Survival After Coronary Revascularization, With and Without Mitral Valve Surgery, in Patients With Ischemic Mitral Regurgitation

Abstract

Background— The most appropriate treatment for patients with ischemic mitral regurgitation (IMR) is often debated. We compared the survival rates of patients with IMR undergoing different treatment strategies, namely: medical therapy, percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), and CABG + mitral valve (MV) surgery. Methods and Results— Patients undergoing catheterization between 1986 and 2001 were included. IMR was defined as: ≥grade 2+ mitral regurgitation (MR) and significant coronary artery disease (CAD) without primary mitral valve disease. Patients undergoing catheterization for the evaluation of congenital or other valvular heart disease were excluded. Multivariable Cox proportional hazards modeling was utilized to assess the independent relation between treatment and survival. Propensity score methods were used to correct for the nonrandom assignment of treatment. Of the 2,757 patients who met study criteria: 1,305 were treated medically, 537 underwent PCI, 687 underwent CABG, and 228 underwent CABG + MV surgery. The median duration of follow-up was 3.2 (0.9, 7.1) years. Patients undergoing CABG + MV surgery had more severe MR and more severe heart failure than those treated by other modalities. After adjusting for differences in baseline characteristics, patients undergoing PCI, CABG, and CABG + MV surgery had a 31% (hazards ratio [HR]=0.69; P =0.0001), 42% (HR=0.58; P =0.0001), and 42% (HR=0.58; P =0.0001) reduction in the risk of death, respectively, compared with those undergoing medical therapy. The performance of mitral valve surgery with CABG was not associated with improved survival versus CABG alone ( P =0.258). Conclusions— Among patients with IMR, treatment with PCI, CABG, or CABG + MV surgery is associated with improved survival compared with medical therapy.

Percutaneous Versus Surgical Revascularization in Patients With Ischemic Mitral Regurgitation

“…16 Alternatively, MV repair may primarily affect other important end points, such as heart failure and adverse remodeling of the LV. 8,17 Our findings agree with the results of previous studies showing that percutaneous and surgical revascularization had comparable long-term survival 4,10 and that MV repair was insufficient to improve long-term survival. 6,7,18 However, to our knowledge, the present study is the first prospective study to demonstrate that compared with revascularization alone, additional mitral annuloplasty significantly improved functional status and long-term event-free survival by decreasing the incidence of persistent and recurrent IMR to 6%.…”

“…[1][2][3] Percutaneous or surgical revascularization has been associated with improved survival compared with medical therapy in patients with IMR, 3,4 but the proper way of revascularization remains controversial. Surgical revascularization has potential benefits of achieving more complete revascularization and improving IMR more effectively by addition of a mitral valve (MV) procedure at the time of coronary artery bypass graft (CABG) surgery.…”

Predictors of Improvement of Unrepaired Moderate Ischemic Mitral Regurgitation in Patients Undergoing Elective Isolated Coronary Artery Bypass Graft Surgery

“…1,5,7,8,16 Because severe IMR is not usually improved by revascularization alone, [17][18][19] current expert consensus 7,8 recommends concomitant restrictive annuloplasty at the time of CABG. On the other hand, in patients with moderate IMR undergoing CABG, the indication for concomitant mitral valve repair is highly controversial.…”

“…However, in these patients, several recent studies have failed to demonstrate a long-term survival benefit of the combined procedure compared with CABG alone. [3][4][5]17,21 These surprising findings may be attributed partly to the high recurrence rate of IMR despite initially successful repair and higher perioperative mortality of the combined procedures compared with CABG alone. 2,13,17,19,[22][23][24] Furthermore, some studies have shown significant improvement in moderate IMR with CABG alone.…”

Initial Results of Posterior Leaflet Extension for Severe Type IIIb Ischemic Mitral Regurgitation

“…Consistent with this analysis are the recent observations that MV repair for ischemic mitral regurgitation fails to provide any survival advantage. [15][16][17][18][19] This lack of benefit may be explained by the fact that up to 30% of patients develop recurrent mitral regurgitation after annuloplasty and coronary artery bypass graft surgery. The limited benefit of the conventional approach has stimulated the development and testing of new methods to more directly address the complex cause of the mitral regurgitation in these patients.…”