Should the mitral valve be repaired for moderate ischemic mitral regurgitation at the time of revascularization surgery? (original) (raw)
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The Journal of Thoracic and Cardiovascular Surgery
Objective: This meta-analysis was conducted to compare clinical and echocardiographic outcomes following isolated coronary artery bypass grafting (CABG) versus CABG and mitral valve (MV) surgery in patients with moderate-to-severe ischemic mitral regurgitation (IMR). Methods: Seven databases were systematically searched to identify relevant studies. For eligibility, studies were required to report on the primary endpoint of perioperative or late mortality. Data were analyzed according to predefined clinical endpoints. Results: Four randomized controlled trials (RCTs) (n ¼ 505) and 15 observational studies (OS) (n ¼ 3785) met the criteria for inclusion. Compared with isolated CABG, concomitant CABG and MV surgery was not associated with increased perioperative mortality (RCTs: relative risk [RR] 0.89, 95% confidence interval [CI], 0.26-3.02; OS: RR 1.40, 95% CI, 0.88-2.23). CABG and MV surgery was associated with significantly lower incidence of moderate-to-severe MR at follow-up (RCTs: RR 0.16, 95% CI, 0.04-0.75; OS: RR 0.20, 95% CI, 0.09-0.48). Late mortality was similar between the surgical approaches in RCTs (hazard ratio [HR] 1.20, 95% CI, 0.57-2.53) and OS (HR 0.99, 95% CI, 0.81-1.21). There were no significant differences in echocardiographic outcomes. These results remained consistent in subgroup analyses restricted to patients with strictly moderate IMR. Conclusions: In patients with moderate-to-severe IMR, the addition of MV surgery to CABG was not associated with increased perioperative mortality. Although concomitant MV surgery reduced recurrence of moderate-to-severe MR at follow-up, this was not associated with a reduction in late mortality. Larger trials with longer follow-up duration are required to further assess longterm survival and freedom from reintervention.
Structural Heart, 2019
Background: This study examined the impact of mitral valve repair (MVRe) on survival of patients with moderate or severe (≥2+) MR and ischemic cardiomyopathy randomized to coronary artery bypass grafting (CABG) versus CABG+surgical ventricular reconstruction (SVR) in the STICH trial. Methods: Among patients with moderate or severe MR and ischemic cardiomyopathy undergoing CABG or CABG+SVR, the impact of MVRe on mortality between the two treatment arms was compared. Results: Among 867 patients with assessment of baseline MR severity, 211 had moderate or severe MR. After excluding 7 patients who underwent mitral valve replacement, 50, 44, 62, and 48 patients underwent CABG, CABG+MVRe, CABG+SVR, and CABG+SVR +MVRe, respectively. Four-year mortality rates were lower following CABG+MVRe than CABG alone (16% vs. 55%; adjusted hazard ratio [HR] 0.30; 95% CI 0.13-0.71). In contrast, the CABG+SVR+MVRe and CABG+SVR groups had similar 4-year mortality of 39% vs. 39% (adjusted HR 0.88; 95% CI 0.46-1.70). MVRe had a more favorable effect on survival in patients undergoing CABG alone compared to CABG+SVR (p = 0.013). Baseline MR severity was similar between patients that received CABG+MVRe and those that underwent CABG+SVR+MVRe. A larger proportion of patients demonstrated a reduction in MR between 4 and 24 months after CABG+MVRe compared to CABG+SVR+MVRe (50.0% versus 25.0%, p = 0.023). Conclusion: In patients with moderate or severe MR and ischemic cardiomyopathy undergoing CABG, MVRe appears to have a favorable effect on survival. The addition of SVR to CABG may attenuate the anticipated benefits of MVRe by limiting the longterm reduction of MR with MVRe.
Heart, Lung and Circulation, 2014
Background Ischaemic mitral regurgitation (IMR) is commonly manifested after coronary artery disease, but it is still controversial as to whether coronary artery bypass grafting (CABG) alone improves postoperative outcome. Objectives A focussed clinical question was designed and a meta-analysis of published studies was performed to identify the impact of mitral valve repair (MVR) in patients with IMR undergoing CABG versus those undergoing CABG alone. Methods Using the Medline database, the Cochrane clinical trials database and online clinical trial databases, we reviewed all RCTs and observational studies examining the impact of MVR and CABG in treating patients with IMR. We searched for literature published before September 2013 and earlier. Results This analysis identified five studies which examined the impact of CABG alone versus combined CABG and MVR in treating patients with IMR, involving 1038 patients, with 423 patients undergoing CABG alone and 615 were performed combined CABG and MVR procedures. There was significant improvement in postoperative mitral regurgitation (MR) grade in combined group, comparing with CABG alone group (WMD: 1.34, 95% CI: 0.47 to 2.21, p = 0.003), but no significant differences were noted between the CABG plus MVR group and CABG alone group in terms of in-hospital mortality (OR: 0.84, 95% CI: 0.44 to 1.61, p = 0.60), MR grade improvement rate (OR: 0.19, 95% CI: 0.02 to 1.66, p = 0.13), postoperative mean NYHA functional class (WMD: 0.33, 95% CI:-0.29 to 0.94, p = 0.30) and five-year survival (OR: 0.77, 95% CI: 0.34 to 1.73, p = 0.53). Conclusions Compared with CABG alone, patients who underwent combined CABG and MVR procedures showed a greater improvement in postoperative MR grade, but in terms of in-hospital mortality, MR grade improvement rate, postoperative mean NYHA functional class and five-year survival, adding MVR to CABG surgery lacks evidence to show its superiority.
Circulation, 2012
Background-The role of mitral valve repair (MVR) during coronary artery bypass grafting (CABG) in patients with moderate ischemic mitral regurgitation (MR) is uncertain. We conducted a randomized, controlled trial to determine whether repairing the mitral valve during CABG may improve functional capacity and left ventricular reverse remodeling compared with CABG alone. Methods and Results-Seventy-three patients referred for CABG with moderate ischemic MR and an ejection fraction Ͼ30% were randomized to receive CABG plus MVR (34 patients) or CABG only (39 patients). The study was stopped early after review of interim data. At 1 year, there was a greater improvement in the primary end point of peak oxygen consumption in the CABG plus MVR group compared with the CABG group (3.3 mL/kg/min versus 0.8 mL/kg/min; PϽ0.001). There was also a greater improvement in the secondary end points in the CABG plus MVR group compared with the CABG group: left ventricular end-systolic volume index, MR volume, and plasma B-type natriuretic peptide reduction of 22.2 mL/m 2 , 28.2 mL/beat, and 557.4 pg/mL, respectively versus 4.4 mL/m 2 (Pϭ0.002), 9.2 mL/beat (Pϭ0.001), and 394.7 pg/mL (Pϭ0.003), respectively. Operation duration, blood transfusion, intubation duration, and hospital stay duration were greater in the CABG plus MVR group. Deaths at 30 days and 1 year were similar in both groups: 3% and 9%, respectively in the CABG plus MVR group, versus 3% (Pϭ1.00) and 5% (Pϭ0.66), respectively in the CABG group. Conclusions-Adding mitral annuloplasty to CABG in patients with moderate ischemic MR may improve functional capacity, left ventricular reverse remodeling, MR severity, and B-type natriuretic peptide levels, compared with CABG alone. The impact of these benefits on longer term clinical outcomes remains to be defined.
Texas Heart Institute journal / from the Texas Heart Institute of St. Luke's Episcopal Hospital, Texas Children's Hospital, 2009
We sought to evaluate retrospectively the outcomes of patients at our hospital who had moderate ischemic mitral regurgitation and who underwent coronary artery bypass grafting (CABG) alone or with concomitant mitral valve repair (CABG+MVr).A total of 83 patients had a reduced left ventricular ejection fraction and moderate mitral regurgitation: 28 patients underwent CABG+MVr, and 55 underwent CABG alone. Changes in mitral regurgitation, functional class, and left ventricular ejection fraction were compared in both groups.The mean follow-up was 5.1 +/- 3.6 years (range, 0.1-15.1 yr). Reduction of 2 mitral-regurgitation grades was found in 85% of CABG+MVr patients versus 14% of CABG-only patients (P < 0.0001) at 1 year, and in 56% versus 14% at 5 years, respectively (P = 0.1), as well as improvements in left ventricular ejection fraction and functional class. One- and 5-year survival rates were similar in the CABG+MVr and CABG-only groups: 96% +/- 3% versus 96% +/- 4%, and 87% +/- ...
Circulation, 2012
Background-The role of mitral valve repair (MVR) during coronary artery bypass grafting (CABG) in patients with moderate ischemic mitral regurgitation (MR) is uncertain. We conducted a randomized, controlled trial to determine whether repairing the mitral valve during CABG may improve functional capacity and left ventricular reverse remodeling compared with CABG alone. Methods and Results-Seventy-three patients referred for CABG with moderate ischemic MR and an ejection fraction Ͼ30% were randomized to receive CABG plus MVR (34 patients) or CABG only (39 patients). The study was stopped early after review of interim data. At 1 year, there was a greater improvement in the primary end point of peak oxygen consumption in the CABG plus MVR group compared with the CABG group (3.3 mL/kg/min versus 0.8 mL/kg/min; PϽ0.001). There was also a greater improvement in the secondary end points in the CABG plus MVR group compared with the CABG group: left ventricular end-systolic volume index, MR volume, and plasma B-type natriuretic peptide reduction of 22.2 mL/m 2 , 28.2 mL/beat, and 557.4 pg/mL, respectively versus 4.4 mL/m 2 (Pϭ0.002), 9.2 mL/beat (Pϭ0.001), and 394.7 pg/mL (Pϭ0.003), respectively. Operation duration, blood transfusion, intubation duration, and hospital stay duration were greater in the CABG plus MVR group. Deaths at 30 days and 1 year were similar in both groups: 3% and 9%, respectively in the CABG plus MVR group, versus 3% (Pϭ1.00) and 5% (Pϭ0.66), respectively in the CABG group. Conclusions-Adding mitral annuloplasty to CABG in patients with moderate ischemic MR may improve functional capacity, left ventricular reverse remodeling, MR severity, and B-type natriuretic peptide levels, compared with CABG alone. The impact of these benefits on longer term clinical outcomes remains to be defined.
Journal of Cardiac Surgery, 2001
Introduction: Mitral valve regurgitation (MR) occurring as a result of myocardial ischemia and global left ventricular (LV) dysfunction predicts poor outcome. This study assessed the feasibility of mitral valve (MV) surgery concomitant with coronary artery bypass grafting (CABG) in patients with mild-to-moderate and moderate ischemic M R and impaired LV function. patients (group 1) and 50 patients (group 2) with grade II and grade 111 ischemic MR and LV ejection fraction (EF) between 17% and 30% underwent combined M V surgery and CABG (group 1) or isolated CABG (group 2). LVEF (%), LV end-diastolic diameter (EDD) (mm), LV end-diastolic pressure (EDP) (mmHg), and LV end-systolic diameter (ESD) (mm) were 27.5