Results of valve replacement for severe mitral regurgitation due to papillary muscle rupture or fibrosis

Late results of mitral valve replacement for papillary muscle rupture (four patients) or fibrosis without rupture (five patients) are described for the first time. Patients underwent operation 3 months to more than 13 years (median 14 months) after the onset of severe mitral regurgitation. Preoperatively all had holosystolic murmurs, atrial and ventricular gallops, cardiomegaly and cardiac failure. Three had class III and six had class IV functional capacity (New York Heart Association Classification). Atrial fibrillation developed in the three patients who had mitral regurgitation for more than 3 years. Left atrial mean pressure (average 27 mm Hg) and V waves (average 46 mm Hg) were greatly increased in all but one patient, and cardiac index (average 2.0 liters/min per m 2) was reduced in all but one. No finding distinguished patients with rupture from those without rupture. The left ventricular angiogram was the best preoperative guide to postoperative results. Of five patients with poor left ventricular contractions, four died (one suddenly 2 days postoperatively and three with cardiac failure, two 6 months and one 62 months postoperatively); 4 months after operation one is limited by the residua of a cerebral embolus. None of the three studied postoperatively showed hemodynamic improvement. In contrast, of four patients with fair or good left ventricular contractions preoperatively, three have class I or II functional capacity 23, 60, 64 months, respectively, after operation, and one died suddenly 41 months after operation. All three studied postoperatively showed marked hemodynamic improvement.