The Impact of Preservation of Annulo-Papillary Continuity During Mitral Valve Replacement Surgery on Right Ventricular Performance
Ahmed Ghoneim1, Amro Serag2, Abdel-Hady Taha2, Hosam Fawzy2, Amr Abdelwahab2, Adam El-Gamel1
1Waikato Hospital, Hamilton, New Zealand2Tanta University, Tanta, Egypt
Objectives: The merits of preservation of the annulo-papillary continuity on the left ventricular function after mitral valve replacement (MVR) has been recognized but its influence on the right ventricular (RV) performance has not been studied. Our aim was to assess the impact of preservation and resection of the mitral valve (MV) apparatus on the RV performance.
We prospectively recruited 148 patients with MV disease, and according to the technique of MVR, they were divided into 3 groups. The resection group (R-MVR) n=59 patients; who had MVR with severing both anterior and posterior chordae, the partial preservation group (P-MVR) n=45 patients; only the posterior leaflet's chordae were preserved, and the total preservation group (T-MVR) n=44 patients; both leaflets chordae were retained. Two-dimensional trans-thoracic echocardiography was used to assess the RV function before and after surgery. Univariable and multivariable analyses were performed to detect the predictors of RV dysfunction (RVD) after surgery.
The RV fractional area change (RVFAC) values were comparable between the three groups pre-operatively (37.4±7.6%, 37.8±6.5%, 34.7±13.0% in R-MVR, P-MVR and T-MVR respectively). The majority of patients had declines immediately after surgery, however in the R-MVR group, the RVFAC had further deterioration at 6-month follow-up (25.4±6.6%) and failed to recover to the pre-operative values in the P-MVR group (33.4±6.8%), while in the T-MVR group, it showed significant improvement (47.4±10.2%).
The pre-operative values of RV myocardial performance index (MPI) were impaired in all groups (0.64±0.15, 0.63±0.13, 0.59±0.13 in R-MVR, P-MVR, and T-MVR in order). Postoperative gradual and progressive improvement was recorded in T-MVR to reach normal values at 6-month follow-up (0.37±0.06) while other groups failed to improve and it was noted that MPI in R-MVR, and P-MVR was 0.67±0.10 and 0.59±0.08 in order. In the 6-month multivariable analysis, total preservation of chordae was a protective factor against RVD (p= 0.001) while total resection was an independent predictor of RVD (p= 0.011). After matching with the propensity score total preservation and resection techniques retained their prognostic effect with significant values (p= 0.001, 0.002 in order).
Preservation of the annulo-papillary continuity of the MV apparatus during MVR is crucial in preserving RV performance with the superiority of total versus partial preservation.
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