Valvular Disease in the Elderly: Influence on Surgical Results

Transcription

1 ORIGINAL ARTICLES Valvular Disease in the Elderly: Influence on Surgical Results Elizabeth A. Davis, MD, Timothy J. Gardner, MD, A. Marc Gillinov, MD, William A. Baumgartner, MD, Duke E. Cameron, MD, Vincent L. Gott, MD, R. Scott Stuart, MD, Levi Watkins, Jr, MD, and Bruce A. Reitz, MD Department of Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland Aortic valve disease in the elderly is primarily calcific stenosis with preservation of left ventricular function. In contrast, mitral valve disease in the elderly often is ischemic in nature with damage occurring to both valve and myocardium. The present study was undertaken to compare results of aortic (AVR) and mitral valve replacement (MVR) in the elderly and to ascertain predictors of poor outcome. Because patients who had concomitant coronary artery bypass grafting (CABG) are included (51% for AVR, 55% for MVR), patients who had isolated CABG were used as a comparison group. Between January 1, 1984, and June 30, 1991, 1,386 patients aged 70 years and older underwent CABG (n = 1,043), AVR (n = 2451, or MVR (n = 98). The operative mortality rates were 5.3% for AVR, 20.4% for MVR, and 5.8% for CABG. Late follow-up of patients undergoing operation in 1984 and 1985 was available for 98% (231/237). Overall survival was comparable for all three groups through the first 5 years of follow-up (AVR, 68% f 8%; MVR, 73% f 8%; CABG, 78% f 3%). After 5 years, survival for patients having AVR and MVR was less than that for those having CABG. Patient age, sex, New York Heart Association functional class, concomitant CABG, prosthetic valve type, native valve pathology, and preoperative catheterization data were examined as possible predictors of outcome by multivariate logistic regression. Among MVR patients, New York Heart Association functional class, ischemic valvular pathology, and higher pulmonary capillary wedge pressure were predictive of operative mortality; poor left ventricular function was a predictor of poor long-term survival (17% versus 100% at 7 years; p < ). Among AVR patients, only advanced functional class was associated with a poor outcome. Compared with MVR patients, AVR patients were older (76.5 f 4.6 versus 74.5 f 3 years; p = ), were more often male (55% versus 39%;~ = 0.006), had a lower pulmonary capillary wedge pressure (18 k 11 versus 24 f 10 mm Hg; p = O.OOOl), and had fewer critically diseased vessels (p = 0.001). These results suggest that AVR in the elderly has an operative mortality similar to that of isolated CABG. In contrast, MVR is less well tolerated, especially in patients with ischemic mitral disease. Survival 5 years postoperatively is similar among AVR, MVR, and CABG patients but becomes significantly worse thereafter for AVR and MVR patients. (Ann Thorac Surg 1993;55:333-8) ne of the most important recent developments in 0 cardiac surgery over the past decade has been the marked increase in the number of elderly patients referred for open heart procedures. At our institution, we have witnessed an increase in mean age of patients undergoing isolated coronary artery bypass grafting (CABG) from 59.7 years in 1984 to 64.2 years in Many elderly patients have cardiac valvular lesions that necessitate valve replacement. Aortic valve disease in the elderly is primarily calcific stenosis with preservation of left ventricular function (LVF). In contrast, mitral valve lesions in the elderly are often complex ischemic lesions. Persistent or repeated episodes of ischemia often result in chronic myocardial damage and dysfunction. Presented at the Twenty-eighth Annual Meeting of The Society of Thoracic Surgeons, Orlando, FL, Feb 3-5, Address reprint requests to Dr Cardner, Division of Cardiac Surgery, Blalock 618, The Johns Hopkins Hospital, 600 N Wolfe St, Baltimore, MD This report presents the experience at our institution with valvular operations in elderly patients. By examining mortality rates and risk factors predictive of a poor outcome for aortic (AVR) or mitral valve replacement (MVR), we have attempted to describe the influence of valvular disease on surgical outcome in the elderly. Material and Methods This study reviews the data for patients aged 70 years or older who underwent AVR or MVR between January 1, 1984, and June 30, 1991, at The Johns Hopkins Hospital. Because patients who had concomitant CABG are included, elderly patients who had isolated CABG were used as a comparison group. Patients who had multiplevalve replacements are excluded from this report. Operative Technique The surgical approach was through a median sternotomy. Extracorporeal perfusion was employed using bubble (earlier years of study) or membrane oxygenators with moderate systemic hypothermia (core temperature, 28" to by The Society of Thoracic Surgeons /93/$6.00

2 334 DAVISETAL VALWLAR DISEASE IN THE ELDERLY Ann Thorac Surg 1993; C). The method of myocardial protection was singledose cold (4 C) crystalloid hyperkalemic cardioplegia injected into the aortic root after placement of the aortic cross-clamp and continuous topical cooling with cold saline solution. Perfusion flow rates were maintained between 1.8 and 2.8 L * min-' - m-* with mean arterial pressure between 50 and 70 mm Hg. A pulmonary artery vent was routinely employed. Data Acquisition Data were obtained by retrospective review of medical records, catheterization and pathology reports, death certificates, and autopsy reports. Data collected from medical records included New York Heart Association (NYHA) functional class, surgical status (elective versus urgenvemergent), and number of postoperative hospital days. Catheterization data consisted of LVF, pulmonary capillary wedge pressure, number of critically diseased vessels (270% narrowing of the luminal diameter), transvalvular gradient, valve area, and degree of regurgitation (graded angiographically from 1 to 4+). Operative reports provided the surgical procedure, valve prosthesis, and gross valvular pathology. Additional description of valvular pathology was obtained from formal pathology reports. Death certificates and autopsy reports provided dates and causes of death. Follow-up Data Follow-up information was obtained on patients who underwent operation in 1984 and Telephone contact was made with the patient, a family member, or the patient's current physician. Statistical Analysis Univariate analysis of potential risk factors for early mortality was performed using,f analysis for discrete variables and unpaired t tests and analysis of variance for continuous variables. To determine independent predictors of mortality, variables with a p value of less than 0.1 in the univariate analysis were entered as covariates in a multivariate logistic regression model that contained age and sex (SAS Institute Inc, Cary, NC). Factors possibly predictive of long-term survival were examined individually by Kaplan-Meier actuarial analysis, and their significance was determined by the Breslow test (BMDP Statistical Software, Los Angeles, CA). All values are expressed as the mean f one standard deviation except survival data, for which the standard error is reported. A p value of less than 0.05 was considered significant. Results The study population consisted of 1,386 patients: 245 underwent AVR, 98 underwent MVR, and 1,043 had isolated CABG. One hundred twenty-five (51%) of the patients who had AVR and 54 (55%) of the patients who had MVR had concomitant CABG. There were 135 men (55%) and 110 women (45%) in the AVR group, 38 men (39%) and 60 women (61%) in the MVR group, and 665 men (64%) and 378 women (36%) in the CABG group. Table I. Summary of Patient Data" Variable Demographics Men Women Age (Y) Age range (Y) NYHA class 1/11 IIInv Status Elective UrgenNemergent Hernodynamics LVF Poor Faidgood PCWP (mm Hg) Valve gradient (mm Hg)b Valve area Angiography 0-Vessel disease 1-Vessel disease 2-Vessel disease 3-Vessel disease AVR MVR In = 245) (n = 98) 135 (55) 110 (45) 76.5 t 4.6 7C90 11 (4) 234 (96) 160 (65) 85 (35) 39 (16) 206 (84) 18 * k t (47) 60 (24) 32 (13) 39 (16) 38 (39) 60 (61) 74.5 t (57) 42 (43) 11 (11) 87 (89) 24 r?: (35) 19 (19) 10 (10) 35 (36) Numbers in parentheses are percentages. Data are for patients with pure aortic stenosis only. AVR = aortic valve replacement; LVF = left ventricular function; MVR = mitral valve replacement; NYHA = New York Heart Association; PCWP = pulmonary capillary wedge pressure. Clinical, hemodynamic, and angiographic characteristics of patients having valve replacement are summarized in Table 1. Bioprostheses were used in 193 AVRs (79%) and 66 MVRs (67%). Five (three AVRs, two MVRs) were Ionescu-Shiley bovine valves; all others were Carpentier- Edwards porcine valves. All mechanical prostheses were St. Jude Medical valves except for one Medtronic valve in the AVR group. Native valve pathology is detailed in Table 2. Pure aortic stenosis accounted for 208 (85%) of all aortic valve Table 2. Valvular Patholomf Variable Pure stenosis Pure regurgitation Mixed stenosis and regurgitation Calafic Ischemic Rheumatic Degenerative Endocarditis Other a Numbers in parentheses are percentages. Aortic Mitral (n = 245) (n = 98) 16 (16) 61 (62) 21 (22) 4 (4) 30 (31) 35 (36) 17 (17) 5 (5) 7 (7)

3 ~ ~ ~~ Ann Thorac Surg 1993;55:333-8 DAVIS ET AL 335 ' - -(II I endocarditis total ischemic I Incidence of 2 and 3 Vessel Disease (%) Fig 1. Incidence of two- and three-vessel disease according to valvular pathology. (AVR = aortic ualvc replacement; MVR = mitral valve replacement.) lesions. One hundred ninety-nine (96%) of these 208 lesions were calcific in nature. Pure mitral regurgitation occurred in 61 patients (62%). Among all patients having MVR, rheumatic disease was suspected in 35 patients (36%). Ischemic lesions were the second most prevalent lesion, occurring in 30 patients (31%). Figure 1 shows the incidence of severe two- and threevessel coronary artery disease (CAD) in AVR and MVR patients according to valvular pathology. Only 29% (71/ 245) of AVR patients and no more than 50% of any pathological subgroup had disease of two vessels or more. In contrast, 46% (45/98) of MVR patients had severe CAD. The incidence was highest in patients with ischemic pathology (90%; 27/30). The median number of days spent in the hospital postoperatively was 11 for AVR and 14 for MVR. The 30-day mortality rate was 3.3% (8/245) for AVR and 14.3% (14198) for MVR. In comparison, similarly aged patients undergoing CABG had a mortality rate of 4.7% (49/1,043). The in-hospital mortality rate was 5.3% (13/245) and 20.4% (20/98) for AVR and MVR, respectively. Elderly CABG patients had a hospital mortality rate of 5.8% (61/1,043) (Table 3). In-hospital mortality rates for valve Table 3. Thirty-Day and In-Hospital Mortality Rates" AVR MVR CABG Mortality (n = 245) (n = 98) (n = 1,043) 30-Day 3.3% 14.3% 4.7% (1%-5.5%) (7.2%-21.3%) (3.4%-6%) In-hospital 5.3% 20.4% 5.8% (2.5%-8.1%) (12.3%-28.5%) (4.3%-7.2%) a Numbers in parentheses show 95% confidence interval. AVR = aortic valve replacement; CABG = coronary artery bypass grafting; MVR = mitral valve replacement CABG Postoperative Years Fig 2. Actuarial survival for elderly patients undergoing aortic value replacement (AVR), mitral valve replacement (MVR), and corona ry artery bypass grafting (CABG). replacement alone were 3.3% (4/120) for AVR and 11.4% (5/44) for MVR. Concomitant CABG increased these rates to 7.2% (9/125) for AVR and 27.8% (15/54) for MVR. In the MVR group, 70% (14/20) of the deaths occurred in patients who were seen with ischemic valvular disease. Operation was urgently or emergently performed in 69% (9113) of the AVR patients and 85% (17/20) of the MVR patients who died. The percentage of in-hospital deaths from cardiac-related causes was 40% (8120) for MVR and 41% (25/61) for CABG but only 31% (4113) for AVR. Among those patients who died in-hospital but beyond the immediate 30-day postoperative period, cardiacrelated deaths were infrequent and occurred in only 2 MVR patients and no AVR or CABG patients. Information on late mortality for patients seen in the first 2 years of the study was available on 231 (98%) of 237 patients. In particular, follow-up data were obtained on 100% (54/54) of the patients having a valve procedure. The mean duration of follow-up was months. Survival rates for AVR, MVR, and CABG are shown in Figure 2. Survival was similar among the three groups through 5 years of follow-up: AVR, 68% f 8%; MVR, 73% f 8%; and CABG, 78% f 3%. After this, the AVR and MVR patients did significantly worse (p < 0.05) with 7-year survival rates of 61% & 8% for AVR and 63% 2 8% for MVR compared with 75% 2 3% for CABG. A number of factors were analyzed as possible predictors of surgical outcome: Age Sex NYHA functional class Valvular lesion Stenotic Regurgitant

4 336 DAVIS ET AL Ann Thorac Surg 1993; Stenotic and regurgitant Left ventricular function Pulmonary capillary wedge pressure Number of critically diseased vessels Concomitant coronary artery bypass grafting Number of coronary grafts Type of prosthesis Bioprosthetic Mechanical Valvular pathology Calcific Rheumatic Ischemic Degenerative Endocarditis For MVR, NYHA functional class (p = 0.03), pulmonary capillary wedge pressure of 25 mm Hg or more (p = 0.049), and ischemic valvular pathology (p = 0.01) were significant predictors of early mortality. For AVR, only NYHA functional class was a significant correlate (p = 0.02). Compared with MVR patients, AVR patients were older (p = ), were more often male (p = 0.006), had a lower pulmonary capillary wedge pressure (p = ), and had fewer critically stenosed vessels (p = 0.001). By univariate analysis, neither aortic valve gradient nor aortic valve area was a significant predictor of early mortality for patients with pure aortic stenosis. Similarly, the degree of aortic or mitral regurgitation did not predict death in patients with purely regurgitant lesions. Only poor LVF was predictive of late death for MVR patients (17% versus 100% survival at 7 years; p < ). Comment Cardiac operations are being performed in elderly patients with increasing frequency and encouraging results. For example, AVR in the elderly has an operative mortality rate of 5% to 10% [l-121 with long-term survival rates similar to that of age- and sex-matched patients in the general population [8, 111. These results have been attributed to improvements in patient selection, myocardial protection, and postoperative care. However, the septuagenarian or octogenarian is not simply the aged equivalent of the younger patient. In the elderly patient, there is a higher incidence of coexisting and serious morbidity, which adversely affects operative outcome [lo, 11, 131. It is noteworthy that most cardiacrelated deaths in this series occurred within 30 days of operation. Deaths occurring after that time but in-hospital were usually due to failure of multiple organ systems, demonstrating the precarious physiologic homeostasis present in elderly patients. Furthermore, the elderly heart is affected by a different spectrum of diseases. With age, the aortic valve undergoes fibrosis and calcification such that senile aortic stenosis is one of the most prevalent valvular lesions in the elderly. In the present study, calcific aortic stenosis was the indication for AVR in 85% (209/245). With advanced age also come an increased incidence of CAD and the effect of ischemia on the myocardium and valvular function. Ischemic mitral regurgitation constitutes a sizable proportion of mitral lesions seen in the elderly. In this series, 30 MVR patients (31%) had ischemic pathology. However, this classification underestimates the true incidence of ischemic heart disease in patients undergoing MVR. As shown in Table 1, 64 (65%) of MVR patients had at least one diseased coronary artery, and 45 (46%) had severe two- or three-vessel disease. Thus, nonischemic valvular pathology did not preclude the presence of serious CAD. Nevertheless, ischemic mitral valve disease identified a subset of patients with severe CAD. The incidence of two- and three-vessel disease in these patients was 90% (27/30). Pure calcific aortic stenosis typically causes concentric hypertrophy of the left ventricle, which may regress after relief of the outflow obstruction. In all but the end-stage case, there is usually little permanent damage to the myocardium, and patients fare well postoperatively [ 141. Indeed, in our series, the early mortality rate of 5.3% for patients undergoing AVR was essentially the same as that of patients having isolated CABG (5.8%), comparable with [6, 81 or less than [3, 111 results reported in other series. Concomitant CABG increased the mortality rate from 3.3% (AVR alone) to 7.2% (AVR + CABG). This finding was also noted in other reports [l, 3, 5, 9, 101 and raises the question how aggressively revascularization should be pursued in the elderly patient with aortic valve disease, especially in the patient without demonstrable preoperative ischemia. The additional intraoperative ischemic time required for bypass grafting may not have been well tolerated. On the other hand, more advanced ventricular dysfunction in patients requiring concomitant CABG may have contributed to the increased mortality rate. Because most patients in this series with coronary lesions amenable to revascularization underwent bypass grafting, the outcome of isolated valve replacement in such patients is not known. Clearly, further studies addressing these issues are needed. Only NYHA functional class correlated with early mortality for AVR. In particular, poor LVF did not correlate with mortality. These results are in agreement with those of Levinson and colleagues [4] in their report of AVR in octogenarians with aortic stenosis. This finding is also consistent with what is known of the natural history of aortic stenosis. Left ventricular function is well preserved until late in the course of the disease. Even then, valve replacement is sometimes curative, and ventricular function is restored to normal [14]. Long-term survival for the first 5 years after AVR paralleled that of CABG patients. The decline in relative survival thereafter is difficult to explain, as no risk factors were identified. Older age in AVR patients compared with MVR or CABG patients may have been contributory. In contrast to calcific disease, ischemic disease may damage not only the valve but also the myocardium. In this situation, valve replacement may do little to improve left ventricular dysfunction, and the condition of patients may continue to deteriorate [15]. Seventy percent of in-hospital deaths after MVR occurred in patients with

5 Ann Thorac Surg 1993; DAVIS ET AL 337 ischemic mitral valve disease. The overall early mortality rate of 20.4% for MVR patients was substantially higher than that of the AVR or CABG group. Multivariate analysis demonstrated that factors indicative of ischemic disease (higher pulmonary capillary wedge pressure and ischemic pathology) were the most important predictors of early death. Tsai and co-workers [9] also found that patients with acute ischemic syndromes require longer periods of cardiopulmonary bypass and cross-clamp time and have increased mortality. Although the number of critically diseased vessels was not found to be a correlate of early death, MVR patients had substantially more CAD than AVR patients. Furthermore, MVR patients who required concomitant coronary revascularization had a substantially higher mortality rate than those who did not (27.8% versus 11.4%), possibly reflecting a greater degree of ischemic myocardial damage. This finding raises the same issues of routine revascularization in elderly patients undergoing valve replacement. Although only 11% of MVR patients had poor LVF, this is probably an underestimation, especially given that 31% of the patients had ischemic disease and 98% were in NYHA class I11 or IV. Typically, LVF is determined by calculating ejection fraction from planimeter areas of left ventricular images in right anterior oblique and left anterior oblique projections. Conditions such as ischemic mitral regurgitation that decrease afterload may cause a misleading normalization of the ejection fraction despite real deterioration in function. Thus, it is likely that many more MVR patients had poorly functioning ventricles than is implied by the catheterization results. It is interesting that poor LVF did not emerge as a significant predictor of early mortality but did correlate with poor long-term survival. It may be that valve replacement (with or without revascularization) in these patients is temporizing but not curative. Although cardiac performance is stabilized or even improved in the immediate postoperative period, LVF may continue to deteriorate further. The published literature contains many reports on the outcome of valve operations in elderly patients. The majority of these have been written (1) to justify an aggressive surgical approach when medical therapy has failed, (2) to refute aortic valvuloplasty as a viable alternative to surgical intervention, or (3) to demonstrate acceptable mortality rates. Our study is unusual in that it examines how valvular disease in the elderly affects surgical outcome. Our results suggest that outcome after valve replacement in elderly patients is primarily a function of the damage incurred by the myocardium as a result of the primary disease, particularly the severity and extent of CAD. Thus, most elderly patients who undergo AVR are seen with a calcified stenotic aortic valve but a wellfunctioning ventricle. The degree of CAD is markedly less than that in MVR patients. Operative outcome is excellent for AVR, with an early mortality similar to that of isolated CABG. In contrast, patients requiring MVR have more serious ischemic disease, which damages both valve and myocardium. Operative outcome is worse in these patients, and long-term survival is dependent primarily on LVF. References Borkon AM, Soule LM, Baughman KL, et al. Aortic valve selection in the elderly patient. Ann Thorac Surg 1988;46: Deleuze P, Loisance DY, Besnainou F, et al. Severe aortic stenosis in octogenarians: is operation an acceptable alternative? Ann Thorac Surg 1990;50:22&9. Bessone LN, Pupello DF, Hiro SP, Lopez-Cuenca E, Glatterer MS Jr, Ebra G. Surgical management of aortic valve disease in the elderly: a longitudinal analysis. Ann Thorac Surg 1988; 46:2&9. Levinson JR, Akins CW, Buckley MJ, et al. Octogenarians with aortic stenosis: outcome after aortic valve replacement. Circulation 1989;8O(Suppl 1): Culliford AT, Galloway AC, Colvin SB, et al. Aortic valve replacement for aortic valve stenosis in persons aged 80 years and over. Am J Cardiol 1991;67: Jamieson WRE, Burr LH, Munro AI, Miyagishima RT, Gerein AN. Cardiac valve replacement in the elderly: clinical performance of biological prostheses. Ann Thorac Surg 1989;48: Merrill WH, Stewart JR, Frist WH, Hammon JW, Bender HW. Cardiac surgery in patients aged 80 years or older. Ann Surg 1990;211: Craver JM, Goldstein J, Jones EL, Knapp WA, Hatcher CR. Clinical, hemodynamic, and operative descriptors affecting outcome of aortic valve replacement in elderly versus young patients. Ann Surg 1984;199: Tsai TP, Matloff JM, Chaux A, et al. Combined valve and coronary artery bypass procedures in septuagenarians and octogenarians: results in 120 patients. Ann Thorac Surg 1986;42: Fiore AC, Naunheim KS, Barner HB, et al. Valve replacement in the octogenarian. Ann Thorac Surg 1989;48:1W. 11. Galloway AC, Colvin SB, Grossi EA, et al. Ten-year experience with aortic valve replacement in 482 patients 70 years of age or older: operative risk and long-term results. Ann Thorac Surg 1990;49: Wanibuchi Y, Takashi I, Sakakibara Y, Shiihara H, Furuta S. Early and late results of valvular surgery in the elderly. Jpn Circ J 1988;52: Horneffer PJ, Gardner TJ, Manolio TA, et al. The effects of age on outcome after coronary bypass surgery. Circulation 1987;76(Suppl 5):6-12. Selzer A. Changing aspects of the natural history of valvular aortic stenosis. N Engl J Med 1987;317:91-8. Cohn LH. Mitral valve surgery: replacement vs reconstruction. Hosp Pract [Off] 1991;26(8): DISCUSSION DR CARY W. AKINS (Boston, MA): In the series you presented, were there any patients who had mitral valve reconstruction rather than mitral valve replacement? Has the team at Johns Hopkins looked at results in that group to find out whether the results in patients who have damaged left ventricles are better if the valve can be repaired rather than replaced?

6 338 DAVISETAL AM Thorac Surg 1993; DR DAVIS We did not include patients undergoing mitral valve repair in this study. Seventy percent of the mitral valve replacement patients who died had severe ischemic disease, typically with papillary muscle rupture or dysfunction. For such patients, valve replacement was the procedure of choice. Patients who underwent mitral valve repair had much less severe disease. Thus, a comparison of outcome for repair versus replacement would be more reflective of the patient s preoperative cardiac function than of the surgical procedure. DR D. CRAIG MILLER (Stanford, CA): How many of the mitral valve replacements for mitral regurgitation were done with preservation of both or one of the leaflets and chordal apparatus? DR DAVIS: I regret that I do not have the data to answer that question. DR BRUCE A. REITZ (Baltimore, MD): Increasingly through the years the chordal apparatus was spared. However, I do not think that was specifically looked at in this study, and so I cannot answer that question. DR MILLER At least by inference, Dr Davis told us a minute ago that the regurgitant mitral valves really were not reparable unless you were willing to reattach ruptured papillary muscles. Could we have comments from Dr David and Dr Cosgrove about how wise (or unwise) this is in patients older than 70 years, the vast majority of whom had coronary disease? DR TIRONE E. DAVID (Toronto, Ont, Canada): I do not repair the mitral valve in patients with ischemic mitral insufficiency, particularly when it is acute. However, when the patient has chronic insufficiency and there is also a component of myxomatous degeneration, I do undertake repair, and the results have been good. When the insuffiaency is purely on the basis of papiuary muscle-ventricular wail dysfunction or due to acute papiuary mus- cle rupture, I replace the mitral valve. My experience with mitral valve repair in these patients has been disappointing. DR MILLER: You are distinguishing these patients from patients who just need a ring or a posterior ring for dilatation? DR DAVID: In our experience, the most common cause of mitral regurgitation due to ischemia is limited mobility of the leaflets along the posteromedial commissure and not prolapse of the leaflets. In 90% of cases, the postemmedial papillary muscle and the posterior left ventricular wall do not contract well, and the wall bulges in systole. This abnormal wall motion drags the medial commissure into the ventricle. It is possible to correct the regurgitation by performing an asymmetrical annuloplasty. The fate of this type of repair is unpredictable because the left ventricle may continue to dilate and mitral regurgitation may recur. DR DELOS M. COSGROVE 111 (Cleveland, OH): Ischemic mitral valve disease continues to be a very serious problem and one that has carried a high mortality. My associates and 1 have not been able to demonstrate that mitral valve repair has improved long-term survival. Survival after mitral valve operation for ischemic mitral disease is directly related to the function of the left ventricle. Patients with dilated left ventricles have a very poor prognosis. DR MILLER: Doctor Davis, could you tell us how you quantified left ventricular systolic function, specifically in patients with mitral regurgitation? You mentioned that it was an adverse predictor of late survival in the patients having mitral valve replacement. You did not study just ejection fraction, I hope. DR DAVIS: Left ventricular function was determined at catheterization by several variables: wall motion, ejection fraction, and end-diastolic pressure. Patients with poor left ventricular function typically had ejection fractions less than 0.30 and enddiastolic pressures greater than 15 mm Hg.