Repair or replace ischemic mitral regurgitation during coronary artery bypass grafting? A meta-analysis

Abstract

BackgroundNo agreement has been reached for the best surgical treatment for patients with chronic ischemic mitral regurgitation (IMR) undergoing coronary artery bypass grafting (CABG). Our objective was to meta-analyze the clinical outcomes of repair and replacement.MethodsA computerized search was performed using Pubmed, Embase, Ovid medline and Cochrane Library. The search terms “ischemic or ischaemic” and “mitral valve” and “repair or replacement or annuloplasty” and “coronary artery bypass grafting” were entered as MeSH terms and keywords. The primary outcomes were operative mortality and late mortality. Secondary outcomes were 2+ or greater recurrence of mitral regurgitation and reoperation rate.ResultsEleven studies were eligible for the final meta-analysis. These studies included a total of 1750 patients, 60.4 % of whom received mitral valve repair. All patients underwent concomitant coronary artery bypass graft. No differences were found in operative mortality (summary odds ratio [OR] 0.65; 95 % confidence interval [CI] 0.43-1.00; p = 0.05), late mortality (summary hazard ratio [HR] 0.87; 95 % confidence interval [CI] 0.67-1.14; p = 0.31) and reoperation (summary odds ratio [OR] 1.47; 95 % confidence interval [CI] 0.90-2.38; p = 0.12). Regurgitation recurrence was lower in the replacement group (summary odds ratio [OR] 5.41; 95 % confidence interval [CI] 3.12-9.38; p < 0.001).ConclusionIn patients with chronic ischemic mitral regurgitation during CABG, mitral valve replacement is associated with lower recurrence of regurgitation. No differences were found regarding survival and reoperation rates.

Treatment of More Than Moderate Ischemic Mitral Regurgitation in Patients Undergoing Left Ventricular Reconstruction

“…These results are also consistent with those of prior studies on patients undergoing mitral valve surgery for more than moderate IMR, but without LVR. [6,20,21,24] A possible explanation for these results is the mechanism underlying IMR—left ventricular adverse remodeling. In primary mitral regurgitation, organic lesions of the mitral valve play an important role in the development of valvular dysfunction, causing remodeling of the left ventricle; however, in the development of the IMR, left ventricular remodeling, which is due to myocardial ischemia, is the cause, rather than the result, of mitral valve dysfunction.…”

Repair or replacement for severe ischemic mitral regurgitation

“…Although several meta-analyses had reported their results on MVR versus MVP, these analyses had included studies involving patients with less severe IMR (MR ≤ 2+). [ 4 – 9 ] Wang and colleagues [ 10 ] reported a subgroup analysis about repair versus replacement for severe IMR, only 3 included studies were not enough to compare these 2 techniques. Our study is the first meta-analysis which included 13 articles to compare repair with replacement for severe IMR.…”

“…Previous meta-analyses drew a conclusion that mitral valve repair (MVP) is associated with better short-term results but with a high recurrence of mitral regurgitation compared with replacement for IMR. [ 4 – 8 ] Wang and colleagues [ 9 ] failed to find a better operative mortality outcome with repair for patients undergoing concomitant CABG. On the reoperation rate and long-term survival, meta-analyses drew different conclusions.…”

“…On the reoperation rate and long-term survival, meta-analyses drew different conclusions. [ 4 – 9 ] In addition, these meta-analyses had included patients with less than severe IMR which could be not appropriate to apply the conclusion for patients with severe IMR. Although Wang and colleagues [ 10 ] had conducted a subgroup meta-analysis on severe IMR, they only included 3 studies which was not enough to draw a convincing result.…”