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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^_*, Eugene H. Blackstone, MD^_*, and Bruce W. Lytle, MD^_*

^_* Department of Thoracic and Cardiovascular Surgery
Department of Quantitative Health Sciences
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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