Percutaneous Versus Surgical Revascularization in Patients With Ischemic Mitral Regurgitation

Abstract

Background-The proper way of revascularization remains controversial in patients with ischemic mitral regurgitation (IMR). We sought to compare the long-term results of percutaneous coronary intervention (PCI) and surgical revascularization in IMR. Methods and Results-From 1996 to 2008, 185 consecutive patients (132 men; age, 63Ϯ9 years) with significant IMR underwent PCI (PCI group) (nϭ66) or coronary artery bypass graft surgery (OP group) (nϭ119). In the OP group, 68 (57%) patients also underwent concomitant mitral annuloplasty. Significant IMR was defined as functional MR occurring Ͼ1 week after myocardial infarction with an effective regurgitant orifice area Ն0.2 cm 2 . During a median follow-up of 54 months, there were 2 operative mortalities, 26 cardiac deaths, and 11 heart failure hospitalizations in the OP group and 22 cardiac deaths and 10 heart failure hospitalizations in the PCI group. The survival and cardiac mortality rates were not significantly different between the 2 groups, but event-free survival rates were significantly higher in the OP group. For the 45 propensity score-matched pairs, the risk of cardiac events was significantly lower in the OP group than in the PCI group (hazard ratio, 0.499; 95% CI, 0.251 to 0.990; Pϭ0.043). Compared with patients who underwent coronary artery bypass graft surgery alone, event-free survival rates were significantly higher in those who underwent additional mitral annuloplasty. Conclusions-Compared with PCI, surgical revascularization is associated with an improved long-term event-free survival, and concomitant mitral annuloplasty should be considered in patients with significant IMR. (Circulation. 2011;124[suppl 1]:S156 -S162.)

Secondary mitral regurgitation (part 2): deliberations on mitral surgery and transcatheter repair

“…In the per-protocol analysis, there were 22 deaths (52%) among 42 patients with CABG alone and 21 deaths (43%) among 49 patients who underwent CABG with mitral surgery; this difference became significant only after adjustment for other prognostic baseline variables. In another study of 119 symptomatic patients (most had moderate MR), those with CABG alone (n=51) and those with CABG plus mitral surgery (n=68) exhibited reductions in LV end-systolic volume (ESV) and increases in the EF 11. However, there was no significant difference in the degree of improvement in the ESV or EF between the two groups.…”

Surgical Revascularization Is Associated With Maximal Survival in Patients With Ischemic Mitral Regurgitation

“…18, 19 Several studies including a 2009 meta-analysis have reported no survival benefit to adding MV repair to coronary artery bypass grafting (CABG) for patients with IMR; 20–25 however, conflicting reports exist including results from a multicenter randomized trial reported by Deja et al suggesting that MV repair may improve survival compared with CABG alone. 26–32 The utility of the current body of evidence in guiding clinical management of IMR is further limited by the preponderance of small patient samples, 21, 22, 25, 27, 30 outdated studies inadequately capturing current IMR assessment techniques and perioperative surgical risk, 20, 23, 26 and lack of comparison groups sufficient to capture the full range of treatment modalities, including medical management, percutaneous coronary intervention (PCI) and CABG with and without MV repair or replacement. 26–30 Given the lack of sufficient evidence to build consensus in treating IMR, multiple investigators have called for randomized trials to better support clinical decision making.…”

“…26–32 The utility of the current body of evidence in guiding clinical management of IMR is further limited by the preponderance of small patient samples, 21, 22, 25, 27, 30 outdated studies inadequately capturing current IMR assessment techniques and perioperative surgical risk, 20, 23, 26 and lack of comparison groups sufficient to capture the full range of treatment modalities, including medical management, percutaneous coronary intervention (PCI) and CABG with and without MV repair or replacement. 26–30 Given the lack of sufficient evidence to build consensus in treating IMR, multiple investigators have called for randomized trials to better support clinical decision making. 4, 5, 11, 13, 14, 18, 25, 26 …”

Ischemic and Functional Mitral Regurgitation in Heart Failure: Natural History and Treatment

“…In the STICH trial, which randomized 1212 patients with HF because of ischemic cardiomyopathy to GDMT vs GDMT and CABG, there was a trend for improved all-cause mortality with CABG (hazard ratio 0. 86 [56] reported a nonrandomized study of 185 undergoing coronary revascularization by PCI (n=66) or CABG (n=119). In a propensitymatched analysis, cardiac events were lower with CABG compared with PCI (hazard ratio 0.499, 95 % CI 0.25-0.99, P = 0.043).…”