End-stage cardiomyopathy and secondary mitral insufficiency surgical alternative with prosthesis implant and left ventricular restoration

BACKGROUND: Secondary mitral insufficiency is a strong risk factor for death in end-stage cardiomyopathy. The possible correction of mitral regurgitation has now been accepted as an alternative to cardiac transplantation in a special subset of patients. We propose a new surgical approach that consists of implantation of a mitral prosthesis that is smaller than the annulus, and preservation and traction of the papillary muscles to reduce sphericity of the left ventricle. METHODS: Between December 1995 and September 2005, 116 patients with dilated cardiomyopathy underwent this procedure, with the following etiologic factors: ischemic (68), idiopathic (43), Chagas disease (3), viral (1), and postpartum (1). The patients were analyzed according to clinical criteria, echocardiographic findings, and morphology of left ventricle. RESULTS: All patients were in an end-stage phase, requiring >2 hospital admissions over the past 3 months, despite receiving full medication. Furthermore, seven were in intensive care unit receiving intravenous drugs or intra-aortic balloon counterpulsation, and one was in cardiogenic shock. Hospital mortality was 16.3% (19/116), yet midterm follow-up showed a relatively flat late survival curve, with evidence of improved clinical status, better echocardiographic parameters, and reduction in ventricular sphericity. CONCLUSIONS: The high early mortality rate related to other clinical conditions at the time of surgery. However, the resultant flat survival after this early interval offers a promising long-term therapeutic alternative for the treatment of patients in refractory heart failure with cardiomyopathy that is associated with moderate or severe secondary mitral regurgitation.