Atrial Fibrillation and Mitral Valve Repair

Angelika Jovin, MD; Dana A. Oprea, MD; Ion S. Jovin, MD; Sabet W. Hashim, MD; Jude F. Clancy, MD

Disclosures

Pacing Clin Electrophysiol. 2008;31(8):1057-1063. 

In This Article

MR and Mitral Repair

Mitral regurgitation (MR) can be organic, caused by intrinsic mitral disease such as rheumatic disease; degenerative, ruptured chord; and perforation of leaflet, or functional, where a normal valve regurgitates because of ventricular dysfunction and mitral annular dilatation. For a long time, rheumatic fever was the predominant cause of organic MR. Now the main causes are mitral valve prolapse and ischemic heart disease.

Patients with MR may remain asymptomatic for many years or even a lifetime. In patients with severe symptomatic MR, the clinical outcome is poor. The average mortality rate is approximately 5% per year and 33% at 8 years in the absence of surgical intervention. Deaths are related to heart failure, sudden death, and complication such as AF, cerebral ischemic events and endocarditis.[21]

Chronic left ventricular overload leads to compensatory dilatation of the left ventricle. Cardiac output is initially maintained. Myocardial decompensation results in symptoms of heart failure and an increase in sudden death. In addition, the backflow into the left atrium causes an enlargement of the left atrium, which leads to AF and elevated pulmonary pressure. When AF occurs and persists for more than 3 months prior to surgery, there is a high risk of postoperative persistence of AF requiring long-term anticoagulation.[22] Because of this, and because the presence of AF is related to increased surgical risk as well as increased postoperative morbidity and possible mortality (see below), AF is regarded as an indication for surgery in patients with MR in whom surgery is likely, even in the absence of left ventricular enlargement or decompensation (the ACC/AHA guidelines state that "MV surgery is reasonable for asymptomatic patients with chronic severe MR, preserved left ventricular (LV) function, and new onset of AF [Level of Evidence: C]").[23]

Although controlled data are not available, mitral valve repair is considered the surgical procedure of choice in patients who are appropriate candidates, including those with rheumatic mitral valve disease[24] and mitral valve prolapse.[25] Valve repair is the optimal surgical intervention for MR.[23] As compared to valve replacement, valve repair results in superior hemodynamics and ventricular function, avoidance of the need for long-term anticoagulation, and less distortion of the ventricular shape. A number of retrospective studies have demonstrated improved LV function and survival in patients undergoing valve repair compared to valve replacement with or without subvalvular preservation.[26,27,28,29,30,31,32] Furthermore, a survival benefit from valve repair may not be seen in higher risk patients with ischemic MR.[33]

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