Can Mitral Valve Replacement Be The First-line Intervention? - LVAD Implantation Alone Vs. Chordal Sparing Mitral Valve Replacement With Submitral Procedures For End-stage Heart Failure
Yasushige Shingu, Takahiro Ishigaki, Tomonori Ooka, Suguru Kubota, Yoshiro Matsui.
Hokkaido university, Sapporo, Japan.
OBJECTIVE: Mitral valve replacement (MVR) is not usually considered as the first-line surgical intervention before left ventricular assist device (LVAD) because the pathology of dilated cardiomyopathy is not the valve but the ventricle. We compared the early clinical outcome of our new surgical approach for MVR to that of LVAD therapy.
METHODS: Subjects were 26 patients who had refractory heart failure due to cardiomyopathy and mitral regurgitation (MR): 14 patients with more than moderate MR who had implantable LVAD and 12 patients with severe MR who were not candidates for heart transplantation and underwent chordal sparing MVR. MVR was conducted with a combination of papillary muscle approximation and suspension (papillary muscle tugging approximation), new modification that we developed in 2015.
RESULTS: The etiology was non-ischemic in all the patients in LVAD and 7 patients in MVR group. Patients were younger and NYHA class was higher in LVAD. Preoperative contractile function was comparable between the groups: LV end-diastolic dimension was 72±6 and 71±10 mm; LV ejection fraction, 24±6% and 22±6%; Mw (a load independent parameter), 35±10 and 36±7 ergcm-3103 in LVAD and MVR group, respectively. There were 2 hospital deaths in LVAD and none in MVR. Postoperative hospital stay was significantly longer in LVAD (112±35 vs. 39±16 days, p<0.01). Overall survival was comparable between the groups. However, 1-year freedom from re-admission rate was lower in LVAD (20% vs. 83%, p<0.01). The reasons for re-admission in LVAD were driveline infection in 4, major bleeding in 3, device failure in 1, and others in 2.
CONCLUSIONS: The early outcome of MVR with our modification adding submitral procedures was better than that of LVAD in terms of hospitalization. Further study is necessary to determine whether the strategy for MVR can prolong LVAD-free period and improve quality of life for those with end-stage heart failure.
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