Mitral Valve Repair Versus Revascularization Alone in the Treatment of Ischemic Mitral Regurgitation

Abstract

Background— For patients with ischemic mitral regurgitation (MR), it is not clear whether adjunctive mitral valve (MV) repair at the time of coronary artery bypass graft surgery (CABG) is beneficial. We sought to test the hypothesis that MV repair with CABG is superior to CABG alone in improving MR without increasing operative or long-term mortality. Methods and Results— A total of 107 consecutive patients with moderate or severe ischemic MR, as determined by preoperative echocardiography, underwent CABG with concomitant MV repair (repair group, n=50) or CABG only (CABG group, n=57). Degree of MR was graded as none, mild, moderate, or severe by the proximal isovelocity surface area method. The groups were similar with respect to age, gender, baseline New York Heart Association class, ejection fraction, and number of bypass grafts. The repair group had a higher percentage of patients with atrial fibrillation or severe MR than the CABG group. The operative mortality was significantly higher for the repair group (12%) than the CABG group (2%), whereas the 5-year actuarial survival rate of the 2 groups was similar (88%±5% versus 87%±6%). On multivariate logistic regression analysis, older age, higher New York Heart Association class, and atrial fibrillation were independent predictors of operative mortality ( P <0.05). Among patients with severe MR, ischemic MR was improved in all patients of the repair group and in 67% of patients in the CABG group ( P <0.001), whereas improvement rates in patients with moderate MR were similar in the 2 groups (75% versus 67%, P=NS). Conclusions— Although MV repair appears to be more effective at reducing ischemic functional MR, CABG alone may be a preferable treatment option for patients with moderate MR and high operative risk factors such as old age or atrial fibrillation.

Surgical treatment of coronary artery disease complicated by mitral insufficiency

“…Some authors consider that correction of mitral insufficiency does not stop the progression of left ventricular remodeling and has no effect on survival. Moreover, there is only additional unreasonable surgical risk [13,20]. Several studies have shown that one third of patients has recurrnet mitral insufficiency after mitral valve repair up to preoperative level within 3-5 years after surgery [14,23].…”

“…Primarily, revascularization of ischemic areas improves regional contractility that reduces severity of MR without need for its correction [11,28]. Moreover, several studies have shown that isolated coronary artery bypass grafting in patients with CAD and moderate MR does not affect long-term survival or functional status [19,20,24,26]. Data of 465 publications devoted to treatment of ischemic MR I-II were analyzed in large observational trial by A. Srivastavaa et al [27].…”

“…Симуль-танные вмешательства на коронарных сосудах и МК зна-чительно увеличивают риск послеоперационной леталь-ности [17,31]. Ряд авторов [13,20] придерживаются мне-ния, что коррекция МН не останавливает прогрессирова-ния ремоделирования ЛЖ и не влияет на выживаемость пациентов, а лишь добавляет необоснованный риск при хирургическом вмешательстве. Несколько исследований [14,23] показали, что у 1 / 3 пациентов после пластики МК наблюдается возврат МН на предоперационный уровень в течение 3-5 лет после операции.…”

“…В первую очередь реваскуляризация ишемизированных зон улуч-шает региональную сократимость, что уменьшает степень регургитации без необходимости коррекции МН [11, 28]. Кроме того, результаты нескольких исследований показа-ли, что выполнение изолированного КШ у пациентов с ИБС в сочетании с умеренной МН не влияет на отдален-ную выживаемость пациентов или их функциональный статус [19,20,24,26]. В большом обзорном исследовании A. Srivastavaa и соавт.…”

Therapeutic decision-making for patients with fluctuating mitral regurgitation

“…Moreover, the additional risk of mitral valve surgery is not negligible, particularly in patients with comorbidities and poor LV function. Very ill patients or elderly individuals with a history of atrial fibrillation might be treated conserva tively with revascularization alone or with a percutaneous approach, 39 although the treatment strategy also depends on the individual's risk profile.…”