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J Am Coll Cardiol, 2005; 45:381-387, doi:10.1016/j.jacc.2004.09.073
© 2005 by the American College of Cardiology Foundation
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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{dagger}, Francis D. Pagani, MD, PhD, FACC{dagger}, Kathy Welch, MS, MPH{ddagger} and Todd M. Koelling, MD, FACC*,*

* Division of Cardiology, Department of Internal Medicine
{dagger} Section of Cardiac Surgery, Department of Surgery
{ddagger} 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.

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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