Stress Echocardiography Protocol for Deciding Type of Surgery in Ischemic Mitral Regurgitation: Predictors of Mitral Regurgitation Recurrence following CABG Alone.

Radoslaw Piatkowski,Grzegorz Opolski,Michal Peller,Marcin Grabowski,Monika Budnik,Janusz Kochanowski

doi:10.3390/jcm10214816

Radoslaw Piatkowski, Grzegorz Opolski + Show 4 more

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https://doi.org/10.3390/jcm10214816

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Abstract

Purpose: Although coronary artery bypass grafting alone (CABGa), or, with mitral annuloplasty (CABGmp), is considered the best therapeutic strategy for patients with ischemic mitral regurgitation (IMR), some recurrences are still reported. The aim of this study was to evaluate the use of the mitral deformation indices (MDI) as a predictor of recurrence of mitral regurgitation in a 12-month follow-up after CABG alone. Methods: A total of 145 patients after myocardial infarction with significant IMR, eligible for CABG, were prospectively enrolled in the study. Mitral valve morphology, left ventricle function, IMR degree as assessed by effective regurgitation orifice area (ERO), myocardial viability, and MDI were assessed prior to surgery. Patients were referred for CABGa (gr.1; n = 90) or CABGmp (gr.2; n = 55) based on clinical assessment, and the results of rest and stress echocardiography (exercise echocardiography and low dose dobutamine echocardiography-DBX). One year after surgery, each patient underwent the evaluation of cardiovascular events. Univariable logistic regression analysis was used to identify the factors of recurrence of IMR in 1 year follow-up. Serial echo examinations were performed in all patients at discharge, and at 1 and 12 months after surgery. Results: Logistic regression analysis revealed that in CABGa, group preoperative changes of tenting area (TA) and coaptation high (CH) during DBX remained the predictors of the recurrence of IMR in 12 months follow-up. TAdbx > 1 cm2 provided a sensitivity of 90% and specificity of 29%, (AUC 0.6436). The best cut-off value for CHdbx was 0.4 cm (sensitivity 90%, specificity 34%; AUC 0.6432). In both groups (CABGa vs. CABGmp) no significant differences were observed in 12-month mortality (1.2% vs. 0%; p = 1.0), hospitalizations due to the heart failure (HF) exacerbation (5.9% vs. 8.5%; p = 0.72), and in the incidence of the composite endpoint (deaths/CV hosp/stroke) (7% vs. 8.5%; p = 0.742). Conclusions: The preoperative assessment of MDI changes during dbx can be used to identify patients with IMR qualified to CABG alone at increased risk of recurrence of IMR in 1 year follow-up. Mitral deformation analysis should be used for a better qualification of patients with IMR to the exact surgical approach.

Highlights

IntroductionA strict correlation between stress-induced (exercise and dobutamine) changes of ischemic mitral regurgitation (IMR), mitral deformation indexes (MDI), myocardium viability, clinical symptoms, and prognosis should be considered when evaluating the eligibility of patients with moderate or severe IMR for the appropriate type of surgery [11,12,13,14]
A strict correlation between stress-induced changes of ischemic mitral regurgitation (IMR), mitral deformation indexes (MDI), myocardium viability, clinical symptoms, and prognosis should be considered when evaluating the eligibility of patients with moderate or severe IMR for the appropriate type of surgery [11,12,13,14]
25 patients were excluded from the analysis (7 patients had a poor acoustic window for dobutamine echocardiography; 4 patients in whom viability was not demonstrated within left ventricular segments with impaired contractility; 14 had contraindications for exercise)

Summary

Introduction

A strict correlation between stress-induced (exercise and dobutamine) changes of IMR, mitral deformation indexes (MDI), myocardium viability, clinical symptoms, and prognosis should be considered when evaluating the eligibility of patients with moderate or severe IMR for the appropriate type of surgery [11,12,13,14]. This would help improve risk stratification and the identification of the subgroups of patients with risk of recurrent IMR and worse prognosis who could likely benefit from different surgical strategies. The greater severity of stress induced IMR and changes of MDI correlates with a greater necessity to perform mitral valve repair to avoid the risk of the recurrence of IMR in long-term follow-up

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