Results of Surgical Coronary Revascularization Alone Versus Combined Surgical Revascularization and Mitral Valve Repair in Patients With Moderate Ischemic Mitral Regurgitation
DOI:
https://doi.org/10.1532/hsf.2773Keywords:
Moderate ischemic mitral regurgitation, CABG, Mitral Valve Repair, RevascularizationAbstract
Background: This is a prospective randomized-controlled study done to evaluate the best surgical option for moderate ischemic mitral regurgitation through either coronary artery bypass grafting only or by performing additional mitral repair.
Methods: Over a nine-month period, 60 patients with ischemic heart disease associated with moderate ischemic mitral regurgitation were equally divided into two groups. Group 1 included 30 patients who had coronary artery bypass grafting with mitral valve repair; Group 2 included 30 patients who had only coronary artery bypass grafting.
Results: There were no significant differences between the study groups, regarding operative data, apart from the cardiopulmonary bypass time and aortic cross-clamp time, which were significantly longer in group 1 (P < 0.001). Only one patient died in group 1 due to severe myocardial dysfunction. During the follow up, the NYHA class improved in group 1, from 2.7 to 1.35 (P < 0.004), compared with group 2, where the NYHA class improved from 2.6 to 1.72 (P = 0.07). The degree of MR improved in 28 patients (93%) in group 1 and 22 patients (73%) in group 2 (P < 0.0001).
Conclusion: The study revealed many advantages of adding mitral repair to surgical revascularization in patients with moderate ischemic mitral regurgitation, with improvement in the degree of MR and NYHA functional class. On the other hand there were no significant differences between the groups, regarding the postoperative course and incidence of mortality.
References
Aklog L, Filsoufi F, Flores KQ, et al. 2001. Does coronary artery bypass grafting alone correct moderate ischaemic mitral regurgitation? Circulation 104:68–75.
Bax JJ, Braun J, Somer ST, et al. 2004. Restrictive annuloplasty and coronary revascularization in ischemic mitral regurgitation results in reverse left ventricular remodeling. Circulation 110:103.
Calafiore AM, Di Mauro M, Gallina S, Di Giammarco G, Iacò AL, Teodori G, Tavarozzi I. 2004. Mitral valve surgery for chronic ischemic mitral regurgitation. Ann Thorac Surg 77:1989-1997.
Campwala ZC, Bansal RC, Wang N, Razzouk A, Pai RG, et al. 2006. Mitral regurgitation progression following isolated coronary artery bypass surgery: frequency, risk factors, and potential prevention strategies. Eur J Cardiothorac Surg 29:348-354.
Di Mauro M, Di Giammarco G, Vitolla G, Contini M, Iaco AL, Bivona A, et al. 2006. Impact of no-to-moderate mitral regurgitation on late results after isolated coronary artery bypass grafting in patients with ischemic cardiomyopathy. Ann Thoracic Surg 81:2128-34.
Duarte IG, Shen Y, MacDonald MJ, Jones EL, Craver JM, Guyton RA. 1999. Treatment of moderate mitral regurgitation and coronary disease by coronary bypass alone: late results. Ann Thoracic Surg. 68:426-30.
El Bardissi AW, Aranki SF, Sheng S, O'Brien SM, Greenberg CC, Gammie JS. 2012. Trends in isolated coronary artery bypass grafting: an analysis of the Society of Thoracic Surgeons adult cardiac surgery database. J Thorac Cardiovasc Surg 143:273-281.
Fattouch K, Guccione F, Sampognaro R, Panzarella G, Corrado E, Navarra E, Calvaruso D, Ruvolo G. 2009. Impact of Moderate Ischemic Mitral Regurgitation After Isolated Coronary Artery Bypass Grafting, J. of Thoracic and Cardiovascular Surgery 138:278-285.
Fattouch K, Guccione F, Sampognaro R, Panzarella G, Corrado E, Navarra E, Calvaruso D, Ruvolo G. 2009. POINT: Efficacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: a randomized trial. J Thorac Cardiovasc Surg 138:278–285.
Flynn M, Curtin R, Nowicki ER, et al. 2009. Regional wall motion abnormalities and scarring in severe functional ischemic mitral regurgitation: a pilot cardiovascular magnetic resonance imaging study. J Thorac Cardiovasc Surg. 137:1063-1070.
Gorman RC, Gorman JH, 3rd, Edmunds LH Jr. 2003. Ischemic mitral regurgitation. In: Cohn LH, Edmunds LH Jr., editors. Cardiac surgery in the adult. New York: McGraw-Hill 51-769.
Grigioni 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 103:1759–1764.
Hickey MS, Smith LR, Muhlbaier LH, Harrell FE Jr, Reves JG, Hinohara T, et al. 1988. Current prognosis of ischemic mitral regurgitation. Circulation. 78:I51-9.
Kang DH, Kim MJ, Kang SJ, et al. 2006. Mitral valve repair versus revascularization alone in the treatment of ischemic mitral regurgitation. Circulation 114:499.
Kim YH, Czer LS, Soukiasian HJ, De Robertis M, Magliato KE, Blanche C, Raissi SS, Mirocha J, Siegel RJ, Kass RM, et al. 2005. Ischemic mitral regurgitation: revascularization alone versus revascularization and mitral valve repair. Ann Thorac Surg 79:1895–1901.
Kumanohoso T, Otsuji Y, Yoshifuku S, Matsukida K, Koriyama C, Kisanuki A, Minagoe S, Levine RA, Tei C. 2003. Mechanism of higher incidence of ischemic mitral regurgitation in patients with inferior myocardial infarction: quantitative analysis of left ventricular and mitral valve geometry in 103 patients with prior myocardial infarction. J Thorac Cardiovasc Surg 125:135-143.
Lam BK, Gillinov AM, Blackstone EH, et al. 2005. Importance of moderate ischemic mitral regurgitation. Ann Thorac Surg 79:462-470.
Lee R, Li S, Rankin JS, et al. 2011. Fifteen-year outcome trends for valve surgery in North America. Ann Thorac Surg 91:677-684.
Mallidi HR, Pelletier MP, Lamb J, et al. 2004. Late outcomes in patients with uncorrected mild to moderate mitral regurgitation at the time of isolated coronary artery bypass grafting. J Thorac Cardiovasc Surg 127:636-644.
Penicka M, Linkova H, Lang O, et al. 2009. Predictors of improvement of unrepaired moderate ischemic mitral regurgitation in patients undergoing elective isolated coronary artery bypass graft surgery. Circulation 120:1474-1481.
Roshanali F, Mandegar MH, Yousefnia MA, Alaeddini F, Wann S. 2006. Low-dose dobutamine stress echocardiography to predict reversibility of mitral regurgitation with CABG. Echocardiography 23:31-37.
Ryden T, Bech-Hanssen O, Brandrup-Wognsen G, et al. 2001. The importance of grade 2 ischaemic mitral regurgitation in coronary artery bypass grafting. Eur J Cardiothorac Surg 20:276–81.
Tolis GA Jr, Korkolis DP, Kopf GS, et al. 2002. Revascularization alone (without mitral valve repair) suffices in patients with advanced ischaemic cardiomyopathy and mild-to-moderate mitral regurgitation. Ann Thorac Surg 74: 1476–80.
Wong DR, Agnihotri AK, Hung JW, et al. 2005. Long-term survival after surgical revascularization for moderate ischemic mitral regurgitation. Ann Thorac Surg 80:570-577.
