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CLINICAL RESEARCH: CARDIAC SURGERY

Impact of Mitral Valve Annuloplasty Combined With Revascularization in Patients With Functional Ischemic Mitral Regurgitation

Tomislav Mihaljevic, MD^_*,_*, Buu-Khanh Lam, MD^_*, Jeevanantham Rajeswaran, MSc, Masami Takagaki, MD^_*, Michael S. Lauer, MD, A. Marc Gillinov, MD^_*,a, Eugene H. Blackstone, MD^_*, and Bruce W. Lytle, MD^_*

^_* Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio.

Manuscript received September 8, 2006; revised manuscript received February 5, 2007, accepted February 5, 2007.

^_* Reprint requests and correspondence: Dr. Tomislav Mihaljevic, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Desk F24, Cleveland, Ohio 44195. (Email: mihaljt{at}ccf.org).

This paper was presented at the 55th Annual Meeting of the American College of Cardiology, Atlanta, Georgia, March 11 to 14, 2006.

Objectives: The aim of this work was to determine whether mitral valve (MV) annuloplasty benefits patients with moderate/severe (3+/4+) functional ischemic mitral regurgitation (MR) who undergo coronary artery bypass grafting (CABG).

Background: Mitral regurgitation is a strong predictor of poor outcomes in patients with ischemic cardiomyopathy; whether correcting it at the time of CABG improves outcomes is less certain.

Methods: From 1991 to 2003, 390 patients with 3+/4+ ischemic MR had CABG with (n = 290) or without (n = 100) MV annuloplasty. Groups were propensity-matched using demographics, extent of coronary disease, regional wall motion, and quantitative electrocardiography. Survival, echocardiographic severity of MR, and New York Heart Association (NYHA) functional class were compared.

Results: One-, 5-, and 10-year survival was 88%, 75%, and 47% after CABG alone and 92%, 74%, and 39% after CABG + MV annuloplasty (p = 0.6). Mortality was increased in patients with severe lateral wall motion abnormalities (p = 0.05), ST-segment elevation in lateral leads (p < 0.004), and higher QRS voltage sum (p < 0.0001). Patients undergoing CABG alone were more likely to have 3+/4+ postoperative MR than those undergoing CABG + MV annuloplasty (48% vs. 12% at 1 year, p < 0.0001). The NYHA functional class substantially improved in both groups (p < 0.001) and remained improved; at 5 years, 23% of patients having CABG + mitral annuloplasty and 25% having CABG alone were in NYHA functional class III/IV.

Conclusions: Although CABG + MV annuloplasty reduces postoperative MR and improves early symptoms compared with CABG alone, it does not improve long-term functional status or survival in patients with severe functional ischemic MR. The MV annuloplasty in this setting, without addressing fundamental ventricular pathology, is insufficient to improve long-term clinical outcomes.

Abbreviations and Acronyms   CABG = coronary artery bypass grafting   CL = confidence limits   IRB = institutional review board   LV = left ventricular   MR = mitral regurgitation   MRI = magnetic resonance imaging   MV = mitral valve   NYHA = New York Heart Association   PET = positron emission tomography   TEE = transesophageal echocardiogram   TTE = transthoracic echocardiogram

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