This Article Full Text Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Acker, M. A. Search for Related Content PubMed PubMed Citation Articles by Acker, M. A. Related Collections Other heart failure CV surgery: valvular disease

Controversies in Heart Failure

Should Moderate or Greater Mitral Regurgitation Be Repaired in All Patients With LVEF <30%?

Mitral Valve Repair in Patients With Advanced Heart Failure and Severe Functional Mitral Insufficiency Reverses Left Ventricular Remodeling and Improves Symptoms

Michael A. Acker, MD

From the Department of Surgery and Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pa.

Correspondence to Michael A. Acker, MD, William Maul Measey Professor of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 6 Silverstein, Philadelphia, PA 19104. E-mail michael.acker@uphs.upenn.edu

An extract of the first 250 words of the full text is provided, because this article has no abstract.

Mitral regurgitation (MR) is commonly observed in patients with heart failure and associated with a poor prognosis.^1–3 Mitral valve repair or replacement to restore valve competency is a well-established procedure when there are symptoms of heart failure and the primary disease is of the valve leaflets. However, recent interest has focused on functional or secondary mitral insufficiency in which the valve leaflets are anatomically normal but do not fully coapt because of annular dilatation and restricted leaflet motion secondary to increased ventricular size and sphericity. Such a remodeled ventricle is often associated with an ejection fraction of 40% and heart failure symptoms of New York Heart Association (NYHA) class III or IV. Surgery in this situation is controversial, as the MR is the consequence and not the cause of left ventricular (LV) dysfunction, and the prognosis, therefore, is more related to the underlying cardiomyopathic process. In addition, it has been thought in the past that elimination of a low pressure runoff might worsen the overload of the left ventricle and contribute to the high mortality seen with mitral valve surgery in heart failure patients.

Progressive LV remodeling characterized by progressive LV dilatation and change to a more spherical shape can result in functional MR as a result of annular dilatation, papillary muscle displacement, and chordal tethering. The functional MR leads to an increased preload, increased wall tension, and increased LV workload, all of which contribute in a positive feedback loop to progressive heart failure. The presence of MR itself is . . . [Full Text of this Article]