Elderly Patients with Moderate Chronic Ischemic Mitral Regurgitation: Coronary Artery Bypass Grafting Alone or Concomitant Mitral Annuloplasty?

Abstract

Background. An increasing number of elderly patients with ischemic mitral regurgitation (IMR) are referred for coronary artery bypass grafting (CABG). However, data about the management of elderly patients with moderate IMR are scanty. This study evaluates the impacts of two surgical approaches (CABG alone or concomitant mitral annuloplasty (MAP)) on in-hospital and midterm outcomes, to attempt to determine an appropriate treatment option for elderly patients with moderate chronic IMR. Methods. All eligible patients over 65 years of age were included and were entered into either a MAP group (patients undergoing CABG plus MAP, n = 96) or a CABG group (patients receiving CABG alone, n = 104). Baseline and surgical characteristics were analyzed, and in-hospital and midterm outcomes between groups were compared after propensity score-matching (1 : 1). Results. Using propensity score-matching, 82 pairs of patients were successfully established in a 1 : 1 ratio. No significant differences between the two matched groups were found regarding surgical mortality (4.9% vs. 1.2%, p=0.173) and major postoperative morbidity. 150 patients (76 in the MAP group and 74 in the CABG group) received regular follow-up visit with the median duration of 37 months. Compared with the CABG group, the MAP group received a similar overall survival but a better recurrent MR-free survival (stratified log-rank p, 0.492 and < 0.001, respectively). Using Cox regression, the MAP group as compared with the CABG group did not affect midterm survival probability (propensity score-adjusted hazard ratio, 0.854; 95% confidence interval, 0.571–2.729, p=0.630). Additionally, patients in the MAP group had a significantly lower ratio of NYHA class III-IV at the latest follow-up by comparison with patients in the CABG group (19.7% vs. 35.5%, p=0.033). Conclusion. Compared with CABG alone, concomitant mitral annuloplasty is associated with improved midterm outcomes (including reduced IMR recurrence and improved cardiac functional class) but shares similar surgical mortality and major postoperative morbidity and may be a promising treatment option for elderly patients with moderate chronic IMR.

Should moderate ischemic mitral regurgitation be corrected during coronary artery bypass grafting? a systematic review and meta‐analysis

“…A total of 448 studies were screened for eligibility, out of which 4 RCTs 6-9 and three observational studies [10][11][12] with propensity-matched data including 1209 patients assessing CABG alone (n = 598) versus CABG with MV surgery (n = 611) were included in the final analysis. The PRISMA flow diagram is presented in Figure 1.…”

“…The percentage of male sex was more than 60 in all of the included studies. The concomitant MV procedure was only MV repair in four RCTs [6][7][8][9] and one observational study, 11 and was MV replacement or MV repair in another one study. 10 The remained one did not report the type of MV surgery.…”

“…All studies [6][7][8][9][10][11][12] including 1209 patients contributed to the analysis of perioperative mortality. Overall, 18 of 598 patients (3.0%) in the combined-procedure group versus 18 of 611 patients (2.9%) in the CABG alone group experienced perioperative death.…”

“…Six studies [6][7][8][9]11,12 including 1166 patients reported on the incidence of perioperative stroke. Overall, 18 of 576 patients (3.1%) receiving CABG combined with MV surgery versus eight of 590 (1.4%) receiving CABG alone suffered perioperative stroke.…”

“…A total of five studies 6,7,9,11,12 including 1136 patients contributed to the analysis of renal failure. Overall, 31 of 562 patients (5.5%) in the combined-procedure group versus 16 of 574 patients (2.9%) in the CABG alone group experienced renal failure.…”