Concomitant Off-Pump Coronary Artery Bypass Grafting Results in Improved In-Hospital Outcomes for Patients with Ischemic Mitral Regurgitation Undergoing Surgery


  • Shahzad G. Raja
  • Mubassher Husain
  • Kareem Salhiyyah
  • Manoraj Navaratnarajah
  • Dimple Chudasama
  • Christopher P. Walker
  • Fouad Amin
  • Mohamed Amrani



Objective: Surgical management of ischemic mitral regurgitation (IMR) has primarily consisted of revascularization with or without the addition of mitral valve repair or replacement. We hypothesize that performing off-pump coronary artery bypass (OPCAB) grafting before fixing MR improves in-hospital outcomes for patients with IMR undergoing surgery.

Methods: From January 2000 through December 2010, a total of 96 consecutive patients with moderate or severe IMR, as determined by preoperative echocardiography, underwent on-pump coronary artery bypass grafting (CABG) (n = 66) or OPCAB (n = 30) revascularization with concomitant mitral valve repair or replacement. A retrospective analysis of a prospectively collected cardiac surgery database (PATS; Dendrite Clinical Systems, Oxford, UK) was performed. In addition, medical notes and charts were reviewed for all study patients.

Results: The 2 groups had similar preoperative demographic and EuroSCORE risk-stratification characteristics. The operative mortality rate for the entire cohort was 9.4%. Patients who underwent OPCAB grafting had a lower operative mortality than those who underwent CABG (3.3% versus 12.1%; P = .006). The mean ±SD cardiopulmonary bypass time (82.7 ± 34.7 minutes versus 160.7 ± 45.2 minutes; P < .001) and cross-clamp time (49.0 ± 22.4 minutes versus 103.4 ± 39.5 minutes; P < .001) were significantly shorter in the off-pump group than in the on-pump group. The OPCAB group also had significantly less in-hospital morbidity and shorter stays in the intensive care unit and the hospital.

Conclusion: Our analysis shows that OPCAB grafting (compared with conventional CABG) before repairing MR is associated with favorable in-hospital outcomes for patients undergoing surgery for IMR.


Al-Ruzzeh S, George S, Bustami M, et al. 2006. Effect of off-pump coronary artery bypass surgery on clinical, angiographic, neurocognitive, and quality of life outcomes: randomised controlled trial. BMJ 332:1365.nAl-Sarraf N, Thalib L, Hughes A, et al. 2011. Cross-clamp time is an independent predictor of mortality and morbidity in low- and high-risk cardiac patients. Int J Surg 9:104-9.nAnyanwu AC, Adams DH. 2008. Ischemic mitral regurgitation: recent advances. Curr Treat Options Cardiovasc Med 10:529-37.nBursi F, Enriquez-Sarano M, Nkomo VT, et al. 2005. Heart failure and death after myocardial infarction in the community: the emerging role of mitral regurgitation. Circulation 111:295-301.nDietl CA, Berkheimer MD, Woods EL, Gilbert CL, Pharr WF, Benoit CH. 1996. Efficacy and cost-effectiveness of preoperative IABP in patients with ejection fraction of 0.25 or less. Ann Thorac Surg 62:401-8.nDoenst T, Borger MA, Weisel RD, Yau TM, Maganti M, Rao V. 2008. Relation between aortic cross-clamp time and mortality—not as straightforward as expected. Eur J Cardiothorac Surg 33:660-5.nGazoni LM, Kern JA, Swenson BR, et al. 2007. A change in perspective: results for ischemic mitral valve repair are similar to mitral valve repair for degenerative disease. Ann Thorac Surg 84:750-7.nGillinov AM, Wierup PN, Blackstone EH, et al. 2001. Is repair preferable to replacement for ischemic mitral regurgitation? J Thorac Cardiovasc Surg 122:1125-41.nGrigioni F, Enriquez-Sarano M, Zehr KJ, Bailey KR, Tajik AJ. 2001. Ischemic mitral regurgitation: long-term outcome and prognostic implications with quantitative Doppler assessment. Circulation 103:1759-64.nGrossi EA, Goldberg JD, LaPietra A, et al. 2001. Ischemic mitral valve reconstruction and replacement: comparison of long-term survival and complications. J Thorac Cardiovasc Surg 122:1107-24.nHealey CM, Kumbhani DJ, Healey NA, Crittenden MD, Gibson SF, Khuri SF. 2009. Impact of intraoperative myocardial tissue acidosis on postoperative adverse outcomes and cost of care for patients undergoing prolonged aortic clamping during cardiopulmonary bypass. Am J Surg 197:203-10.nHickey MS, Smith LR, Muhlbaier LH, et al. 1988. Current prognosis of ischemic mitral regurgitation: implications for future management. Circulation 78(suppl):I51-9.nIung B. 2003. Management of ischaemic mitral regurgitation. Heart 89:459-64.nLaPar DJ, Kron IL. 2011. Should all ischemic mitral regurgitation be repaired? When should we replace? Curr Opin Cardiol 26:113-7.nLarmann J, Theilmeier G. 2004. Inflammatory response to cardiac surgery: cardiopulmonary bypass versus non-cardiopulmonary bypass surgery. Best Pract Res Clin Anaesthesiol 18:425-38.nLavana JD, Fraser JF, Smith SE, Drake L, Tesar P, Mullany DV. 2010. Influence of timing of intraaortic balloon placement in cardiac surgical patients. J Thorac Cardiovasc Surg 140:80-5.nLemma MG, Coscioni E, Tritto FP, et al. 2012. On-pump versus off-pump coronary artery bypass surgery in high-risk patients: operative results of a prospective randomized trial (on-off study). J Thorac Cardiovasc Surg 143:625-31.nLetsou GV, Wu YX, Grunkemeier G, Rampurwala MM, Kaiser L, Salaskar AL. 2011. Off-pump coronary artery bypass and avoidance of hypothermic cardiac arrest improves early left ventricular function in patients with systolic dysfunction. Eur J Cardiothorac Surg 40:227-32.nMiceli A, Fiorani B, Danesi TH, Melina G, Sinatra R. 2009. Prophylactic intra-aortic balloon pump in high-risk patients undergoing coronary artery bypass grafting: a propensity score analysis. Interact Cardiovasc Thorac Surg 9:291-4.nMicovic S, Milacic P, Otasevic P, et al. 2008. Comparison of valve annuloplasty and replacement for ischemic mitral valve incompetence. Heart Surg Forum 2008;11:E340-5.nPiérard LA, Carabello BA. 2010. Ischemic mitral regurgitation: pathophysiology, outcomes and the conundrum of treatment. Eur Heart J 31:2996-3005.nPuskas JD, Thourani VH, Kilgo P, et al. 2009. Off-pump coronary artery bypass disproportionately benefits high-risk patients. Ann Thorac Surg 88:1142-7.nPuskas JD, Williams WH, O'Donnell R, et al. 2011. Off-pump and on-pump coronary artery bypass grafting are associated with similar graft patency, myocardial ischemia, and freedom from reintervention: long-term follow-up of a randomized trial. Ann Thorac Surg 91:1836-42.nRaja SG, Dreyfus GD. 2008. Current status of off-pump coronary artery bypass surgery. Asian Cardiovasc Thorac Ann 16:164-78.nRankin JS, Hickey MS, Smith LR, et al. 1989. Ischemic mitral regurgitation. Circulation 79:116-21.nSalis S, Mazzanti VV, Merli G, et al. 2008. Cardiopulmonary bypass duration is an independent predictor of morbidity and mortality after cardiac surgery. J Cardiothorac Vasc Anesth 22:814-22.nVahanian A, Baumgartner H, Bax J, et al. 2007. Guidelines on the management of valvular heart disease: the Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology. Eur Heart J 28:230-68.n



How to Cite

Raja, S. G., Husain, M., Salhiyyah, K., Navaratnarajah, M., Chudasama, D., Walker, C. P., Amin, F., & Amrani, M. (2013). Concomitant Off-Pump Coronary Artery Bypass Grafting Results in Improved In-Hospital Outcomes for Patients with Ischemic Mitral Regurgitation Undergoing Surgery. The Heart Surgery Forum, 16(1), E15-E20.