mortality was as high as 15%. Indeed, half of these patients underwent surgery in cardiogenic shock and under mechanical ventilation, and this is in contrast to the relatively low prevalence of IABP implanted preoperatively (9%), most likely indicating better cardiovascular conditions as compared to post-AMI or AE patients.

The importance of comorbidities in term of postoperative outcome instead of aetiology of MV disease has been elegantly demonstrated by the Cleveland Clinic group [21]. In their analysis of 1.110 patients with ischaemic or degenerative MR, patient profile, mainly extent of coronary disease and LV dysfunction, influenced post-surgical outcome rather than the cause of valve insufficiency. Our data partially confirm these findings, since coronary artery disease and LV function were the most important predictors of unfavourable prognosis, either at early- or long-term.

Surgery for MV disease has evolved along the time, and, currently, MV reconstruction represents the gold standard in case of MR. The advantage of MV repair over replacement has been consistently demonstrated [22]. The role of different types of MV surgery, however, has been rather controversial in high-risk patients [7–9]. In our study, early and late outcome were not different in ASMR patients after valve repair or replacement, in agreement with the data recently described by the Cleveland Clinic group [7] and previously by other investigators [4,8,9]. The maintenance of MV/ventricular continuity is considered another important determinant of MV surgery, particularly in the aim of preserving early- and long-term LV contractility [23]. On the contrary, our series showed that the maintenance of MV chordae by leaving one or both leaflet integrity during prosthetic valve implantation did not apparently play a protective role in relation to postoperative outcome, also in terms of late LV function. The limited number of patients with severed MV leaflet, however, does not allow us to draw any definitive conclusions in this respect and, hence, respect of MV leaflets and chordae remains highly advisable while performing MV replacement, particularly in these high-risk patients.

4.1 Study limitations
This study contains the obvious limitations related to the multicentre and retrospective format of data collection. Indeed, the clinical evaluation and procedures were performed in different centres by different surgeons who might have differently assessed and evaluated the clinical or cardiopulmonary conditions. No randomisation was carried out in terms of surgical technique, either in terms of repair or replacement, making any conclusive analysis of potential inference of the type of surgery not applicable.

The number of patients at risk for long-term analysis was low.

In the acute endocarditis groups MV surgery might have occurred in a different disease phase, and no accurate information was available regarding the actual sepsis state with potential inference on postoperative results. No full neurological profiles were available in the AE group. Preoperative embolisation and neurological compromise might have influenced the perioperative course. No complete information was available in terms of time from AMI to ASMR. The clinical and cardio circulatory conditions of recent AMI are well known determinants of surgical results and this effect cannot be underestimated [24], particularly in light of higher rates of perioperative low cardiac output syndrome. Information about CPB or ischaemic times could not be also fully collected. These important data might have provided additional information regarding perioperative outcome, particularly in the cases where prolonged operating times were recorded. Postoperative echocardiographic evaluation was not performed by a core lab, making postoperative LV function, prosthetic valve or repaired MV assessment potentially unreliable.

	5. Conclusions

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusions Appendix A Appendix B References

 
This study, to our knowledge, represents the largest analysis of patients operated on in emergency for ASMR. This retrospective multicentre series showed that ASMR remains a surgical challenge. In our overall experience, almost one surgical candidate over four dies early after the surgical correction, and, interestingly, the type of surgical correction, either repair or replacement (preserving or not the valve leaflets) did not provide any beneficial effect at short or long-term postoperatively. Surgery for ASMR secondary to degenerative valve disease (usually chordal rupture) appears to portend a more favourable early and late prognosis, although still with a 15% of in-hospital mortality.

The presence of cardiogenic shock, left ventricular dysfunction, ASMR caused by or associated with coronary artery disease, and AE were negative predictors in terms of early survival as well as of freedom from cardiac-related events at follow-up.

In post-AMI patients, associated CABG procedure conferred a protective role only at long-term. Infective aetiology of ASMR showed to account for the highest incidence of major cardiac-related events in the postoperative period.

Finally, re-analysis of strategies of patient management in the presence of ASMR appears highly advisable since no substantial improvement, particularly in post-AMI patients, have been observed along the 20 year-span of this study.

	Appendix A

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusions Appendix A Appendix B References

 
Conference discussion

Dr M. Antunes (Coimbra, Portugal): You have presented a large series of patients with acute mitral valve regurgitation operated on as emergencies in six – it was six in the text, I see that it is seven now – different centres in Italy and Spain. Three groups of aetiology, myocardial infarction, degenerative and infective, render the study group quite heterogeneous, and consequently I find some difficulty in studying and comparing. These are very sick patients with a very poor natural history and prognosis. Naturally your operative mortality was high, as would be expected, but one has to consider that it is at least 10 times higher than would be expected of elective procedures, which obviously raises some question marks about the indication for emergency procedures, which in fact you conclude in your last slide but to which I didn’t have access prior to your presentation. Having in mind advances in medical therapy, one can question what our attitude should be.

I have a couple of comments and questions for you. First, this is obviously a historical series; it goes from 1986 to 2006. Were there any changes in the distribution of both the cases and the different pathologies throughout these years? Did you analyse your results? I saw in one of your slides that there was an analysis, and apparently there wasn’t much difference in the different time periods, but how complete was that analysis? I would like some more details. What percentage of your acute cases with relation of total number of cases, if it is possible to know, what is currently the percentage of these type of acute cases in your practice?

Second, I was a little perturbed by the large number of cases in the degenerative group. Usually these cases are not that acute and result from ruptured chordae or from already present prolapse of a leaflet. And even if they present in an acute phase, it is usually easy to get them out of an acute phase and then operate on them electively. Could you give some details about that? Also I am worried in this same group about the number of mitral valve replacements. In this particular group, which percentage of mitral valve replacements did you do, because degenerative cases usually are repaired.

Finally, you found that there was no early or long-term survival difference in patients who had mitral valve replacement versus mitral valvuloplasty. What explains this? What are the reasons for there being no difference, since most of us have an experience that the long-term results in the general series are completely different between repair and replacement.

Dr Lorusso: As regards the distribution, it was one of our major aims to analyse whether the surgery performed in the early ages was different from the result we had recently, and this didn’t seem to be the case, to our surprise. As you saw, there is a slight trend towards reduced early mortality, but it didn’t reach statistical significance in each of the groups we studied. So the reply is we didn’t see any discrepancy or difference among groups along the time.

Regarding the percentage of the degenerative group, you are right. In a paper of Horstkotte published quite recently, about 42 patients entering the intensive care unit in acute pulmonary oedema because of mitral regurgitation, half of the patients were in shock because of acute myocardial infarction, 25% were due to acute endocarditis, and only 5% were due to degenerative mitral valve disease. In our study the degenerative group reached 25%. I think this could be a bias due also to the reputation of the centres. We are doing a lot of mitral valve repair in all the centres involved. So probably we see more patients from secondary hospitals aiming at more conservative surgery.

But also I made a study about that. The majority of these patients were in systemic arterial hypertension, which is well known to be more and more prevalent in patients with cardiovascular diseases. Systemic arterial hypertension has been also shown to be more and more prevalent in patients with degenerative mitral valve disease. So I think that we are going to face more and more of these patients, more than in the past. We made an analysis about the distribution, and we can confirm that degenerative mitral valve disease is getting more frequent than in the past. However, this factor didn’t reach statistical significance, but it was definitely a trend.

Regarding the difference about repair or replacement, again, as you saw, 27% received mitral valve repair and 73% valve replacement, with only 7% of the patients with no leaflet preservation. This is a multicentre trial, so I think the surgeon attitude, especially because there was 66% of patients in shock, was to be really as fast as possible and to replace while maintaining the annular ventricular continuity, particularly in the ischaemic group. From the patient data, I cannot say why it was not possible to repair more valves. But again, looking at this data, it doesn’t seem that, in this very high risk patient group, the type of mitral valve surgery plays a critical role, to be honest, and you could see it either in the early or in the late survival.

We looked at left ventricular ejection fraction, and in all patients, including the survivors, only 10 patients showed persistent left ventricular dysfunction, but this was in the post AMI group. So also in that respect, mitral valve repair or replacement didn’t play a critical role in the respect of left ventricular function preservation or recovery. But again, the left ventricular annular continuity was maintained in the vast majority (93%), of the patients with a replaced mitral valve. So I guess that the results could have been in favour of mitral repair in case the valve leaflet were not maintained. But this was not the case in our series.

Dr P. Kolh (Liege, Belgium): Two short questions. You said that there was no significant change over time, but was there an evolution in the way the patients were managed either preoperatively or during the operation, and as a consequence of this question, you said that we should be more aggressive, but in what way? Can you give us some of your insights?

Dr Lorusso: Regarding patient management, we had to look, as reported in the slides, at 39 variables: preoperative, intraoperative, and demographics. And what we saw, the kind of surgical management, like the myocardial preservation, didn’t play a major role in terms of postoperative results. Although we changed in some centres from crystalloid cardioplegia to blood cardioplegia, this was not found to be a critical factor.

Regarding the management, to be honest, I don’t think that in some patients coming to the rescue unit, or to the intensive care unit in frank pulmonary oedema and cardiogenic shock, taking these patients right away to the OR is an optimal strategy. I know I am provocative, but it could be that first you have to introduce an intra-aortic balloon pump, reduce the lung congestion, if it is possible, of course, and then taking these patients probably after a few days to the OR. I think this would dramatically change the early mortality of the patients.

Dr Kolh: Decrease the afterload, yes.

Dr C. Yankah (Berlin, Germany): I am talking about the same predictive factors for early death, whether in your analysis you also considered the interval between surgery and the referral time, and also how many patients underwent intra-aortic balloon pump in a cardiogenic state before surgery?

Dr Lorusso: Regarding the time, unfortunately we did not have all this information available, like, for instance, the time interval from acute myocardial infarction to surgery. So we couldn’t make this analysis at all.

Regarding intra-aortic balloon pump, if you look at the number of intra-aortic balloon pumps placed in the degenerative and acute endocarditis, it is very, very low, it is a few percent, as compared to 40% of the post AMI patients. I think this also makes a difference. We should be more aggressive and implant an intra-aortic balloon pump as soon as possible, even if you have an acute endocarditis with all the problems of sepsis and infection.

In our experience, one patient every four cases dies early after surgery. So we should improve our patient management, definitely, and this was seen in our evaluation along the time. So I don’t think we are doing a great job in preoperative patient management. Our aim should be to improve it.

	Appendix B

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusions Appendix A Appendix B References

 
Variables entered in the model

	Acknowledgments

 
This study was realized with the active support of the following surgeons: Tiziano Gherli (Cardiac Surgery Unit, University of Parma, Italy), Ettore Vitali (Cardiac Surgery Unit, Ospedale Niguarda, Milan, Italy), Ottavio Alfieri (Cardiac Surgery Unit, San Raphael Hospital, Milan, Italy), Giovanni Mariscalco and Sandro Ferrarese (Cardiac Surgery Unit, University of Insubria, Varese, Italy), Carlos Mestres, Jaim Mulet, Miguel Josa, and José Luis Pomar (Department of Cardiovascular Surgery, Hospital Clinic, Barcelona). We are also in debt with ‘Associazione Cuore e Ricerca’ and the ‘Heart Synergy Group’ for the valuable support.

We are grateful to Judith Wilson for the revision of the manuscript.

	Footnotes

 
Presented at the 21st Annual Meeting of the European Association for Cardio-thoracic Surgery, Geneva, Switzerland, September 16–19, 2007.

	References

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion 5. Conclusions Appendix A Appendix B References

 

1. Horstkotte D, Schulte HD, Niehues R, Klein RM, Piper C, Strauer BE. Diagnostic and therapeutic considerations in acute, severe mitral regurgitation: experience in 42 consecutive patients entering the intensive care unit with pulmonary edema. J Heart Valve Dis 1993;2:512-522.[Medline]
2. Tcheng JE, Jackman JD, Nelson CL, Gardner LH, Smith RL, Rankin JS, Califf RM, Stack RS. Outcome of patients sustaining acute ischemic mitral regurgitation during myocardial infarction. Ann Int Med 1992;117:18-24.[Abstract/Free Full Text]
3. Chevalier P, Burry H, Fahran F, Cuchera M, Jegaden O, Obadia JF, Kirkorian G, Touboul P. Perioperative outcome and long-term survival of surgery for acute post-infarction mitral regurgitation. Eur J Cardiothoracic Surg 2004;26:330-335.[Abstract/Free Full Text]
4. Tavakoli R, Weber A, Brunner-La Rocca H, Bettex D, Vogt P, Pretre R, Jenni R, Turina M. Results of surgery for irreversible moderate to severe mitral regurgitation secondary to myocardial infarction. Eur J Cardiothorac Surg 2002;21:818-824.[Abstract/Free Full Text]
5. Thompson CR, Buller CE, Sleeper LA, Antonelli TA, Webb JG, Jaber WA, Abel JG, Hochman JS, for the Shock Investigators Cardiogenic shock due to acute severe mitral regurgitation complicating acute myocardial infarction: a report from the Shock Trial Registry. J Am Coll Cardiol 2000;36(Suppl. A):1104-1109.[Abstract/Free Full Text]
6. Grossi EA, Goldberg JD, LaPietra A, Ye X, Zakov P, Sussman M, Delianides J, Culliford AT, Esposito RA, Ribakove GH, Galloway AC, Colvin SB. Ischemic mitral valve reconstruction and replacement: comparison of long-term survival and complications. J Thorac Cardiovasc Surg 2001;122:1107-1124.[Abstract/Free Full Text]
7. Gillinov MA, Wierup PN, Blackstone EH, Bishay ES, Cosgrove DM, White J, Lytle BW, McCarthy PM. Is repair preferable to replacement for ischemic mitral regurgitation?. J Thorac Cardiovasc Surg 2001;122:1125-1141.[Abstract/Free Full Text]
8. Cohn LH, Rizzo RJ, Adams DH, Couper GS, Sullivan TE, Collins Jr. JJ, Aranki SF. The effect of pathophysiology on the surgical treatment of ischemic mitral regurgitation: operative and late risks of repair versus replacement. E J Cardiothorac Surg 1995;9:568-574.[CrossRef]
9. Hausmann H, Siniawski H, Hotz H, Hofmeister, Chavez T, Schimdt G, Hetzer R. Mitral valve reconstruction and mitral valve replacement for ischemic mitral insufficiency. J Card Surg 1997;12:8-14.[Medline]
10. Tepe NA, Edmunds LH. Operation for acute postinfarction mitral insufficiency and cardiogenic shock. J Thorac Cardiovasc Surg 1985;89:525-530.[Abstract]
11. Chen Q, Darlymple-Hay MJ, Alexiou C, Ohri SK, Haw MP, Livesey SA, Monro JL. Mitral valve surgery for acute papillary muscle rupture following myocardial infarction. J Heart Valve Dis 2002;11:27-31.[Medline]
12. Acar AR, Doukas G, Szafranek A, Alexiou C, Boehm MC, Chin D, Sosnowski A, Spyt TJ. Mitral valve repair and revascularization for ischemic mitral regurgitation: predictors of operative mortality and survival. J Heart Valve Dis 2002;11:793-800.[Medline]
13. Romesburg HC. Cluster analysis for researchers. NC: Lulu Press; 2004pp. 1–330.
14. Harrel FE, Lee KL, Califf RM, Pryor DB, Rosati RA. Regression modelling strategies for improved prognostic prediction. Statistics in Medicine 1984;3:143-152.[Medline]
15. Harrel Jr. FE, Lee KL, Mark DB. Multivariable prognostic models: issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors. Stats Med 1996:361-387.
16. Hosmer DW, Lemeshow S. Applied logistic regression. 2nd ed.. New York: Wiley-Interscience; 2000143–202.
17. Grunkemeier GL, Jamieson E, Miller C, Starr E. Actuarial versus actual risk of porcine structural valve deterioration. J Thorac Cardiovasc Surg 1994;108(4):709-718.[Abstract/Free Full Text]
18. Singh JP, Evans JC, Levy D, Larson MG, Freed LA, Fuller DL, Lehman B, Benjamin EJ. Prevalence and clinical determinants of mitral, tricuspid, and aortic regurgitation (the Framingham Heart Study). Am J Cardiol 1999;83:897-902.[CrossRef][Medline]
19. Acar AR, Doukas G, Szafranck A, Alexion C, Bohem MC, Chin D, Sosnowski A, Spyt TJ. Mitral valve repair and revascularization for ischemic mitral regurgitation: predictors of operative mortality and survival. J Heart Valve Dis 2002;11:793-800.[Medline]
20. Feringa HH, Shaw LJ, Polderman D, Hoeks S, van der Wall EE, Dion R, Bax JJ. Mitral valve repair and replacement in endocarditis: a systematic review of literature. Ann Thorac Surg 2007;83:564-570.[Abstract/Free Full Text]
21. Gillinov MA, Blackstone EH, Rajeswaran J, Mawad M, McCarthy PM, Sabik III JF, Shiota T, Lytle BW, Cosgrove DM. Ischemic versus degenerative mitral regurgitation: does etiology affect survival?. Ann Thorac Surg 2005;80:811-819.[Abstract/Free Full Text]
22. Shuhaiber J, Anderson RJ. Meta-analysis of clinical outcomes following surgical mitral valve repair or replacement. Eur J Cardiothorac Surg 2007;31:267-275.[Abstract/Free Full Text]
23. Yun KL, Sintek CF, Miller DC, Pfeffer TA, Kochamba GS, Khonsari S, Zile MR. Randomized trial comparing partial versus complete chordal-sparing mitral valve replacement: effects on left ventricular volume and function. J Thorac Cardiovasc Surg 2002;123:707-714.[Abstract/Free Full Text]
24. Hochmann JS, Buller CE, Sleeper LA, Boland J, Dzavik V, Sanborn TA, Godfrey E, White HD, Lim J, LeJemtel T. Cardiogenic shock complicating acute myocardial infarction – etiologies, management and outcome (Shock Trial Registry). J Am Coll Cardiol 2000;36(Suppl. A):1063-1070.[Abstract/Free Full Text]

This article has been cited by other articles:

				K. K. Stout and E. D. Verrier Acute Valvular Regurgitation Circulation, June 30, 2009; 119(25): 3232 - 3241. [Full Text] [PDF]

				O. Sokullu, H. Deniz, S. Sanioglu, and F. Bilgen Reply to Sersar et al. Eur. J. Cardiothorac. Surg., February 1, 2009; 35(2): 378 - 379. [Full Text] [PDF]

				M. Foroughi, S.-A. Hassantash, H. Saadat, and A. Ghanavaty Unusual ethiologies of severe acute mitral regurgitation not requiring surgery Eur. J. Cardiothorac. Surg., October 1, 2008; 34(4): 925 - 925. [Full Text] [PDF]

				R. Lorusso, G. De Cicco, and S. Gelsomino Reply to Foroughi et al. Eur. J. Cardiothorac. Surg., October 1, 2008; 34(4): 926 - 926. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Roberto Lorusso Sandro Gelsomino Cesare Beghi Claudio Russo Michele De Bonis Andrea Colli Andrea Sala Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lorusso, R. Articles by Sala, A. Search for Related Content PubMed PubMed Citation Articles by Lorusso, R. Articles by Sala, A. Related Collections Valve disease