(Screen 2 - 5:30 PM Saturday) Mitral Valve Function after Anomalous Left Coronary Artery from the Pulmonary Artery Repair: Does Mitral Regurgitation Improve when Left Ventricular Function is Normal Preoperatively?

Find board locations here.

Abstract:

Introduction: In patients with anomalous left coronary artery from the pulmonary artery (ALCAPA), there is a subset who have mitral regurgitation (MR) with preserved left ventricle (LV) function secondary to coronary collateral vessels. Studies exploring the status of MR after coronary reimplantation surgery are limited.

Hypothesis: Patients with normal LV function and significant MR will not have improvement of mitral valve function with coronary reimplantation alone.

Methods: We conducted a retrospective analysis of all patients undergoing isolated ALCAPA surgery from January 2009 to March 2018 at 22 centers participating in Collaborative Research from the Pediatric Cardiac Intensive Care Society (CoRe-PCICS). We compared the degree of MR (by echocardiography) in patients with normal or mildly diminished LV systolic function (Normal) to those with moderate or worse LV systolic dysfunction (Abnormal) prior to the procedure and through 3 years of follow up.

Results:
Our cohort included 228 patients - 76 Normal and 152 Abnormal. Normal group median age was 5 years (IQR 5 months–15 years) versus 3.5 months (IQR 2.5 months – 5.5 months) in the Abnormal group (p-value < 0.0001). Normal group mean pre-operative ejection fraction (EF) was 60% (range 42-85; SD 9.6) versus 25% (range 7-57; SD 11) in the Abnormal group. At latest follow-up EF had normalized in all.
The Abnormal group had a significantly worse degree of pre-operative MR (p-value < 0.0001) and discharge MR (p-value=0.001). At 1 and 3 year follow up, however, the Abnormal group had a significantly greater decrease in the degree of MR - 1 yr, p-value=0.018; 3 yr p-value=0.006. Pre-operatively, 77/152 (51%) patients in the Abnormal group and 20/76 (26%) in the Normal group had ≥moderate MR. By 3 year follow up, this percentage was reduced by a factor of 3 in the Abnormal group versus 1.6 in the Normal group. (Figure)

Conclusions: Spontaneous improvement in MR after ALCAPA repair appears to vary based on LV function at presentation. While moderate or severe MR is less common in patients with normal LV function prior to surgery, coronary reimplantation alone is less likely to lead to normalization of mitral function and should prompt consideration of concomitant mitral repair at the time of the coronary repair.