Ischemic mitral regurgitation: revascularization alone versus revascularization and mitral valve repair

Restrictive annuloplasty on remodeling and survival in patients with end-stage ischemic cardiomyopathy

OBJECTIVES

To elucidate the influence of concomitant restrictive mitral annuloplasty (RMA) on postoperative left ventricular (LV) reverse remodeling and survival in patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting (CABG).

METHODS

This study comprised 157 patients with ischemic cardiomyopathy (LV ejection fraction ≤40%) who underwent CABG and completed echocardiographic examination at 1 year after surgery, with 84 (54%) undergoing concomitant RMA for clinically relevant ischemic mitral regurgitation. The primary end point was postoperative reduction in LV end-systolic volume index (LVESVI). The secondary end point was overall survival. Median follow-up was 5.1 years.

RESULTS

At baseline, patients who underwent CABG with RMA had a larger LVESVI (83 ± 23 vs 75 ± 24 mm; P = .046). One-year postoperatively, CABG with RMA reduced the LVESVI more than did CABG alone (37% vs 21% from baseline; P < .001), yielding nearly identical postoperative LVESVI (53 ± 27 vs 61 ± 26 mm; P = .065). In multivariable logistic regression analysis, concomitant RMA was associated with significant LV reverse remodeling (odds ratio, 2.79; 95% CI, 1.34-5.78; P = .006). The prevalence in moderate or severe mitral regurgitation was not different between the groups (7% vs 10%; P = .58). Survival rates were similar between the groups (5 years, 78% vs 83%; P = .35).

CONCLUSIONS

In patients with ischemic cardiomyopathy undergoing CABG, concomitant RMA was associated with significant reduction in LVESVI. The influence of LV reverse remodeling on survival remains undetermined.

Whole Blood del Nido versus Cold Blood Microplegia in Adult Cardiac Surgery: A Propensity-Matched Analysis

Objectives  Few studies have evaluated the outcomes of whole blood microplegia in adult cardiac surgery. Our novel protocol includes removing the crystalloid portion and using the Quest Myocardial Protection System (MPS) for the delivery of del Nido additives in whole blood. This study sought to compare early and late clinical outcomes of whole blood del Nido microplegia (BDN) versus cold blood cardioplegia (CBC) following adult cardiac surgery. Materials and Methods  A total of 361 patients who underwent cardiac surgery using BDN were compared with a contemporaneous control group of 934 patients receiving CBC. Propensity matching yielded 289 BDN and 289 CBC patients. Chi-square analysis and Fisher's exact test were performed to compare preoperative, operative, and postoperative characteristics on the matched data. Primary outcome was operative mortality, and secondary outcomes included clinical outcomes such as stroke, cardiac arrest, and intra-aortic balloon pump use. The Kaplan-Meier method was used to compare actuarial survival between the two groups using a log-rank test. Results  After matching, preoperative characteristics and surgery type were similar between groups. Cardioplegia type did not affect the primary end point of operative mortality. The rate of postoperative intra-aortic balloon pump was lower in BDN patients compared with CBC patients (0 vs. 2%; p  = 0.01). There was no difference in late survival. Conclusion  Our novel protocol BDN was comparable with CBC, with similar clinical outcomes and no difference in operative mortality or actuarial survival. Further studies should evaluate the long-term outcomes of this technique.

Isolated OPCABG in moderate chronic ischemic mitral regurgitation: is it a justifiable alternative approach ?

OBJECTIVE

Current evidence does not allow a consensus on the management of moderate chronic ischemic mitral regurgitation (CIMR). We compared moderate CIMR patients undergoing off-pump CABG (OPCABG) alone and CABG + MV repair for early mortality, major adverse systemic events (MASE) and mid-term functional outcomes.

METHODS

210 patients with moderate CIMR who underwent off-pump coronary artery bypass grafting (OPCABG) Group I (n = 106) or CABG + mitral valve repair (MV rep) Group II (n = 104) were followed prospectively. For comparison, patients were further sub-divided based on the product of regurgitant fraction and ejection fraction "RFEF"(Good/Bad) and MR jet direction (Central/Eccentric). The primary end point of the study was mortality and secondary end points were MASE, percentage improvements in indexed left ventricle end-systolic volume (LVESVI %), MR grade and functional outcomes of the patients.

RESULTS

In-hospital and overall mortality was significantly lower in Group I (1.89% vs. 13.46%, p < 0.001 and 5.66% vs. 15.38%; p = 0.024 respectively). Group II had significantly higher MASE, ventilation time, mean ICU and hospital stay. At 36 months, LVESVI% (17.56% ± 9.12% vs. 18.81% ± 7.48%; p = 0.279), MR grade improvement (80.18% vs. 83.50%; p = 0.544), NYHA class and MLHF scores were also similar in both groups. On subgroup analysis, Good RFEF with Central jet subgroup had comparable improvement in LVESVI% and MR grade with either procedure, while Bad Eccentric subgroup showed a significantly higher improvement in LVESVI% and MR grade with CABG + MV repair.

CONCLUSION

OPCABG is associated with significantly reduced mortality and MASE with comparable improvement in LVEDVI% and MR grade. CABG + MV Rep results in significant improvement in LVEDVI% and MR grade in patients with bad eccentric MR. The recommended procedures in the "Good Central" and "Bad Eccentric" subsets are CABG and CABG + Mvrepair, respectively.

Clinical Impact of Computational Heart Valve Models

This paper provides a review of engineering applications and computational methods used to analyze the dynamics of heart valve closures in healthy and diseased states. Computational methods are a cost-effective tool that can be used to evaluate the flow parameters of heart valves. Valve repair and replacement have long-term stability and biocompatibility issues, highlighting the need for a more robust method for resolving valvular disease. For example, while fluid-structure interaction analyses are still scarcely utilized to study aortic valves, computational fluid dynamics is used to assess the effect of different aortic valve morphologies on velocity profiles, flow patterns, helicity, wall shear stress, and oscillatory shear index in the thoracic aorta. It has been analyzed that computational flow dynamic analyses can be integrated with other methods to create a superior, more compatible method of understanding risk and compatibility.

10-Year Results of Mitral Repair and Coronary Bypass for Ischemic Regurgitation: A Randomized Trial

BACKGROUND

The decision to treat moderate ischemic mitral regurgitation (IMR) at the time of coronary artery bypass surgery (CABG) remains controversial. We previously conducted a prospective randomized trial that showed a benefit of adding restricted annuloplasty to bypass surgery (CABG-Ring group) in terms of IMR grade, New York Heart Association classification, and left ventricle reverse remodeling. Here, we present the long-term (>10 years) follow-up data from this randomized trial.

METHODS

The original trial arms accounted for 54 patients in the CABG-alone and 48 in the CABG-Ring group; patients were re-contacted for follow-up to obtain relevant clinical and echocardiographic information.

RESULTS

The mean follow-up was 160.4 ± 45.5 months. Survival probabilities in the CABG-alone and CABG-Ring groups were 96% vs 93% at 3 years, 85% vs 89% at 6 years, 79% vs 85% at 9 years, 77% vs 83% at 12 years, and 72% vs 80% at 15 years, respectively (P = .18) Freedom from at least moderate IMR or reintervention at last follow-up was also higher in the CABG-Ring group (P < .001). Compared with the CABG-alone group, the CABG-Ring group had a higher degree of left ventricular reverse remodeling (54.7 ± 6.9 mm vs 51.6 ± 6 mm, respectively; P = .03), lower New York Heart Association class (P < .001), and a lower rate of rehospitalization (P = .002).

CONCLUSIONS

Long-term follow-up data from our randomized trial further support the utility of performing restricted annuloplasty at the time of CABG to prevent further progression of IMR, mitral reintervention, and left ventricle remodeling. Untreated IMR was associated with significantly higher New York Heart Association class and rehospitalization.

Ischemic Mitral Regurgitation: A Multifaceted Syndrome with Evolving Therapies

Dysfunction of the left ventricle (LV) with impaired contractility following chronic ischemia or acute myocardial infarction (AMI) is the main cause of ischemic mitral regurgitation (IMR), leading to moderate and moderate-to-severe mitral regurgitation (MR). The site of AMI exerts a specific influence determining different patterns of adverse LV remodeling. In general, inferior-posterior AMI is more frequently associated with regional structural changes than the anterolateral one, which is associated with global adverse LV remodeling, ultimately leading to different phenotypes of IMR. In this narrative review, starting from the aforementioned categorization, we proceed to describe current knowledge regarding surgical approaches in the management of IMR.

Clinical outcomes following surgical mitral valve repair or replacement in patients with rheumatic heart disease: a meta-analysis

Background

The clinical outcome of mitral valve repair (MVP) is considerably more favorable than that of mitral valve replacement (MVR) in patients with degenerative mitral disease. However, rheumatic heart disease (RHD) is still the predominant cause of mitral valve surgery in developing countries and the advantages of MVP in RHD have still not been definitely proven. The aim of this meta-analysis was thus to evaluate the suitability of MVP in patients with RHD. Considering the difference between mechanical and biological valves, we distinguished them from each other and compared them with MVP individually.

Methods

A comparison of clinical outcomes of MVP and MVR in patients with RHD was performed based on clinical trial data. Relevant articles published from January 1, 1990 until March 1, 2020 were identified in Pubmed, Cochrane Library, and China National Knowledge Infrastructure database (CNKI). Studies that lacked direct comparisons between MVP and MVR were excluded.

Results

A total of 16 studies with 8659 patients were included in the analysis. The MVP group displayed lower early and long-term mortality, and fewer valve-related events and major adverse events. However, this patient group required more reoperations compared with the MVR group. Similar results were observed after distinguishing between mechanical and bioprosthetic valves to compare MVP with MVR (mech-valves), but no statistically significant difference was identified in the reoperation rate between MVP and MVR (bio-valves). MVP was further associated with increased risk of mitral reoperation in patients undergoing concomitant aortic valve replacement (AVR) surgery but without any improved early and long-term survival.

Conclusions

MVP and MVR are beneficial for patients with RHD. For skilled surgeons, MVP can be performed for some suitable patients with RHD and is preferred for elderly patients or patients with contraindications of anticoagulation. However, MVR is more appropriate when concomitant AVR is needed.

Moderate ischemic mitral incompetence: does it worth more ischemic time?

OBJECTIVES

Ischemic mitral regurgitation (IMR) is a common finding following myocardial infarction or ischemia. Management of moderate IMR is still a hot topic. Adding mitral valve repair (MVr) to coronary artery bypass grafting (CABG) is questionable. The goal of this study was to assess and compare short-term clinical and echocardiographic results of moderate IMR treated by CABG alone versus another group of patients treated by CABG plus MVr.

METHODS

Eighty consecutive patients with ischemic heart disease (IHD) and moderate IMR were divided randomly into two equal groups: group I (40) had only CABG and group II (40) had CABG plus MVr. Patients were evaluated at 1-week, 3-months and 1-year intervals postoperatively.

RESULTS

After 1-year follow-up, our study revealed statistically significant improvement in the grade of mitral regurgitation (MR) in group II than group I. The mean value for effective regurgitant orifice area (EROA) was 0.22 ± 0.13 for group I versus 0.03 ± 0.03 for group II (P = 0.001) and for vena contracta (VC), it was 3.8 ± 2.24 for group I versus 0.4 ± 0.49 for group II (P = 0.000). There was also a significant reduction in the New York Heart Association (NYHA) functional class in both groups.

CONCLUSIONS

MVr can be performed safely and concomitantly with CABG in patients having moderate IMR, and its addition to CABG have significant short-term impact on clinical or echocardiographic outcome of patients.

Experience of the management of coronary artery bypass graft only on moderate ischemic mitral regurgitation: A single-center retrospective study

To summary the impact of off-pump coronary artery bypass grafting (CABG) only on patients with moderate ischemic mitral regurgitation and survival.We retrospectively analyzed 109 patients with coronary artery disease (CAD) complicated by moderate mitral regurgitation, from January, 2008 to December, 2014, in the Department of Cardiovascular Surgery at the No. 2 Hospital of Jilin University undergoing off pump CABG only. Preoperative clinical characteristics, complications after surgery, and outcome (survivor or death) were assessed. We observed the degree of mitral valve regurgitation, left ventricular ejection fraction (LVEF), left ventricular and left atrial size, left ventricular end-diastolic volume (LVEDV) preoperative, and New York Heart Association (NYHA) functional class, postoperative 10 days before discharge, and 6 months and longer after surgery. The statistical data were processed by SPSS 19 software with computer; statistical significant difference with P < .05.Overall in-hospital mortality was 2.75% (3 patients). Patients had lower mean LVEF in the postoperative compared with the preoperative period, but all the patients had higher LVEF since 6 months than preoperative period (P < .001). Compared with the preoperative dates, postoperative valvular regurgitation, left ventricular and atrial size and LVEDV postoperative 10 days before discharge, 6 months and more longer after surgery reduced significantly (P < .001). Rapid atrial fibrillation occurred in 19 cases during perioperative and returned to normal before discharge. The symptom of angina was disappeared in all patients before discharge. The mean follow-up time was 60.16 ± 17.98 months (range 36-96 months). Two patients died of major adverse cardiac events including heart failure and ventricular fibrillation. Three patients died of lung cancer, and 2 patients died of stroke during the longer follow-up.Off-pump CABG can be performed safely in patients with CAD complicated by moderate mitral regurgitation. The efficacy of CABG only is well demonstrated by the significant improvement of LVEF and NYHA functional class, and by the decrease of left ventricular and atrial size, LVEDV, and mitral regurgitation grade.

Moderate ischemic mitral regurgitation: coronary artery bypass grafting with versus without simultaneous treatment of the mitral valve

BACKGROUND

Ischemic mitral regurgitation (IMR) is a frequent complication of coronary artery heart disease and is associated with increased mortality. Controversies exists whether patients with moderate IMR may benefit from a combined procedure with coronary artery bypass grafting (CABG) and treatment of mitral regurgitation.

METHODS

451 patients with moderate IMR (grade 2) receiving either CABG alone (CABG only) or additional mitral valve repair or replacement (CABG+MV) were included in this observational single-centre study. Patients were matched according to the number of bypass grafts, preoperative NYHA functional class and age. In total, 42 patients (21 CABG only, 21 CABG+MV) were analysed.

RESULTS

The mean follow-up was 4.3±1.9 years. CABG alone reduced the IMR grade to 1.2±0.5, whereas the combined procedure resulted in a decrease to 0.6±0.7 (P=0.039). NYHA functional class was reduced from grade 2.8±0.6 to 1.6±0.5 (CABG only) and 2.0±1.1 (CABG+MV, P=0.55). Three- and five-year survival rates were 71% and 53% in the CABG only group compared to 60% both after 3 and 5 years in the CABG+MV group (P=0.89).

CONCLUSIONS

In this observational study, combined CABG and surgical treatment of moderate IMR was associated with a more effective reduction of IMR than CABG alone. No statistically significant differences in survival or NYHA functional class were observed. Further studies will need to investigate the value of additional mitral valve surgery in moderate IMR.

Predictors of Mortality in Patients With Severe Ischemic Cardiomyopathy Undergoing Surgical Mitral Valve Intervention

Background

Ischemic mitral regurgitation is associated with substantial risk of death. Although surgical mitral valve intervention (MVi) may improve symptoms, it has not been shown to improve survival. The aim of this study was to identify predictors of mortality in patients with ischemic mitral regurgitation and MVi.

Methods and Results

We evaluated 117 consecutive patients (age, 65±10 years) with advanced ischemic cardiomyopathy who underwent cardiac magnetic resonance and subsequent MVi between January 1, 2002 and January 1, 2012. Cardiac magnetic resonance was used to assess left ventricular remodeling and myocardial scarring. The effective regurgitant orifice area was calculated from the proximal isovelocity surface area by echocardiography. There were 43 deaths (37%) during follow‐up (median, 62 months). On multivariable analysis, age ≥70 years (P=0.013), diabetes mellitus (P=0.001), dyslipidemia (P=0.012), papillary muscle scar (P=0.010), incomplete revascularization (P=0.001), and total scar %×effective regurgitant orifice area ≥0.20 cm² (P=0.005) were each independently associated with all‐cause mortality. Although patients with effective regurgitant orifice area <0.2 cm² at baseline demonstrated an increased hazard ratio of 3.3 for every 10% increase in scar, the hazard ratio increased to 9 for every 10% increase in scar in those with baseline effective regurgitant orifice area ≥0.20 cm². Mortality also was significantly higher in patients with incomplete revascularization compared with those with vascularized viable myocardium (61% versus 28%; P<0.001).

Conclusions

Increased total scar burden and the presence of incomplete revascularization are powerful predictors of mortality in patients with advanced ischemic cardiomyopathy undergoing MVi. Viability assessment with cardiac magnetic resonance imaging can identify which patients with ischemic mitral regurgitation are at highest risk for mortality after surgical MVi.

Meta-Analysis of Usefulness of Concomitant Mitral Valve Repair or Replacement for Moderate Ischemic Mitral Regurgitation With Coronary Artery Bypass Grafting

Moderate ischemic mitral regurgitation (MR) is often present in patients undergoing coronary artery bypass grafting (CABG). However, the clinical benefit of repairing moderate MR during CABG is unproven. We searched multiple databases to identify original studies comparing isolated CABG versus combined CABG and MR surgery (mitral valve surgery with coronary artery bypass grafting [MVCABG]); survival (either early or midterm) was the primary end point. Risk ratio (RR) or standardize mean difference was selected as the effect estimates; survival was compared by pooling hazard ratios. All results are presented with 95% CIs; p <0.05 is statistically significant. Eleven studies (7 retrospective and 4 randomized controlled trials; 547 MVCABG and 900 CABG patients) were included in our meta-analysis. Concomitant mitral valve repair significantly prolonged surgical duration (p <0.01). Early mortality (MVCABG 6.9% and CABG 6%) was comparable (RR 1.3 [0.9 to 1.8]; p = 0.11). At follow-up, the MVCABG patients had similar New York Heart Association class (standardize mean difference -0.73 (-1.64 to 0.18; p = 0.11). However, patients who underwent concomitant mitral valve surgery had less MR at follow-up (recurrent significant MR, RR 0.37 [0.22 to 0.62]; p = 0.001; mean MR grade, mean difference = 0.39 [0.26 to 0.59]; p <0.001). Midterm survival rate (mean follow-up 5 years) was comparable in both groups (hazard ratio for mortality in the MVCABG cohort 1.1 [0.9 to 1.3]; p = 0.38). In conclusion, concomitant repair of moderate ischemic MR leads to improved mitral valve competence at follow-up; however, this was not translated into any functional or survival benefit for adding valve repair to CABG for these patients at 5 years of follow-up.

[Long-term results of surgical treatment of patients with aortic valve disease and functional mitral insufficiency]

AIM

To analyze long-term surgical results in patients with aortic valve disease and concomitant mitral regurgitation (MR) depending on volume of valve surgery.

MATERIAL AND METHODS

It was studied 5-year results in 71 patients with aortic valve disease and different degree of mitral regurgitation. Patients were divided into 3 groups. Control group included 40 patients after aortic valve replacement (AVR) and no mitral insufficiency. The 2nd group consisted of 16 patients after AVR and concomitant mitral regurgitation degree 2-3. The 3rd group - 15 patients after aortic and mitral valve replacement. Mortality in long-term postoperative period, quality of life, incidence of complications and echocardiography data were analyzed.

RESULTS

There was no significant improvement of mitral regurgitation after AVR. It was showed that persistent MR decreases remote survival and quality of life as well as deteriorates echocardiography data. Herewith these data in the 3rd group did not differ from the control group.

CONCLUSION

Double-valve replacement may be advisable in patients with aortic valve disease and concomitant moderate MR because persistent MR deteriorates long-term

RESULTS

However prolonged time of cardiopulmonary bypass, aortic cross-clamping, greater blood loss require comprehensive approach to advanced cardiac surgery.

Echocardiographic Assessment of Ischaemic Mitral Regurgitation, Mechanism, Severity, Impact on Treatment Strategy and Long Term Outcome

Introduction:

The commonest mitral regurgitation etiologies are degenerative (60%), rheumatic post-inflammatory, 12%) and functional (25%). Due to the large number of patients with acute MI, the incidence of ischaemic MR is also high. Ischaemic mitral regurgitation is a complex multifactorial disease that involves left ventricular geometry, the mitral annulus, and the valvular/subvalvular apparatus. Ischaemic mitral regurgitation is an important consequence of LV remodeling after myocardial infarction.

Research Objectives:

The objective of this study is to determine the role of echocardiography in detecting and assessment of mitral regurgitation mechanism, severity, impact on treatment strategy and long term outcome in patients with myocardial infarction during the follow up period of 5 years. Also one of objectives to determine if the absence or presence of ischaemic MR is associated with increased morbidity and mortality in patients with myocardial infarction.

Patients and methods:

The study covered 138 adult patients. All patients were subjected to echocardiography evaluation after acute myocardial infarction during the period of follow up for 5 years. The patients were examined on an ultrasound machine Philips iE 33 xMatrix, Philips HD 11 XE, and GE Vivid 7 equipped with all cardiologic probes for adults and multi-plan TEE probes. We evaluated mechanisms and severity of mitral regurgitation which includes the regurgitant volume (RV), effective regurgitant orifice area (EROA), the regurgitant fraction (RF), Jet/LA area, also we measured the of vena contracta width (VC width cm) for assessment of IMR severity, papillary muscles anatomy and displacement, LV systolic function ± dilation, LV regional wall motion abnormality WMA, LV WMI, Left ventricle LV remodeling, impact on treatment strategy and long term mortality.

Results:

We analyzed and follow up 138 patients with previous (>16 days) Q-wave myocardial infarction by ECG who underwent TTE and TEE echocardiography for detection and assessment of ischaemic mitral regurgitation (IMR) with baseline age (62 ± 9), ejection fraction (EF 41±12%), the regurgitant volume (RV) were 42±21 mL/beat, and effective regurgitant orifice area (EROA) 20±16 mm², the regurgitant fraction (RF) were 48±10%, Jet/LA area 47±12%. Also we measured the of vena contracta width (VC width cm) 0,4±0,6 for assessment of IMR severity. During 5 years follow up, total mortality for patients with moderate/severe IMR–grade II-IV (54.2±1.8%) were higher than for those with mild IMR–grade I (30.4±2.9%) (P<0.05), the total mortality for patients with EROA ≥20 mm²(54±1.9%) were higher than for those with EROA <20 mm²(27.2±2.7%) (P<0.05), and the total mortality for patients with RVol ≥30 mL (56.8±1.7%) were higher than for those with RVol<30ml (29.4±2.9%) (P<0.05). After assessment of IMR and during follow up period 64 patients (46%) underwent CABG alone or combined CABG with mitral valve repair or replacement. In this study, the procedure of concomitant down-sized ring annuloplasty at the time if CABG surgery has a failure rate around 24% in terms of high late recurrence rate of IMR during the follow period especially after 18–42 months.

Conclusion:

The presence of ischaemic MR is associated with increased morbidity and mortality. Chronic IMR, an independent predictor of mortality with a reported survival of 40–60% at 5 years. Ischaemic mitral regurgitation has important prognosis implications in patients with coronary heart disease. Recognizing the mechanism of valve incompetence is an essential point for the surgical planning and for a good result of the mitral repair. It is important that echocardiographers understand the complex nature of the condition. Despite remarkable progress in reparative surgery, further investigation is still necessary to find the best approach to treat ischaemic mitral regurgitation.

Surgical Strategies for Management of Mitral Regurgitation: Recent Evidence from Randomized Controlled Trials

In contrast to mitral regurgitation (MR) caused by structural abnormality of the valve ("primary" MR), about which there is increasing consensus regarding treatment, there is increasing controversy around the management of functional or "secondary" MR, of which "ischemic mitral regurgitation" (IMR) is a common cause. While the trend in the management of primary MR is increasingly aggressive, with wide agreement on the preference for repair over replacement such that debate centers on earlier and earlier repair even among asymptomatic patients, the situation is reversed in the setting of secondary MR with uncertainly beyond the mode of management (repair or replacement) to the value of intervening at all. This is, in part, because the term IMR has been somewhat loosely applied by the medical and surgical communities to include regurgitation secondary to active myocardial ischemia, as well as that resulting from a completed myocardial infarct. As a result, there is considerable variability in reported outcomes of surgical interventions for IMR. In addition, the natural history of IMR is quite adverse-more so than that of many solid organ malignancies-and its surgical treatment has traditionally carried a higher operative mortality than many cardiac surgical procedures, including similar operations for primary MR and incidental coronary artery disease. Added to this, with recent advances in both the medical and surgical treatment of heart failure improving nonoperative outcomes and simultaneously reducing operative risk compared to reports from previous decades, the landscape has been quite dynamic. Here, we review the issues surrounding surgical treatment for IMR, along with available evidence supporting different approaches, to lend an informed perspective on the divergent opinions among experts in this field and guide the appropriate management of the individual patient.

Is valve repair preferable to valve replacement in ischaemic mitral regurgitation? A systematic review and meta-analysis

Ischaemic mitral regurgitation (MR) is associated with poor survival. The favoured surgical option remains debatable. Our aim was to perform a meta-analysis to compare the outcomes of mitral valve repair (MVRp) with replacement (MVR). A literature search was conducted in PubMed, Medline and Ovid using the terms 'ischaemic mitral regurgitation', 'repair' and 'replacement'. The primary outcome measure was 30-day survival. The secondary outcome measures were MR recurrence and reoperation. Out of 310 articles, 18 fulfilled the inclusion criteria. A total of 3978 patients were included: 2563 (64%) MVRp cases and 1415 (36%) MVR cases. Operative techniques included annuloplasty for MVRp and subvalvular apparatus-sparing MVR techniques. Thirty-day mortality was lower after MVRp compared with MVR [OR 0.42; (95% CI 0.33-0.54; P = 0.0001)]. There was no difference in long-term survival ranging 1-5 years (HR 0.85, 95% CI 0.65-1.12). Recurrence of MR was significantly higher in the MVRp group (OR 4.26, 95% CI 2.52-7.22), as was the rate of reoperation (OR 2.03, 95% CI 1.49-2.77). Although MVR for ischaemic MR has a higher 30-day mortality rate compared with MVRp, MVRp is associated with the higher rate of MR recurrence and the need for reoperation. MVR remains an attractive option for ischaemic MR.

Impact of additive mitral valve surgery to coronary artery bypass grafting on mortality in patients with coronary artery disease and ischaemic mitral regurgitation: a systematic review and meta-analysis of randomized trials and observational studies

Aims

Treatment of ischaemic mitral regurgitation (IMR) remains controversial. While IMR is associated with worse outcomes, randomized controlled trials (RCTs) and observational studies provided conflicting evidence regarding the benefit of mitral valve replacement (MVR) or repair (MVr) in addition to coronary artery bypass grafting (CABG). We conducted a meta-analysis incorporating data from published RCTs and observational studies comparing CABG vs. CABG + MVR/MVr.

Methods and results

We searched PubMed, MEDLINE, Embase, Ovid, and Cochrane for RCTs and observational studies comparing CABG (Group 1) vs. CABG + MVR/MVr (Group 2). Outcome was 30-day and 1-year mortality after surgical intervention. Mantel-Haenszel odds ratio (OR) was calculated using random-effects meta-analysis for the outcome. Heterogeneity was assessed by I2 statistics. Four RCTs and 11 observational studies met the inclusion criteria (5781 patients, 507 in RCTs, 5274 in observational studies). Group 1 vs. 2 weighted mean left ventricular ejection fraction in RCTs and combined RCTs/observational studies was 41.5 ± 12.3 vs. 40.3 ± 10.4% ( P -value = 0.24) and 45.5 ± 7.2 vs. 38 ± 10% ( P -value < 0.001), respectively. In RCTs, there was no difference in 30-day [OR: 0.95, 95% confidence interval (95% CI): 0.30-3.08, P = 0.94] or 1-year (OR: 0.90, 95% CI: 0.43-1.87, P = 0.78) mortality, respectively. For combined RCTs/observational studies, there was no difference in mortality at 30 days (OR: 0.67, 95% CI: 0.43-1.04, P = 0.08) or at 1 year (OR: 0.90, 95% CI: 0.7-1.15, P = 0.39).

Conclusion

In a meta-analysis of RCTs and observational studies of IMR patients, the addition of MVR/MVr to CABG did not improve survival.

Short-Term and Long-Term Survival After Revascularization with or without Mitral Valve Surgery of Patients with Ischemic Mitral Valve Regurgitation: A Meta-Analysis

BACKGROUND There is no consensus on whether mitral valve repair or replacement (MVRR) must be performed to treat ischemic mitral regurgitation (MVR) after myocardial infarction. Our objective in this study was to investigate the efficacy of coronary artery bypass grafting (CABG) combined with or without MVRR for the ischemic MVR. MATERIAL AND METHODS An article search was performed in OvidSP, PubMed, Cochrane Library, and Embase. In these articles, researchers compared the efficacy of CABG with or without MVRR in treating patients with ischemic MVR after acute coronary syndrome (ACS). We performed a meta-analysis to compare the differences in the short-term and long-term survival rates of patients treated with CABG only and those treated with both CABG and MVRR. Secondary outcomes were compared with the preoperative and postoperative degree of MVR, left ventricular end-systolic volume (LVESV), left ventricular ejection fraction (LVEF), and New York Heart Association (NYHA) class. RESULTS Out of the 1183 studies, we selected only 5 articles. A total of 3120 patients were enrolled; the CABG and MVRR group included 575 patients, while the CABG only group included 2545 patients. Long-term survival was higher in the CABG only group (hazard ratio [HR], 1.34; 95% confidence interval [CI] 1.15-1.58, P=0.003). Hospital mortality was similar in both the groups (odds ratio [OR], 2.54; 95% CI, 0.65-9.95; P=0.18). No differences were found in the degree of residual MVR, the mean of LVESV, LVEF, or NYHA class. CONCLUSIONS In patients with ischemic MVR, the short-term survival rate was similar in both groups. Moreover, there was no significant improvement in the long-term survival rates of patients treated with both CAG and MVRR.

Surgical treatment of moderate ischemic mitral regurgitation

BACKGROUND

Ischemic mitral regurgitation is associated with increased mortality and morbidity. For surgical patients with moderate regurgitation, the benefits of adding mitral-valve repair to coronary-artery bypass grafting (CABG) are uncertain.

METHODS

We randomly assigned 301 patients with moderate ischemic mitral regurgitation to CABG alone or CABG plus mitral-valve repair (combined procedure). The primary end point was the left ventricular end-systolic volume index (LVESVI), a measure of left ventricular remodeling, at 1 year. This end point was assessed with the use of a Wilcoxon rank-sum test in which deaths were categorized as the lowest LVESVI rank.

RESULTS

At 1 year, the mean LVESVI among surviving patients was 46.1±22.4 ml per square meter of body-surface area in the CABG-alone group and 49.6±31.5 ml per square meter in the combined-procedure group (mean change from baseline, -9.4 and -9.3 ml per square meter, respectively). The rate of death was 6.7% in the combined-procedure group and 7.3% in the CABG-alone group (hazard ratio with mitral-valve repair, 0.90; 95% confidence interval, 0.38 to 2.12; P=0.81). The rank-based assessment of LVESVI at 1 year (incorporating deaths) showed no significant between-group difference (z score, 0.50; P=0.61). The addition of mitral-valve repair was associated with a longer bypass time (P<0.001), a longer hospital stay after surgery (P=0.002), and more neurologic events (P=0.03). Moderate or severe mitral regurgitation was less common in the combined-procedure group than in the CABG-alone group (11.2% vs. 31.0%, P<0.001). There were no significant between-group differences in major adverse cardiac or cerebrovascular events, deaths, readmissions, functional status, or quality of life at 1 year.

CONCLUSIONS

In patients with moderate ischemic mitral regurgitation, the addition of mitral-valve repair to CABG did not result in a higher degree of left ventricular reverse remodeling. Mitral-valve repair was associated with a reduced prevalence of moderate or severe mitral regurgitation but an increased number of untoward events. Thus, at 1 year, this trial did not show a clinically meaningful advantage of adding mitral-valve repair to CABG. Longer-term follow-up may determine whether the lower prevalence of mitral regurgitation translates into a net clinical benefit. (Funded by the National Institutes of Health and the Canadian Institutes of Health Research; ClinicalTrials.gov number, NCT00806988.).

Surgical management of moderate ischemic mitral valve regurgitation: Where do we stand?

Ischemic mitral regurgitation (IMR) represents a common complication after myocardial infarction. The valve is anatomically normal and the incompetence is the result of papillary muscles displacement and annular dilatation, causing leaflets tethering. Functionally the leaflets present a restricted systolic motion due to tethering forces that displaces the coaptation surface toward the left ventricle apex. The patients present poor left ventricular function at the time of surgery and the severity of the mitral regurgitation increases the risk of mortality. Currently there is general agreement to treat surgically severe IMR nevertheless strong evidences for patient with moderate insufficiency remains poor and proper treatment debated. The most effective surgical approach for the treatment of IMR remains debated. Some authors demonstrated that coronary artery bypass graft (CABG) alone is beneficial in patients with IMR. Conversely, in most patients, moderate IMR will persist or worsen after CABG alone which translate in higher long-term mortality as a function of residual mitral regurgitation severity. A probable reason for this unclear surgical management of functional MR is due to the contemporary suboptimal results of reparative techniques. The standard surgical treatment of chronic IMR is CABG associated with undersized annuloplasty using complete ring. Though, the recurrence of mitral regurgitation remains high (> 30%) because of continous left ventricle remodeling. To get better long term results, in the last decade, several subvalvular procedures in adjunct to mitral anuloplasty have been developed. Among them, surgical papillary muscle relocation represents the most appreciated option capable to restore normal left ventricle geometry. In the next future new preoperative predictors of increased mitral regurgitation recurrence are certainly needed to find an individual time period of treatment in each patient with moderate IMR.

Posterior papillary muscle anchoring affects remote myofiber stress and pump function: finite element analysis

BACKGROUND

The role of posterior papillary muscle anchoring (PPMA) in the management of chronic ischemic mitral regurgitation (CIMR) is controversial. We studied the effect of anchoring point direction and relocation displacement on left ventricular (LV) regional myofiber stress and pump function.

METHODS

Previously described finite element models of sheep 16 weeks after posterolateral myocardial infarction (MI) were used. True-sized mitral annuloplasty (MA) ring insertion plus different PPM anchoring techniques were simulated. Anchoring points tested included both commissures and the central anterior mitral annulus; relocation displacement varied from 10% to 40% of baseline diastolic distance from the PPM to the anchor points on the annulus. For each reconstruction scenario, myofiber stress in the MI, border zone, and remote myocardium as well as pump function were calculated.

RESULTS

PPMA caused reductions in myofiber stress at end-diastole and end-systole in all regions of the left ventricle that were proportional to the relocation displacement. Although stress reduction was greatest in the MI region, it also occurred in the remote region. The maximum 40% displacement caused a slight reduction in LV pump function. However, with the correction of regurgitation by MA plus PPMA, there was an overall increase in forward stroke volume. Finally, anchoring point direction had no effect on myofiber stress or pump function.

CONCLUSIONS

PPMA reduces remote myofiber stress, which is proportional to the absolute distance of relocation and independent of anchoring point. Aggressive use of PPMA techniques to reduce remote myofiber stress may accelerate reverse LV remodeling without impairing LV function.

Surgical Strategy for Moderate Ischemic Mitral Valve Regurgitation: Repair or Ignore?

<p><strong>Background:</strong> Ischemic heart disease is a significant complication of atherosclerosis. Myocardial infarction after the development of coronary artery disease can lead to a number of serious complications, including ischemic mitral regurgitation (IMR). Currently there is no consensus regarding the preferred therapeutic modality for moderately severe IMR. In this study, the postoperative outcome of concomitant coronary artery bypass (CABG) and mitral valve repair was compared with that of CABG alone in two groups of patients with moderately severe IMR.</p><p><strong>Methods:</strong> A total of 84 patients who underwent operations for coronary artery disease and moderately severe IMR were included in the study. Preoperative demographic and clinical characteristics were recorded at the time of admission. The severity of mitral regurgitation was graded using transthoracic echocardiography and left ventriculography.</p><p><strong>Results:</strong> Significant postoperative improvements were observed in ejection fraction and systolic diameter compared to preoperative values (<em>P</em> = .006 and <em>P</em> = .020 respectively, in the intervention group, <em>P</em> = .001 and <em>P</em> = .001 respectively, in the control group). The decrease in pulmonary artery pressure (PAP) was significant only in the intervention group (<em>P</em> = .001). There was a significantly marked reduction in the severity of IMR in the intervention group compared to control.</p><p><strong>Conclusion:</strong> Surgical repair of the mitral valve in conjunction with CABG for moderately severe IMR appears to be more effective than isolated CABG for certain outcome parameters, including decreased severity of mitral regurgitation and decreased pulmonary artery pressure.</p>

Surgical revascularization is associated with maximal survival in patients with ischemic mitral regurgitation: a 20-year experience

BACKGROUND

The optimal treatment for ischemic mitral regurgitation remains actively debated. Our objective was to evaluate the relationship between ischemic mitral regurgitation treatment strategy and survival.

METHODS AND RESULTS

We retrospectively reviewed patients at our institution diagnosed with significant coronary artery disease and moderate or severe ischemic mitral regurgitation from 1990 to 2009, categorized by medical treatment alone, percutaneous coronary intervention, coronary artery bypass grafting (CABG), or CABG plus mitral valve repair or replacement. Kaplan-Meier methods and multivariable Cox proportional hazards analyses were performed to assess the relationship between treatment strategy and survival, with the use of propensity scores to account for nonrandom treatment assignment. A total of 4989 patients were included: medical treatment alone=36%, percutaneous coronary intervention=26%, CABG=33%, and CABG plus mitral valve repair or replacement=5%. Median follow-up was 5.37 years. Compared with medical treatment alone, significantly lower mortality was observed in patients treated with percutaneous coronary intervention (adjusted hazard ratio, 0.83; 95% confidence interval, 0.76-0.92; P=0.0002), CABG (adjusted hazard ratio, 0.56; 95% confidence interval, 0.51-0.62; P<0.0001), and CABG plus mitral valve repair or replacement (adjusted hazard ratio, 0.69; 95% confidence interval, 0.57-0.82; P<0.0001). There was no significant difference in these results based on mitral regurgitation severity.

CONCLUSIONS

Patients with significant coronary artery disease and moderate or severe ischemic mitral regurgitation undergoing CABG alone demonstrated the lowest risk of death. CABG with or without mitral valve surgery was associated with lower mortality than either percutaneous coronary intervention or medical treatment alone.

Surgical management of ischemic mitral regurgitation: indications, procedures, and future prospects

Ischemic mitral regurgitation (IMR) is one of the most important risk factors affecting prognosis of patients who suffer from myocardial infarction. The mechanisms of IMR, the indications for surgical intervention, the operative procedures, and the limitations of surgical procedures are discussed in this review article.

[Mitral regurgitation in heart failure. Surgical therapy]

The optimal treatment of mitral regurgitation concomitant to heart failure remains controversial. A lack of consensus between cardiologists and cardiac surgeons, because of limited studies and heterogeneous data, has led to vaguely defined guidelines and different handling in the clinical routine in the past. However, progress in the operative management with excellent results of individual experienced centers suggests that a variety of patients might benefit from surgical therapy. Each patient should be evaluated individually regarding the benefits of surgical therapy which requires an interdisciplinary approach ("heart team") due to the complex pathophysiology and demanding diagnostics.

Ischaemic mitral regurgitation: The effects of ring annuloplasty and suture annuloplasty repair techniques on left ventricular re-remodeling

OBJECTIVE

To examine the mid-term results of patients on whom a coronary revascularization as well as a mitral ring and suture annuloplasty have been performed due to coronary artery disease (CAD) and ischaemic mitral regurgitation (IMR).

METHODOLOGY

Totally 73 patients on whom a revascularization and a mitral valve repair due to CAD and IMR had been performed in our clinic between 2000-2008 were included in the study. Patients were divided into two groups one of which included 38 patients (52.05%) on whom a coronary artery bypass graft (CABG) and a ring annuloplasty on the mitral valve had been performed (Group 1) and the other one 35 patients (47.95%) on whom only suture annuloplasty as well as a CABG had been performed (Group 2). The study was planned retrospectively and study data have been obtained by screening the hospital registries retrospectively. In the mid-term, patients were invited for a check and their intragroup and intergroup echocardiographic parameters and functional capacities were assessed statistically.

RESULTS

In pre-operational and post-operational intragroup assessment in terms of echocardiographic findings; although LVEDD, LVESD, EDV, PAP and the degree of recurrent MR have been decreased in both groups, the decrease in LVESD and PAP and the low degree of recurrent MR were statistically significant in Group 1 patients (p=0.047, p=0.023, p=0.01, respectively). When the mid-term intergroup echocardiograpic findings were assessed; PAP and recurrent MR have been determined statistically lower in Group 1 patients (p=0.005, p=0.08, respectively). The length of intensive care unit stay, length of hospitalization and length of detachment from respiratory support were statistically significantly longer in ring annuloplasty performed group (p=0.012, p=0.033, p=0.029, respectively).

CONCLUSIONS

In moderate to severe IMR patients, a positive contribution can be provided to ventricular remodeling by a ring annuloplasty through a significant decrease in left ventricular diameter and a low recurrent MR and PAP.

Quantitative evaluation of change in coexistent mitral regurgitation after aortic valve replacement

OBJECTIVES

Management of intermediate degrees of mitral regurgitation during aortic valve replacement for aortic stenosis remains controversial. We sought to evaluate the degree of reduction of mitral regurgitation in patients undergoing aortic valve replacement, as well as a mathematical relationship between aortic valve gradient reduction and the degree of mitral regurgitation decrement.

METHODS

We retrospectively analyzed demographic, intraoperative, and echocardiographic data on 802 patients who underwent aortic valve replacement or aortic root replacement between January 2010 and March 2011. A total of 578 patients underwent aortic valve replacement or aortic root replacement without intervention on the mitral valve. We excluded 88 patients with severe aortic insufficiency, 3 patients who underwent ventricular assist device placement, 4 patients who underwent prior mitral valve replacement, and 21 patients with incomplete data, yielding 462 patients for analysis. For each patient, the degree of pre- and postoperative mitral regurgitation was graded on a standard 0 to 4+ scale.

RESULTS

Of the 462 patients, 289 patients had at least mild mitral regurgitation. On average, mitral regurgitation decreased 0.24 degrees per patient for this cohort of 289 patients. Of the 56 patients with at least moderate mitral regurgitation, mitral regurgitation decreased 0.54 degrees per patient. Of 62 patients who underwent isolated aortic valve replacements, who had at least mild mitral regurgitation, and who had no evidence of structural mitral valve disease, mitral regurgitation decreased 0.24 degrees per patient. Linear regression analysis revealed no relationship between reduction in mitral regurgitation and gradient reduction across the aortic valve.

CONCLUSIONS

Reduction in mitral regurgitation after relief of aortic outflow tract obstruction is modest at best. Further, the magnitude of gradient change across the aortic valve has little influence on the degree of reduction in mitral regurgitation. These observations argue at minimum for performing a prospective evaluation of the clinical benefits of addressing moderate mitral regurgitation at the time of aortic valve intervention and may support a more aggressive approach to concomitant mitral surgery.

Mitral valve surgery for dilated cardiomyopathy: current status and future roles

There are a large number of patients with functional mitral regurgitation resulting from dilated cardiomyopathy. The decision between surgical correction and medical management of severe mitral regurgitation in heart failure can be difficult. The data regarding long-term benefits and mortality after surgical intervention are contradictory. Recent data suggest that mitral regurgitation can be surgically corrected in heart failure with symptomatic improvements and beneficial reverse remodeling. Contrary to prior beliefs, mitral valve repair can be performed safely with minimal postoperative mortality. Data from multi-institutional, randomized prospective trials will help to elucidate many of the questions and concerns regarding repair of severe functional mitral regurgitation.

Surgical treatment of functional mitral regurgitation

Incidence of functional mitral regurgitation (FMR) is increasing due to aging and better survival after acute myocardial infarction, the most frequent cause of FMR. At the basis of FMR there is a displacement of one of both papillary muscle(s) and/or annular enlargement, which can be primitive or, more often, secondary. There is general agreement that its natural history is unfavorable, as witnessed by a considerable body of evidences. However, even if there is no clear evidence that surgical treatment of FMR changes consistently the outcome of patients with this disease, at least in terms of survival, there are some studies which show that function improves, as well as the global quality of life. The guidelines reflect this uncertainty, providing no clear indications, even in the gradation of severity of the FMR. Surgical techniques are variable and are mainly addressed to the annulus (restrictive annuloplasty), which is only a part of the anatomic problem related to FMR. Insertion of a prosthesis inside the native valve is appearing more and more a valuable option rather than a bail out procedure. On the other side, techniques addressed to modify the position of the papillary muscles appear to be still under investigation and not yet in the armamentarium of surgical treatment of FMR. Even after many years, rules are not established and results are fluctuating, but how and when to treat FMR is becoming more and more a topic of interest in cardiac surgery.

Another multidisciplinary look at ischemic mitral regurgitation

Ischemic mitral regurgitation (IMR) continues to challenge surgeons and scientists alike. This vexing clinical entity frequently complicates myocardial infarction and carries a poor prognosis both in the setting of coronary disease and idiopathic dilated cardiomyopathy. Ischemic mitral regurgitation encompasses a difficult patient population that is characterized by high operative mortality, poor long term outcomes, and frequent recurrent insufficiency after standard surgical repair. Yet optimal surgical repair and improved clinical outcomes can only be achieved with better knowledge of the pathophysiology of IMR which is still incompletely understood. The causative mechanism of IMR appears to lie in the annular and subvalvular frame of the valve rather than leaflet or chordal structure leading to such labels as "ischemic," "functional," "non-organic," and "cardiomyopathy associated" being applied in the clinical literature. Although ischemic mitral regurgitation is a prevailing clinical entity, it has not been consistently defined in the literature, contributing to considerable confusion and contradictory results of clinical studies. As the mechanisms of pathophysiology have been better elucidated, novel surgical and interventional strategies have been developed recently to provide better treatment for this difficult patient population. In this review, we undertake a multidisciplinary update of the pathophysiology, classification, and surgical and interventional treatment of ischemic mitral regurgitation in today's clinical practice.

Moderate mitral regurgitation accelerates left ventricular remodeling after posterolateral myocardial infarction

BACKGROUND

Chronic ischemic mitral regurgitation (MR) is associated with poor outcome. However, the effect of chronic ischemic MR on left ventricular (LV) remodeling after posterolateral myocardial infarction (MI) remains controversial. We tested the hypothesis that moderate MR accelerates LV remodeling after posterolateral MI.

METHODS

Posterolateral MI was created in 10 sheep. Cardiac magnetic resonance imaging was performed 2 weeks before and 2, 8, and 16 weeks after MI. Left ventricular and right ventricular volumes were measured, and regurgitant volume was calculated as the difference between LV and right ventricle stroke volumes.

RESULTS

Multivariate mixed effects regression showed that LV volumes at end diastole and end systole and LV sphericity were strongly correlated with both regurgitant volume (p < 0.0001, p = 0.0086, and p = 0.0007, respectively) and percent infarct area (p = 0.0156, p = 0.0307, and p < 0.0001, respectively). Conversely, whereas LV hypertrophy (LV wall volume) increased from 2 weeks to 16 weeks after MI, there was no effect of either regurgitant volume or percent infarct.

CONCLUSIONS

Moderate MR accelerates LV remodeling after posterolateral MI. Further studies are needed to determine whether mitral valve repair is able to slow or reverse MI remodeling after posterolateral MI.

Should all ischemic mitral regurgitation be repaired? When should we replace?

PURPOSE OF REVIEW

Ischemic mitral regurgitation (IMR) is a major source of morbidity and mortality. Although mitral valve repair has become recently popularized for the treatment of IMR, select patients may derive benefits from replacement. The purpose of this review is to describe current surgical options for IMR and to discuss when mitral valve replacement (MVR) may be favored over mitral valve repair.

RECENT FINDINGS

Current surgical options for the treatment of IMR include surgical revascularization alone, mitral valve repair, or MVR. Although surgical revascularization alone may benefit patients with mild-moderate IMR, most surgeons advocate the performance of revascularization in combination with either mitral valve repair or replacement. In the current era, mitral valve repair has proven to offer improved short-term and long-term survival, decreased valve-related morbidity, and improved left ventricular function compared with MVR. However, MVR should be considered for high-risk patients and those with specific underlying mechanisms of IMR.

SUMMARY

In the absence of level one evidence, mitral valve repair offers an effective and durable surgical approach to the treatment of mitral insufficiency and remains the operation of choice for IMR. MVR, however, is preferred for select patients. Future randomized, prospective clinical trials are needed to directly compare these surgical techniques.

Outcomes of coronary artery bypass grafting and reduction annuloplasty for functional ischemic mitral regurgitation: a prospective multicenter study (Randomized Evaluation of a Surgical Treatment for Off-Pump Repair of the Mitral Valve)

OBJECTIVE

Functional ischemic mitral regurgitation is a complication of ventricular remodeling; standard therapy is reduction annuloplasty and coronary artery bypass grafting. Unfortunately, outcomes are retrospective and contradictory. We report a multicenter study that documents the outcomes of reduction annuloplasty for functional ischemic mitral regurgitation.

METHODS

Twenty-one centers randomized 75 patients to the coronary artery bypass grafting + reduction annuloplasty subgroup that was the control arm of the Randomized Evaluation of a Surgical Treatment for Off-pump Repair of the Mitral Valve trial. Entry criteria included patients requiring revascularization, patients with severe or symptomatic moderate functional ischemic mitral regurgitation, an ejection fraction 25% or greater, a left ventricular end-diastolic dimension 7.0 cm or less, and more than 30 days since acute myocardial infarction. All echocardiograms were independently scored by a core laboratory. Reduction annuloplasty was achieved by device annuloplasty. Two patients underwent immediate intraoperative conversion to a valve replacement because reduction annuloplasty was unable to correct mitral regurgitation; as-treated results are presented.

RESULTS

Thirty-day mortality was 4.1% (3/73). Patients received an average of 2.8 bypass grafts. Mean follow-up was 24.6 months. Mitral regurgitation was reduced from 2.6 ± 0.8 preoperatively to 0.3 ± 0.6 at 2 years. Freedom from death or valve reoperation was 78% ± 5% at 2 years. There was significant improvement in ejection fraction and New York Heart Association class with reduction of left ventricular end-diastolic dimension. Cox regression analyses suggested that increasing age (P = .001; hazard ratio, 1.16 per year; 95% confidence interval, 1.06-1.26) and renal disease (P = .018; hazard ratio, 3.48; 95% confidence interval, 1.25-9.72) were associated with decreased survival.

CONCLUSIONS

Coronary artery bypass grafting + reduction annuloplasty for functional ischemic mitral regurgitation predictably reduces mitral regurgitation and relieves symptoms. This treatment of moderate to severe mitral regurgitation is associated with improved indices of ventricular function, improved New York Heart Association class, and excellent freedom from recurrent mitral insufficiency. Although long-term prognosis remains guarded, this multicenter study delineates the intermediate-term benefits of such an approach.

Is mitral valve repair superior to replacement for chronic ischemic mitral regurgitation with left ventricular dysfunction?

Background

This study was undertaken to compare mitral valve repair and replacement as treatments for ischemic mitral regurgitation (IMR) with left ventricular dysfunction (LVD). Specifically, we sought to determine whether the choice of mitral valve procedure affected survival, and discover which patients were predicted to benefit from mitral valve repair and which from replacement.

Methods

A total of 218 consecutive patients underwent either mitral valve repair (MVP, n = 112) or mitral valve replacement (MVR, n = 106). We retrospectively reviewed the clinical material, operation methods, echocardiography check during operation and follow-up. Patients details and follow-up outcomes were compared using multivariate and Kaplan-Meier analyses.

Results

No statistical difference was found between the two groups in term of intraoperative data. Early mortality was 3.2% (MVP 2.7% and MVR 3.8%). At discharge, Left ventricular end-systolic and end-diastolic diameter and left ventricular ejection fraction (LVEF) were improved more in the MVP group than MVR group (P < 0.05), however, in follow-up no statistically significant difference was observed between the MVR and MVP group (P > 0.05). Follow-up mitral regurgitation grade was significantly improved in the MVR group compared with the MVP group (P < 0.05). The Kaplan-Meier survival estimates at 1, 3, and 5 years were simlar between MVP and MVR group. Logistic regression revealed poor survival was associated with old age(#75), preoperative renal insufficiency and low left ventricular ejection fraction (< 30%).

Conclusion

Mitral valve repair is the procedure of choice in the majority of patients having surgery for severe ischemic mitral regurgitation with left ventricular dysfunction. Early results of MVP treatment seem to be satisfactory, but several lines of data indicate that mitral valve repair provided less long-term benefit than mitral valve replacement in the LVD patients.

Impact of moderate ischemic mitral regurgitation after isolated coronary artery bypass grafting

BACKGROUND

The aim of the study was to evaluate the clinical and echocardiographic outcomes, at rest and under exercise testing, of patients with moderate ischemic mitral regurgitation (IMR) undergoing isolated coronary artery bypass graft surgery (CABG).

METHODS

Between February 2003 and March 2008, 180 patients with moderate IMR who had isolated CABG were enrolled. Patients were matched 1:2 (n = 360) with patients who underwent isolated CABG without IMR (by propensity score). The study endpoints were freedom from all death, cardiac related-death, late events, and cardiac-related events. Late outcomes and left ventricular remodeling were evaluated according to preoperative percent of ejection fraction. Symptoms and MR grade under exercise test were investigated. Mean follow-up was 30 ± 16 months.

RESULTS

The 5-year freedom from all deaths and from cardiac-related deaths among patients without IMR versus with IMR was, respectively, 90.5% ± 1.8% versus 73.7% ± 2.1% (p < 0.001) and 94.2% ± 1.6% versus 79.5% ± 1.5% (p < 0.001). Ischemic mitral regurgitation affects significantly late survival only in patients with ejection fraction 40% or less. The 5-year freedom from cardiac-related events among patients without and with IMR was, respectively, 88.2% ± 2.1% and 62.1% ± 1.2% (p < 0.0001). Patients with IMR experienced more cardiac-related events in comparison with patients without IMR. Ischemic mitral regurgitation promotes left ventricular remodeling in all patients. During exercise testing, the grade of MR moved from mild to moderate in 10 patients (28.5%) and to severe in 5 (14.3%). Among the 42 patients with moderate MR at rest, 32 patients (76%) moved from moderate to severe MR during exercise.

CONCLUSIONS

Ischemic mitral regurgitation significantly increases the incidence of cardiac-related deaths among patients with ejection fraction 40% or less and the incidence of cardiac-related events, and promotes left ventricular remodeling. Most patients who had at-rest residual mild to moderate MR presented with a worse MR grade under exercise with the appearance of dyspnea.