Mitral valve replacement combined with coronary artery operation: determinants of early and late results

Surgical management of coexisting coronary artery and valvular heart disease

PURPOSE

Combined coronary artery bypass (CAB) and valve surgery is one of the most challenging surgical procedures, but the operative results have improved over the years.

MATERIALS AND METHODS

From 1989 through 2004, combined CAB and valve operations were performed in 125 patients. Mean age was 63 years, and 86 patients were male. Forty-six patients were diagnosed with coronary artery disease during preoperative evaluation for valvular heart disease (VHD). All patients underwent CAB, and one or more underwent valve replacement or repair (mitral: 54, aortic: 61, tricuspid: 3, DVR: 7) simultaneously.

RESULTS

Mean number of distal graft was 1.98 +/- 1.07, and LIMA was used in 68% of patients. Early mortality occurred in 6 patients (4.8%), and the causes were heart failure (4) and sepsis (2). Mean follow-up duration was 91.4 +/- 40.9 months (range: 47-245), and late mortality occurred in 4 patients. Kaplan Meier estimated survival rates at 1, 5, and 10 years were 94.4 %, 92.3%, and 89.9%, respectively.

CONCLUSION

Combined coronary and valve operations can be performed safely with optimal surgical results. Although the surgical mortality of coexisting coronary and VHD is higher than either isolated coronary or valvular operations, it may not affect the long-term survival.

Mild to moderate mitral regurgitation in patients undergoing coronary bypass grafting: effects on operative mortality and long-term significance

BACKGROUND

Patients undergoing bypass grafting (CABG) often present with mitral regurgitation (MR). While surgical strategy for patients with either trace or severe MR is well established, the need for a valve procedure with mild (2) to moderate (3+) mitral regurgitation is controversial.

METHODS

We reviewed 1,939 consecutive CABG patients (1987 to 1999). A preoperative echocardiogram performed when clinically indicated graded MR from 1 to 4+. Patient characteristics, hospital mortality, and long-term survival were compared between 167 patients with grade 2 to 3+ MR and controls. A multivariate analysis identified independent predictors for long-term mortality.

RESULTS

The MR patients were more often female and older; had increased comorbidities including hypertension, diabetes, and heart failure; had more extensive coronary disease and worse left ventricular (LV) function; and required urgent surgery more often. Operative mortality was 0.8% in no MR patients and 1.8% in MR patients (p not significant). Long-term survival for MR patients with poor LV function (LV grade 3 to 4) was significantly lower (53% versus 75% at 10 years, p = 0.001). Independent predictors of poor long-term survival were advanced age, LV dysfunction, heart failure, diabetes, prior cerebrovascular accident, peripheral vascular disease, and no left internal mammary artery use.

CONCLUSIONS

Coronary artery bypass graft patients with mild or moderate MR have worse baseline characteristics but operative mortality with CABG alone is not significantly increased. Long-term prognosis for MR patients with poor LV function is worse compared with patients with no MR but MR was not an independent predictor of long-term mortality. To determine whether surgical correction of MR would improve results, a prospective randomized trial seems warranted.

Gender-related differences in morbidity and mortality during combined valve and coronary surgery

BACKGROUND

Gender-related differences in morbidity and mortality are well described for coronary artery bypass grafting but are not well understood for combined valve and bypass surgery.

METHODS

We reviewed retrospectively the morbidity and mortality of 1570 consecutive patients who underwent combined valve and bypass procedures at the Toronto General Hospital between January 1990 and October 2000.

RESULTS

There were 1073 men (68%) and 497 women (32%). The mean ages (+/- 1 SD) of women and men were 69 +/- 9 and 68 +/- 9 years, respectively (P =.02). Of the 1570 total patients, 973 patients (62%) underwent aortic valve and coronary bypass surgery, 481 patients (31%) had mitral valve and coronary bypass operations, and 116 (7%) patients had double or triple valve and coronary bypass operations. Preoperative hypertension (P =.002), diabetes (P =.001), and atrial fibrillation (P =.001) were seen more frequently in women. Body surface area was significantly lower in women (P =.0001). At presentation, more women were in congestive heart failure (69% vs 58%, P =.001) and in New York Heart Association functional class III or IV (25% vs 19%, P =.001). Although there was no difference in the number of women with three or more diseased vessels (32% vs 38%), only 35% of women received three or more grafts compared with 44% of men (P =.001). The use of left internal thoracic grafts, although uncommon in the whole study population (36%), was less common in women than in men (26% vs 41%, P =.001). Multivariable logistic analyses for morbidity and mortality showed female gender to be an independent risk factor. Mitral valve replacement, age, left ventricular dysfunction, New York Heart Association classes III and IV, and association of tricuspid valve disease, diabetes, peripheral vascular disease, and preoperative renal failure were found to be independent risk factors for mortality.

CONCLUSION

Female gender is an independent risk factor for combined morbidity and mortality during and after combined valve and coronary bypass surgery. As with isolated coronary artery bypass grafting, women undergoing combined procedures have more premorbid conditions, are more often in heart failure, had an equal incidence of triple vessel disease but received fewer grafts than men, and, therefore, were more frequently incompletely revascularized.

Trends in the surgical management of ischemic mitral regurgitation

The surgical approach to ischemic mitral regurgitation (IMR) remains a topic of considerable controversy. Will coronary artery bypass alone suffice, or should the valve be intervened upon? The poor late survival of patients with IMR is well recognized, but it remains unknown if this can be altered by addressing the valve directly. And if surgery is undertaken, should the valve be repaired or replaced? The underlying mechanisms of IMR remain incompletely understood, and although current theory focuses on the role of alterations in ventricular geometry in its pathogenesis, IMR is most often addressed by annuloplasty alone. Is this sufficient, or does the ventricle itself require "remodeling?" The debate is confounded by imprecise terminology that fails to distinguish between acute and chronic disease, and active ischemia from completed infarction. Available clinical information is from retrospective studies with all of their inherent limitations and potential for bias. Still, progress is being made as increasing attention is focused on this clinically important entity.

[Risk assessment of mitral valve surgery combined with myocardial revascularization]

INTRODUCTION AND OBJECTIVES

Patients with combined mitral valve operation and coronary artery surgery represent a high risk group. The aim of this retrospective study was to evaluate which factors affect early and late postoperative results in this particular group of considered high risk patients. PATIENTS AND METHOD. Between 1984 and 1997, 264 patients (mean age: 63 +/- 7.3 years) underwent mitral valve surgery (199 patients; 75% mitral valve replacement, 25% mitral valve repair) in combination with coronary revascularization (mean 2.4 +/- 1.3 grafts). Follow-up comprised a mean of 69 +/- 42 months and was 98.3% complete.

RESULTS

Early mortality was 10.6% (28/264). Ischemic mitral regurgitation operated on in emergent status, moderate to severe reduced left ventricular function and advanced age (> 60 years) were independently associated with early hospital mortality (p < 0.05). Ischemic etiology of mitral valve disease (emergency and elective operations), severity of mitral regurgitation and New York Heart Association (NYHA) functional class IV were related to early hospital mortality, only with univariate statistics. Actuarial survival was 86, 69 and 48% at 1, 5 and 10 years, respectively. The preoperative NYHA functional class was the only variable independently related to late survival. Eighty-five percent of the surviving patients were in NYHA functional class I and II.

CONCLUSIONS

Mitral valve operation combined with coronary artery bypass grafting is associated with a high early hospital mortality. Independent risk factors of early mortality are emergency operation of ischemic mitral valve disease, reduced left ventricular function and advanced age. Long term survival is independently influenced only by preoperative NYHA functional class IV.

Combined mitral valve and coronary artery surgery: ischemic versus non-ischemic mitral valve disease

OBJECTIVES

Mitral valve combined with coronary artery surgery is associated with a higher hospital mortality than each operation in particular. Controversy exists regarding the predictive value of ischemic mitral valve disease (MVD) on outcome.

METHODS

Between 1984 and 1997, 262 patients underwent mitral valve operations (replacement, n = 198; repair, n = 64) in combination with coronary revascularization. The etiology of MVD was secondary to ischemic heart disease (group I) in 82 (31%) patients, and non-ischemic (group II) in 180 (69%) patients (rheumatic, 139 patients (53%); degenerative, 41 patients (16%)). Both groups were similar in age, cardiac risk factors and pulmonary artery pressure. Patients of group I had significantly more severe coronary artery disease, more often an impaired left ventricle and myocardial infarction, and were in a worse functional condition. The mean number of bypass grafts was significantly higher in group I. The follow-up was 98% (230/234 patients).

RESULTS

With 19.5%, the hospital mortality was significantly increased in group I compared with 6.7% in group II (P = 0.002; overall, 10.7%). Mitral valve repair or replacement had no influence on early outcome, although mitral valve repair was performed more often in group I (37 versus 19%). The survival (valve-related event-free survival) after discharge from hospital in the 1st, 5th and 10th year was 94 (94%), 70 (66%) and 53% (35%) in group I and 96 (95%), 79 (76%) and 54% (41%) in group II, respectively. The long-term functional capacity was equally good in both groups (New York Heart Association mean, 1.86 versus 1.72).

CONCLUSIONS

Patients with ischemic MVD are in a worse cardiac condition with significantly higher hospital mortality than patients with non-ischemic MVD and coronary artery bypass grafting. Once discharged from hospital, both groups have comparable long-term outcomes, with the best results in patients with degenerative MVD.

Papillary muscle repair surgery in ischemic mitral valve patients

BACKGROUND

Ischemic mitral regurgitation (MR), when ischemia/infarction has resulted in fibrotic degeneration and elongation of papillary muscles, carries a high risk for the patient and a technical challenge for the surgeon. We have developed a papillary-shortening plasty for this specific pathology.

METHODS

Papillary muscle repair was performed in 88 patients (7.2%) where degenerated and fibrotic elongated papillary muscles were found, which resulted in a prolapse of one or more parts of the mitral valve leaflets (MR III-IV). All patients had a papillary muscle-shortening plasty using a pericardium pledged-reinforced polytetrafluoroethylene suture and a ring annuloplasty. Because the cause of regurgitation in this specific group of patients was ischemic, concomitant coronary bypass grafting was required in all patients, with 2.2 grafts/patient.

RESULTS

There were five hospital deaths (5.7%). Postoperative mitral valve function was satisfactory in all patients: no residual mitral regurgitation (MR 0) was found in 80 patients (90.9%), mild regurgitation (MR I) in 5 patients (5.7%), and moderate regurgitation (MR I-II) was observed in 3 patients (3.4%). Within a short mean follow-up period of 18.6 months (3 to 40 months), there was one late death (1.2%). The actuarial freedom from reoperation and thromboembolic complications was 100%, but there were two anticoagulation-induced gastric bleeding complications (2.3%). All patients were in New York Heart Association functional class I or II at the time of follow-up.

CONCLUSIONS

Our data show that careful assessment of papillary muscle pathology is mandatory, and that a papillary muscle-shortening plasty is a simple but valuable surgical tool to repair the mitral valve in this specific group of high-risk patients with ischemic mitral regurgitation.

Influence of concomitant CABG and urgent/emergent status on mitral valve replacement surgery

BACKGROUND

Outcomes and resource utilization of patients undergoing mitral valve replacement (MVR) with or without concomitant coronary artery bypass grafting (CABG) were reviewed.

METHODS

Data for 1,844 patients undergoing isolated primary MVR at Emory University Hospitals between 1980 and 1997 were recorded prospectively in a computerized database.

RESULTS

The four groups included patients undergoing elective MVR with (n = 360) or without CABG (n = 1332) and urgent/emergent MVR with (n = 66) or without CABG (n = 86). Length of stay was significantly higher in patients undergoing elective MVR with CABG (15 days) than in those without CABG (11 days) but was not significantly different in patients undergoing urgent/emergent MVR with CABG (17 days) than in those without CABG (19 days). In-hospital mortality was significantly higher for patients undergoing elective (14%) or urgent/emergent (41%) MVR with CABG than in those undergoing MVR without CABG (elective:6%; urgent/emergent:20%). The 19-year survival rate was 32% for patients undergoing elective MVR with CABG compared with 51% for those without CABG and 28% for patients undergoing urgent/emergent MVR with CABG compared with 46% for those without CABG. Multivariate correlates of long-term mortality included older age, concomitant CABG, and urgent/emergent status. Hospital costs were significantly higher for patients undergoing elective MVR with ($33,216) than for those without ($23,890) CABG. No significant difference in cost were noted between patients undergoing urgent/emergent MVR with ($40,535) and without ($31,981) CABG.

CONCLUSIONS

The addition of CABG or urgent/emergent status to patients undergoing MVR significantly increases morbidity, mortality, and costs. Careful scrutiny of the benefits versus resource utilization is required for patients undergoing high risk MVR.

Ten-year trends in heart valve replacement operations

BACKGROUND

There has been increasing concern in recent years about the quality and cost of heart valvular replacement procedures. The purpose of this study is to examine the profile of patients undergoing valvular operations during the past decade, and to look at trends in outcome and resource utilization over that period.

METHODS

Clinical and procedural data of 2,972 patients undergoing heart valve replacement at Emory University Hospitals between 1988 and 1997 were recorded prospectively on standardized forms by trained medical personnel and entered into a computerized database.

RESULTS

There were 1,802 patients undergoing aortic valve replacement (AVR), 966 undergoing mitral valve replacement (MVR), and 204 undergoing combined aortic and mitral valve procedures (AVR + MVR). No patients were excluded. There was a statistically significant trend for patients undergoing AVR, MVR, or AVR + MVR over time to be older and sicker by multiple criteria. Nonetheless, procedural outcome and inhospital mortality for patients undergoing AVR remained unchanged. Cost and length of stay increased from 1988 to 1992 when a concerted effort to decrease resource utilization began. Between 1992 and 1997 for AVR, length of stay decreased from 13.4 to 8.0 days and cost from $37,047 to $21,856. Similarly, between 1992 and 1997 for MVR, length of stay decreased from 15.6 to 8.1 days and cost from $45,072 to $21,747. The net result over the time period from 1988 to 1997 was an average decline in the cost of operation of $785 a year, adjusted for other factors.

CONCLUSIONS

This study reveals that outcome of valvular replacement during the period from 1988 to 1997 has remained constant despite the patients becoming older and sicker during the same period. This constant outcome has been accomplished, but length of stay has decreased significantly. Hospital costs increased during the first years of the study period, but then decreased to levels in 1997 that were equal to or significantly less than 1988 levels.

Treatment of moderate mitral regurgitation and coronary disease by coronary bypass alone: late results

BACKGROUND

In cases of moderate mitral regurgitation and coronary artery disease operative strategy continues to be debated between coronary artery bypass grafting alone and concomitant valve replacement or repair. We previously reported on 58 patients with moderate mitral regurgitation who had coronary artery bypass grafting between 1977 and 1983. We present the late results for this original cohort (test group), and a matched control group of coronary artery bypass grafting patients without mitral regurgitation (n = 58).

METHODS AND RESULTS

In the original cohort, the hospital mortality rate was 3.4% (2 of 58), and 80.4% (45 of 56) of hospital survivors were alive at the time of initial follow-up (mean, 4.3+/-2.3 years). Hospital mortality in the control group was 6.9% (4 of 58 patients). Follow-up was 98.2% (108 of 110 patients) complete, with a mean follow-up time of 10.3+/-5.5 years. Kaplan-Meier curves for hospital survivors showed similar 5- and 10-year survival rates between the two groups (p = 0.59). On multivariate analysis, age 65 years or more, congestive heart failure class III or IV, and pulmonary capillary wedge pressure more than 17 mm Hg were significant (p < 0.05) independent predictors of diminished survival in the test group.

CONCLUSIONS

Patients with moderate mitral regurgitation and coronary artery disease treated solely with coronary artery bypass grafting had acceptable early and late results. Moderate mitral regurgitation at the time of revascularization does not always warrant operative correction.

Mortality and morbidity among patients who undergo combined valve and coronary artery bypass surgery: early and late results

AIM

To describe mortality and morbidity early and late after combined valve surgery and coronary artery bypass grafting (CABG) as compared with CABG alone.

PATIENTS AND METHODS

All patients from western Sweden in whom CABG in combination with valve surgery or CABG alone was carried out in 1988-1991.

RESULTS

Among 2116 patients who underwent CABG, 35 (2%) had this combined with mitral valve surgery and 134 (6%) had this combined with aortic valve surgery, whereas the remaining 92% underwent CABG alone. Patients who underwent combined valve surgery and CABG were older, included more women and had a higher prevalence of previous congestive heart failure and renal dysfunction but on the other hand a less severe coronary artery disease. Among patients who underwent mitral valve surgery in combination with CABG the mortality over the subsequent 5 years was 45%). The corresponding figure for patients who underwent aortic valve surgery in combination with CABG was 24%. Both were higher than for CABG alone (14%; P < 0.0001 and P = 0.003, respectively). In a stepwise multiple regression model mitral valve surgery in combination with CABG was found to be an independent significant predictor for death but aortic valve surgery in combination with CABG was not. Among patients who underwent mitral valve surgery in combination with CABG and were discharged alive from hospital 77% were rehospitalized during the 2 years following the operation as compared with 48% among patients who underwent aortic valve surgery in combination with CABG and 43% among patients with CABG alone. Multiple regression identified mitral valve surgery in combination with CABG as a significant independent predictor for rehospitalization but not aortic valve plus CABG.

CONCLUSION

Among patients who either underwent CABG in combination with mitral valve surgery or aortic valve surgery or CABG alone, mitral valve surgery in combination with CABG was independently associated with death and rehospitalization, but the combination of aortic valve surgery and CABG was not.

Determinants of early and late results of combined valve operations and coronary artery bypass grafting

BACKGROUND

Factors determining the outcome of operative correction of valvular abnormalities combined with coronary artery bypass grafting are still incompletely defined.

METHODS

Determinants of early and late (more than 90 days) deaths and event-free survival were studied for combined valve operations and coronary artery bypass grafting in 741 patients using multivariate analysis.

RESULTS

Ninety-day survival probability was 89% (95% confidence interval, 87% to 92%). Preoperative risk factors for early death were age, female sex, renal failure, New York Heart Association class IV or V, and mitral insufficiency. The operative risk factor was the duration of aortic cross-clamping. Five- and 10-year survival probabilities were 74% (95% confidence interval, 71% to 78%) and 43% (95% confidence interval, 36% to 50%), respectively. Preoperative risk factors for late death were age, preoperative renal failure, New York Heart Association class IV or V, vessel disease, and nonsinus rhythm. Five- and 10-year event-free survival probabilities were 57% (95% confidence interval, 53% to 61%) and 23% (95% confidence interval, 17% to 28%), respectively. Preoperative risk factors for non-event-free survival were age, female sex, reduced left ventricular function, mitral regurgitation, and pacemaker rhythm.

CONCLUSION

The demographic factors of age and female sex; the comorbid condition of renal failure; the cardiac conditions of advanced New York Heart Association class, left ventricular function, mitral regurgitation, vessel disease, and cardiac rhythm; and the operative condition of ischemia time are the most important predictors of clinical outcome after combined valve operations and coronary artery bypass grafting.

Up to thirty-year survival after aortic valve replacement in the small aortic root

Aortic valve replacement (AVR) in the small aortic root has been reported to be associated with obstruction of left ventricular output. This study was designed to investigate the determinants of long-term survival after the implantation of small size prostheses. From September 1961 to December 1993, 2,977 patients underwent isolated aortic valve replacement at our institution. Of these patients, 447 who were older than 18 years received small size (21 mm or less) prostheses. Long-term survival was investigated in the 404 patients who survived operation (more than 30 days) with 92% follow-up completeness (mean +/- deviation 7.1 +/- 6.4; maximum, 31 years). The age was younger than 50 years in 62 patients, 50 to 59 years in 60, 60 to 69 years in 99, 70 to 79 years in 138, and 80 to 94 years in 45; 67% were men. Thirty patients (7%) had previous AVR. Prosthesis usage included early Starr-Edwards models in 130 (32%), current Starr-Edwards (model 1260 since 1969) in 50 (12%), Carpentier-Edwards (porcine) in 113 (28%), and other prostheses in 111 patients (27%). One hundred sixteen patients (26%) had concomitant coronary artery bypass grafting (CABG). Eleven variables (age divided as above, sex, preoperative functional class, body surface area [BSA], small BSA [less than 1.6, 1.7, 1.8, or 1.9 m2], period of operation, previous AVR, type of prosthesis, size of prosthesis, concomitant CABG, and re-replacement) were investigated with regard to the long-term survival by the Kaplan-Meier method, and age, concomitant CABG, and type of prosthesis were significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Reoperation on prosthetic heart values. Patient-specific estimates of in-hospital events

Reoperation on prosthetic heart valves is increasingly under consideration for both clinical and prophylactic indications. To determine the correlates of hospital events, including in-hospital mortality, new persisting neurologic deficit, and length of postoperative stay, a three-institution study of 2246 consecutive prosthetic valve reoperations performed on 1984 patients between 1963 and 1992 was undertaken. The combined experience ranged from high-risk patients coming moribund to the operating room to an important number of well individuals undergoing prophylactic reoperations on potentially failing valves. The risk-unadjusted hospital mortality was 10.8%, neurologic deficit at hospital discharge 1.1%, and length of stay 10 days (median). Multivariably determined correlates of outcome included age at reoperation, degree, severity, and acuity of impairment of cardiac function, extensiveness of valvular heart disease, coexisting morbid conditions, number of previous heart operations, and concomitant procedures. The risk-adjusted hospital mortality for the first elective reoperation in a good-risk patient was 1.3% (90% confidence limits 0.3% to 4.4%), neurologic deficit 0.3% (90% confidence limits 0.02% to 1.8%), and length of postoperative stay 7 days (90% confidence limits 4 to 13), emphasizing the wide variance in outcome events. Equations were developed to permit wide application of the results of the study for quantitatively estimating the risk of outcome events based on individual preoperative patient characteristics. These estimates should be useful for informed patient consent, considerations of prophylactic valve replacement, and cost and resource use.

Risk factors for operative mortality in elderly patients undergoing internal mammary artery grafting

From January 1986 through June 1992, 512 elderly patients (70 years and older) underwent internal mammary artery grafting (IMAG). The operative mortality in these patients was 7.62% (39 of 512), which was significantly higher than that (1.97% [60 of 3,047]; p < 0.0001) in younger patients (under 70 years old). To investigate the risk factors in the elderly, the data from the 512 patients were evaluated by univariate analysis and multiple logistic regression. Of 53 variables analyzed, nine preoperative variables (age, smoking history, congestive heart failure, myocardial infarction, New York Heart Association functional class, ejection fraction, left main artery disease, stenosis of the left anterior descending artery, and reoperation), three intraoperative variables (emergency operation, bilateral IMAG, and right IMAG), and nine postoperative variables were significantly associated with the higher mortality (p < 0.05). In particular, the operative mortality was significantly higher in the patients undergoing right IMAG (21.62% [8 of 37]) than that in patients only undergoing left IMAG (6.53% [31 of 475]; p < 0.004). The significant preoperative and intraoperative variables and the variables that have a tendency for correlation (p < 0.2) to mortality were included in a stepwise multiple logistic regression. The regression analysis demonstrated that right IMAG, reoperation, history of myocardial infarction, age, left main artery disease, history of smoking, and postoperative complications are the risk factors for the elderly undergoing IMAG. Therefore, particular care should be taken in those patients scheduled to undergo IMAG. The role of right IMAG in the elderly should be further clarified before universal acceptance of the technique in these patients.

Aortic valve replacement: determinants of operative mortality

Contradictory results have been reported regarding risk factors for aortic valve replacement (AVR). This study was designed to investigate determinants of operative mortality for AVR with emphasis on concomitant coronary artery bypass grafting (CABG) and old age. Between January 1986 and June 1992, 371 patients with a mean age of 61.99 +/- 0.76 years underwent AVR. There were 256 men (69.0%) and 115 women (31.0%). Twenty-six patients (7.0%) were 80 years old or older, and 97 (26.1%) were between 70 and 80 years old. Of these patients, 210 (56.6%) had isolated AVR, 142 (38.3%) had concomitant CABG, and 31 (8.4%) had concomitant mitral valve operations. Twenty patients (5.4%) underwent emergency operation. There were 33 operative deaths (8.9%). Univariate analysis and stepwise multiple logistic regression analysis were used to determine the risk factors for operative mortality. In the univariate analysis, 13 preoperative variables (sex, age, history of congestive heart failure, myocardial infarction, arrhythmia, functional class, class I/II versus III/IV, four variables related to aortic valve pathology, ejection fraction, left ventricular function) and 20 perioperative variables (emergency operation, individual surgeon, myocardial protection by type and route of cardioplegia, type of prosthesis, size of prosthesis, mean size by survival, small versus large size, concomitant procedure, concomitant CABG (versus others or AVR alone), concomitant mitral valve operation (versus others or AVR alone), concomitant CABG and MV operation, aortic cross-clamp time, cardiopulmonary bypass time, use and time of insertion of intraaortic balloon pump, low cardiac output, postoperative complications) were examined.(ABSTRACT TRUNCATED AT 250 WORDS)