Surgery for acute ischemic mitral incompetence
Emergency surgical correction of severe mitral incompetence complicating acute myocardial infarction still remains a therapeutic challenge for various reasons including the poor hemodynamic condition of these patients preoperatively, the potentially limit
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Introduction
Emergency surgical correction of severe mitral incompetence complicating acute myocardial infarction still remains a therapeutic challenge for various reasons including the poor hemodynamic condition of these patients preoperatively, the potentially limited amount of residual viable myocardium , and the technical difficulties associated with the surgical procedure . On the basis of a clinical experience that encompasses 25 patients who underwent emergency surgery for acut e ischemic mitral incompetence, we address the main surgical issues that continue to be raised by this life-threatening clinical entity. Patient population
From 1972 through 1988, 25 patients required an acute operation for early postinfarction mitral incompetence. There were 23 men and two women who ranged in age from 46 to 83 years (mean: 60 years). Twenty-three patients had inferior and two had anterolateral wall infarctions . The interval between acute myocardial infarction and the appearance of the murmur of mitral insufficiency rang ed from 1 to 14 days. At the time of admission , all patients were in cardiogenic shock or in intractable left ventricular failure with pulmonary edema. Six of them were supported by the intraaortic balloon pump prior to surgery. The clinical diagnosis of mitral regurgitation was confirmed by echocardiograms and cardiac catheterization. Coronary angiograms were performed in only seven patients ; three of them were found to have a tight stenosis of the left anterior descending coronary artery in addition to occlusive disease of the artery supplying the infarcted myocardium . At operation , 15 patients had a complete rupture of the posterior papillary muscle; six had partial rupture involving the posterior papillary muscle in five cases and the anterior papillary muscle in one case . The remaining four patients had papillary muscle dysfunction involving the posterior papill ary muscle in three cases and the anterior one in one case . The 25 patients underwent prosthetic valve replacement. All of these were performed through a left atrial approach. Of the 25 pro sthetic valves, 15were mechanical valves and 10 were bioprostheses. Three patients had additional single bypass grafts to the left anterior descending coronary artery. 195 H. O. Vetter et al. (eds.), Ischemic Mitral Incompetence © Springer-Verlag Berlin Heidelberg 1991
Results
Six patients died intra-, or postoperatively. Two patients could not be weaned from cardiopulmonary bypass. Two additional patients died in the Intensive Care Unit of persistently low cardiac output. Two other patients died 6 and 19 days after operation , respectively, one of pulmonary sepsis and the second, suddenly. There were 19 hospital survivors, 11 of whom had required intra-aortic balloon pump support postoperatively . Discussion
Patients with postinfarction mitral incompetence can fit into three categories: 1) those with an early and transient murmur, without hemodynamic consequences; 2) those with a mitral insufficiency of delayed onset , and which can be tr
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