Echo-Guided Mitral Repair Drake et al: Echo-Guided Mitral Repair

Background—Echocardiography is available in the most basic healthcare environments. Mitral repair is potentially curative and, when possible, recommended over replacement. The efficacy of echo-guided repair has not been established. Methods and Results—We developed a succinct set of precisely defined images observed to be highly concordant with intraoperative findings. These images guided intervention on 237 consecutive patients. None were lost to follow-up and serial echocardiography was obtained on all repairs. This analysis includes 2,037 echocardiograms. The intent to repair or replace was documented preoperatively in 98.7%. Concordance was associated with successful repair (97.8% vs. 57.1%; P=0.001). Three-dimensional concordance was higher than two-dimensional (100% vs. 94.4%; P=0.05). Echocardiography guided a graduated surgical approach for degenerative and myopathic repairs by quantifying segmental prolapse, anterior leaflet closing angles, and tenting for integration of secondary chord-lysis (P<0.001) and commissural width (P<0.01). Repair rates increased from 46.5% to 77.6% (P<0.001). Concomitant Society of Thoracic Surgeons (STS) rates were 46.6% (vs. unguided 46.5%; P=0.99) and 54.9% (vs. echoguided 77.6%; P<0.001). Repair was successful in 91.5% of isolated echo-guided mitral operations (vs. concomitant STS 70.0%; P<0.001). Echo-guided repair rates for degenerative, myopathic, and inflammatory diseases were 99.0%, 97.1%, and 84.2% with linearized annual recurrent regurgitation of 0.63%, 2.19%, and 4.37% respectively. Conclusions—Echocardiography can reliably identify repairable mitral disease and guide intervention. Echo-guided repair is associated with a higher rate of initial success than unguided historical and concomitant national controls. Three-dimensional echo improves concordance. Secondary chord-lysis is associated with durable repair and may prevent ventricular remodeling.