MR valve non-invasive repair in low EF

[ujjainih]

Dear Doctor,
My father is 61 year Indian. He has had a standard EF between 35-39% in last 7 months after a big heart attack and a bypass operation. He has moderate SHF & DHF. Recently he has developed 'moderate severe' MR lekage (Regurgitation) and EF has gone down to 30%.  But he is feeling quite Ok, even better than few months back, he can walk for 25 minutes and he has only very little occasional breathlessness. He is attending meetigs for 5-6 hours without problem.  So  I am confused as symptomatically he is better than before but EF is low and varying, sometime it is 30% sometime 42% don't know what to believe? He has moderate PAH too (reduced earlier he had severe PAH)). Now his doctors are saying that another open heart is too risky, he should try non-invasive valve repair. He is taking ACE inhibitor, Betablocker, Statin, Laxis, Clopilet (blood thinner), Lanoxin (very low), Apresol etc

My questions are:
1. Why EF is varying between 30-42% over few weeks ? is it for MR?
2. Why he is feeling Ok (even better) despite drop in EF ?
3. Can a non-invasive MR repair be done and if yes how urgently shall we do it? where is it done best ?

I will be most thankful to get some advice

yours sincerely
Ujjaene

[wibby]

A related discussion, EvalveMitraClip or robotic repair of mitral valve was started.

[Cleveland Clinic]

My point with the bypasses is that some of them don't hold up for a long time, in fact, as many as 15% of the vein bypasses close by the time the patient leaves the hospital from the original surgery.  The arterial bypasses last a long time, greater than 10 years.  Since your dad is doing well, I would not do anything at this point.  Continue to follow up with the doctor and keep taking the meds.  Typically if the ejection fraction does not improve to greater than 35% 6 months after the surgery, we recommend that some like him should probably get a defibrillator or even a CRT-D device.  I would bring this up next time you see your cardiologist.

[ujjainih]

Many thanks for your quick response. I will follow your advice. My father most probably does not have more blocked arteries as a bypass has already been done, but about bypass grafting, I will have to ask his doctor about this. You are right, he has dialeted left ventricle. So is there any chance that with medicine his MR will improve and he could be stable ? (also EF will be stable?) Can we do anything else to help him ?
I am really sorry for asking these questions again but I am really feeling so worried and helpless, I am so thankful for your advice.

yours sincerely

Ujjaene

[Cleveland Clinic]

1.  EF is poorly reproducible, so it tends to vary from one exam to the next.  Also, you are correct is saying that the MR could affect the estimation of EF.  
2.  Symptoms are more important than the actual EF.  His heart has remodeled slightly and the ACE inhibitors and other meds that he's on are helping quite a bit.
3.  Because he most likely has ischemic MR or MR related to ischemic cardiomyopathy (dilated left ventricle), the likelihood that he will benefit from a non-invasive or even invasive procedures is unfortunately, very low.  Even a redo OHS has a low success rate.  I would consider doing a catheterization to assess whether or not there is some underlying ischemic heart disease (blocked arteries or bypass grafts).  If there aren't any I would continue with current medical management, especially, that symptomatically he's doing well.