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

Aklog, Lishan; Filsoufi, Farzan; Flores, Kathryn Q.; Chen, Raymond H.; Cohn, Lawrence H.; Nathan, Neera; Byrne, John G.; Adams, David H.

doi:10.1161/hc37t1.094706

Cited by 296 publications

(177 citation statements)

References 15 publications

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“…For example, grading discrepancies between pre-CPB TEE and preoperative TTE MR grading have been well established; pre-CPB TEE underestimates MR severity, probably because of changes in loading conditions. [21][22][23][24] Likewise, decreased loading may lead to underestimation of ΔP m across the aortic valve while under general anesthesia. This consequence has practical importance because artificially low-gradient measurements despite normal LVEF could lead to confusion and underestimation of disease.…”

Section: Discussionmentioning

confidence: 99%

Discordance in Grading Methods of Aortic Stenosis by Pre-Cardiopulmonary Bypass Transesophageal Echocardiography

Whitener

McKenzie

Akushevich

et al. 2016

Anesthesia &Amp; Analgesia

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Discordance in Grading Aortic Stenosis by Pre-CPB TEE aortic valve. For this reason, AVA calculation is prone to error compared with a ΔP m measurement.Although inconsistencies for grading AS with AVA and ΔP m are well known for preoperative TTE, they are routinely used for grading AS in the pre-cardiopulmonary bypass (pre-CPB) context. In this study, we investigate the frequency of discordance between grading AS with ΔP m measurements and AVA calculations during pre-CPB transesophageal echocardiography (TEE) to provide insight into their reliability for pre-CPB assessment of AS severity. Conventional AS severity cutoffs were derived from TTE studies performed in awake, spontaneously breathing patients.14-18 However, cardiac anesthesiologists perform pre-CPB TEE in anesthetized patients receiving positive pressure ventilation. Because general anesthesia and positive pressure ventilation may influence cardiac loading conditions, we hypothesized that grading discordance by pre-CPB TEE would be higher than previously reported for TTE by others. METHODSWe obtained Duke University IRB approval, which granted waiver of consent to perform a retrospective database study for information collected between January 1, 2000, and December 31, 2012. This study was an investigator-initiated, single-center, retrospective review of the Duke University, Department of Anesthesiology perioperative echocardiography-reporting database. This database includes all adult patients who have undergone cardiac surgery at Duke University Medical Center and had a TEE report generated electronically since January 1, 2000. The Duke Health Information Technologies Solutions (DHTS) Perioperative Development Group (PDG) maintains the reporting system. A cardiothoracic anesthesiology fellow, attending, or both, generated TEE reports as part of a dedicated perioperative echocardiography training program. All imaging and reports were subsequently reviewed offline by an independent cardiothoracic anesthesiologist to confirm the accuracy of the report. Subject SelectionWe reviewed all patients in the database, who underwent AVR with or without coronary artery bypass grafting from January 1, 2000, until December 31, 2012. Patients were included if the echocardiographer reported both a pre-CPB ΔP m and an AVA. Patients were excluded if they had emergency surgery or repeat sternotomy. Patients were also excluded if they had an ejection fraction <55%, moderate or severe mitral regurgitation (MR), or severe aortic insufficiency (AI). Definitions of Variables Statistical AnalysisIRB approval was obtained in early 2013; therefore, we collected retrospective data as far as possible, up through December 31, 2012. Pre-CPB TEE ΔP m and AVA values were extracted for all patients meeting clinical inclusion criteria. These values were grouped according to AS severity (mild, moderate, and severe) and compared for discordance rates based on current grading guidelines for ΔP m and AVA. Values were considered "discordant" if there was disagreement between severities bas...

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Section: Discussionmentioning

confidence: 99%

Discordance in Grading Methods of Aortic Stenosis by Pre-Cardiopulmonary Bypass Transesophageal Echocardiography

Whitener

McKenzie

Akushevich

et al. 2016

Anesthesia &Amp; Analgesia

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“…29 Such a dramatic variation in MR is observed most commonly in the operating room, where anaesthetic induction can reduce moderate MR to trace levels, confounding decisions regarding the need for mitral valve repair. 30 Inotropic agents can also reduce the severity of MR (Figure 2). 31 The underestimation of intraoperative MR might contribute to an i naccurate diagnosis of recur rent MR after isolated CABG surgery.…”

Section: Exercise-induced Changes In Mrmentioning

confidence: 99%

“…30,40 Although CABG surgery alone seems to produce long term survival rates similar to those for combined surgery, patients with untreated secondary MR at the time of isolated CABG surgery have an increased risk of hospitalization for heart failure during follow up. 41,42 The main aim of combined surgery is to improve long term functional status and quality of life.…”

Section: Surgical Optionsmentioning

confidence: 99%

Therapeutic decision-making for patients with fluctuating mitral regurgitation

2015

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| Mitral regurgitation (MR) is a common, progressive, and difficult-to-manage disease. MR is dynamic in nature, with physiological fluctuations occurring in response to various stimuli such as exercise and ischaemia, which can precipitate the development of symptoms and subsequent cardiac events. In both chronic primary and secondary MR, the dynamic behaviour of MR can be reliably examined during stress echocardiography. Dynamic fluctuation of MR can also have prognostic value; patients with a marked increase in regurgitant volume or who exhibit increased systolic pulmonary artery pressure during exercise have lower symptom-free survival than those who do not experience significant changes in MR and systolic pulmonary artery pressure during exercise. Identifying patients who have dynamic MR, and understanding the mechanisms underlying the condition, can potentially influence revascularization strategies (such as the surgical restoration of coronary blood flow) and interventional treatment (including cardiac resynchronization therapy and new approaches targeted to the mitral valve).

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“…Treatment of background CAD by coronary artery bypass grafting (CABG) alone does not correct IMR in most patients. 7,8 Restrictive mitral valve annuloplasty (MVA) in combination with CABG, however, is conventionally considered as the standard surgical approach for IMR. 9 Unfortunately, this procedure does not improve the long-term survival, 2,10,11 and the rate of persistent or recurrent mitral regurgitation (MR) is reported to be as high as 30% or more in experienced centers.…”

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confidence: 99%

Novel Echocardiographic Indices as Predictors of Immediate Recurrence after Undersized Ring Annuloplasty for Ischemic Mitral Regurgitation

et al. 2015

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Background and aim: Ischemic mitral regurgitation (IMR) is among the most serious complications of myocardial infarction which doubles the late mortality; mainly treated by undersizing ring annuloplasty. To find some preoperative echocardiographic indices that predict immediate failure of mitral valve annuloplasty (MVA), we designed the present study with more focusing on some novel parameters. Method: Transthoracic echocardiography (TTE) indices of consecutive patients referred with 3+ or 4+ IMR were registered 24 hours before surgery. Thirty days later, a second TTE was performed. According to the results, the patients were categorized as the "successful" group (with 1+ or less mitral regurgitation) and the "unsuccessful" group (with 2+ or higher MR). Preoperative TTE indices were compared among the two groups using suitable statistical tests. Results: Of the total of 126 cases, 68 had successful and 58 had unsuccessful MVA. Statistically significant differences were found between the two groups for left ventricular ejection fraction (LVEF) (P = 0.007), left ventricular end systolic volume (LVESV) (P = 0.044), and basal-interpapillary muscle distance (IPMD) diastolic-to-systolic ratio (DSR) (P = 0.008). Receiver Operating Characteristic analysis demonstrated 37.5%, 3.85 cm 3 , and 1.25, as the best cutoff points for LVEF (P = 0.03, sensitivity: 81%, specificity: 69%), LVESV (P = 0.023, sensitivity: 83%, specificity: 57%), and basal-IPMD DSR (P = 0.001, sensitivity: 100%, specificity: 95%), respectively. Conclusion: Among all TTE indices, LVEF, LVESV, and basal-IPMD DSR were helpful to differentiate between the successful and unsuccessful MVA results. We believe the basal-IPMD DSR as a novel index could be targeted in the future studies. (Echocardiography 2015;32:1339-1346

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

Cited by 296 publications

References 15 publications

Discordance in Grading Methods of Aortic Stenosis by Pre-Cardiopulmonary Bypass Transesophageal Echocardiography

Discordance in Grading Methods of Aortic Stenosis by Pre-Cardiopulmonary Bypass Transesophageal Echocardiography

Therapeutic decision-making for patients with fluctuating mitral regurgitation

Novel Echocardiographic Indices as Predictors of Immediate Recurrence after Undersized Ring Annuloplasty for Ischemic Mitral Regurgitation

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