Does Coronary Artery Bypass Grafting Alone Correct Moderate Ischemic Mitral Regurgitation?

Abstract

Background The optimal management of moderate (3+ on a scale of 0 to 4+) ischemic mitral regurgitation (MR) remains controversial. Some advocate CABG alone, whereas others favor concomitant mitral annuloplasty. To clarify the optimal management of these patients, we evaluated the early impact of isolated CABG on moderate ischemic MR. Methods and Results Between January 1992 and August 1999, 136 patients (54% male, mean age 70.5 years, mean New York Heart Association class 2.7, mean ejection fraction 38.1%) with a preoperative diagnosis of moderate ischemic MR, without leaflet prolapse or pathology, underwent isolated CABG. Thirty-eight (28%) of 136 patients had intraoperative transesophageal echocardiography (TEE) before CABG, and 68 (50%) had postoperative transthoracic echocardiography (TTE) within 6 weeks of surgery. The subgroups of patients undergoing intraoperative TEE and postoperative TTE had preoperative characteristics similar to the overall group. The 30-day operative mortality was 2.9% ( \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(\frac{4}{136}\) \end{document} ). Intraoperative TEE downgraded the severity of MR to mild or less (0 to 2+) in 89% ( \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(\frac{34}{38}\) \end{document} ). On postoperative TTE, 40% ( \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(\frac{27}{68}\) \end{document} ) continued to have at least moderate MR (3 to 4+), 51% ( \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(\frac{35}{68}\) \end{document} ) improved somewhat to mild (2+) MR, and only 9% ( \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(\frac{6}{68}\) \end{document} ) had resolution of their MR (0 to 1+). The mean preoperative, intraoperative, and postoperative MR grades were 3.0±0.0, 1.4±1.0, and 2.3±0.8, respectively ( P <0.001). Conclusions CABG alone for moderate ischemic MR leaves many patients with significant residual MR and may not be the optimal therapy for most patients. Intraoperative TEE may significantly underestimate the severity of ischemic MR. A preoperative diagnosis of moderate MR may warrant concomitant mitral annuloplasty.

Is a good perioperative echocardiographic result predictive of durability in ischemic mitral valve repair?

“…Surgical correction, either by replacement or repair, is generally recommended for 3ϩ and 4ϩ IMR. [9][10][11] In comparative analyses, repair seems to benefit most patients with IMR, with the possible exception of high-risk groups (higher New York Heart Association [NYHA] functional class or emergency operation). 1,12 In patients who undergo repair, residual MR greater than 1ϩ is associated with increased late mortality.…”

“…1,[5][6][7][8] Operative mortality is increased for patients undergoing mitral valve operation and revascularization in the presence of IMR when compared with nonischemic MR 4,6,7 or revascularization alone.Surgical correction, either by replacement or repair, is generally recommended for 3ϩ and 4ϩ IMR. [9][10][11] In comparative analyses, repair seems to benefit most patients with IMR, with the possible exception of high-risk groups (higher New York Heart Association [NYHA] functional class or emergency operation). 1,12 In patients who undergo repair, residual MR greater than 1ϩ is associated with increased late mortality.…”

Long-term Influence of Mild to Moderate Ischemic Mitral Regurgitation after Off-pump Coronary Artery Bypass Surgery

“…These patients also showed a higher prevalence of cardiovascular mortality, severe heart failure, and recurrent myocardial infarction. Grigioni and colleagues showed that in the chronic phase of a myocardial infarction, the presence of IMR was associated with excess mortality independently of baseline characteristics and severe ventricular dysfunction [4]. Risk of death was directly related to the importance of IMR [4].…”

“…Grigioni and colleagues showed that in the chronic phase of a myocardial infarction, the presence of IMR was associated with excess mortality independently of baseline characteristics and severe ventricular dysfunction [4]. Risk of death was directly related to the importance of IMR [4]. In patients undergoing primary percutaneous coronary intervention (PCI) in the set up of an acute MI [16], Pellizzon's study showed that survival was markedly reduced in patients with IMR at both 30 days and 1 year, and increased with severity of mitral regurgitation [17].…”

“…However, the optimal management of moderate IMR still remains controversial. There have been pros and cons about concurrent mitral valve reparative procedures at the time of CABG in managing IMR patients [1,2,[4][5][6][7][8].…”