CLINICAL RESEARCH: LEFT VENTRICULAR DYSFUNCTION
Impact of mitral valve annuloplasty on mortality risk in patients with mitral regurgitation and left ventricular systolic dysfunction
Audrey H. Wu, MD, MPH*,
Keith D. Aaronson, MD, MS*,
Steven F. Bolling, MD, FACC ,
Francis D. Pagani, MD, PhD, FACC,
Kathy Welch, MS, MPH and
Todd M. Koelling, MD, FACC*,*
* Division of Cardiology, Department of Internal Medicine
Section of Cardiac Surgery, Department of Surgery
Center for Statistical Consultation and Research, University of Michigan Health Systems, Ann Arbor, Michigan.
Manuscript received February 10, 2004;
revised manuscript received September 17, 2004,
accepted September 21, 2004.
* Reprint requests and correspondence: Dr. Todd M. Koelling, University of Michigan Health Systems, Women's Hospital, Room L3623, 1500 East Medical Center Drive, Ann Arbor, Michigan 48109-0271 (Email: tkoellin{at}med.umich.edu).
OBJECTIVES: This study was designed to assess effects of mitral valve annuloplasty (MVA) on mortality in patients with mitral regurgitation (MR) and left ventricular (LV) systolic dysfunction.
BACKGROUND: Mitral valve annuloplasty improves hemodynamics and symptoms in these patients, but effects on long-term mortality are not well established.
METHODS: We retrospectively analyzed consecutive patients with significant MR and LV systolic dysfunction on echocardiography between 1995 and 2002. Cox regression analysis, including MVA as a time-dependent covariate and propensity scoring to adjust for differing probabilities of undergoing MVA, was used to identify predictors of death, LV assist device implantation, or United Network for Organ Sharing-1 heart transplantation.
RESULTS: Of 682 patients identified, 419 were deemed surgical candidates; 126 underwent MVA. Propensity score derivation identified age, ejection fraction, and LV dimension to be associated with undergoing MVA. End points were reached in 120 (41%) non-MVA and 62 (49%) MVA patients. Increased risk of end point was associated with coronary artery disease (hazard ratio [HR] 1.80, 95% confidence interval [CI] 1.30 to 2.49), blood urea nitrogen (HR 1.01, 95% CI 1.005 to 1.02), cancer (HR 2.77, 95% CI 1.45 to 5.30), and digoxin (HR 1.66, 95% CI 1.15 to 2.39). Reduced risk was associated with angiotensin-converting enzyme inhibitors (HR 0.65, 95% CI 0.44 to 0.95), beta-blockers (HR 0.59, 95% CI 0.42 to 0.83), mean arterial pressure (HR 0.98, 95% CI 0.97 to 0.99), and serum sodium (HR 0.93, 95% CI 0.90 to 0.96). Mitral valve annuloplasty did not predict clinical outcome.
CONCLUSIONS: In this analysis, there is no clearly demonstrable mortality benefit conferred by MVA for significant MR with severe LV dysfunction. A prospective randomized control trial is warranted for further study of mortality with MVA in this population.
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Abbreviations and Acronyms
| | ACE = angiotensin-converting enzyme | | CI = confidence interval | | HF = heart failure | | HR = hazard ratio | | LV = left ventricular | | MR = mitral regurgitation | | MVA = mitral valve annuloplasty | | OR = odds ratio | | UNOS = United Network for Organ Sharing |
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