Functional mitral regurgitation (FMR) is associated with increased mortality and has been considered a marker for advanced heart disease, yet the value of mitral valve repair (MVr) in this population remains unclear. This study aims to evaluate the impact of reducing FMR burden through surgical MVr on survival. Patients with severe FMR who underwent MVr with an undersized, complete, rigid, annuloplasty between 2004 and 2017 were assessed (n = 201). Patients were categorized based on grade of recurrent FMR (0-4). Time-to-event Kaplan-Meier estimations of freedom from death or reoperation were performed using the log-rank test. Cox proportional hazards models evaluated all-cause mortality and reported in hazards ratios (HR) and 95% confidence intervals (CI). Patients were categorized by postoperative recurrent FMR: 45% (91/201) of patients had grade 0, 29% (58/201) grade 1, 20% (40/201) grade 2, 2% (4/201) grade 3%, and 4% (8/201) grade 4. The cumulative incidence of reoperation with death as a competing risk was higher in patients with grades ≥3 recurrent FMR compared to grades ≤2 (44.6% vs 14.6%, subhazard ratio 3.69 [95% CI, 1.17-11.6]; P = 0.026). Overall freedom from death or reoperation was superior for recurrent FMR grades ≤2 compared to grades ≥3 (log-rank P < 0.001). Increasing recurrent FMR grade was independently associated with mortality (HR 1.30 [95% CI, 1.07-1.59] P = 0.009). Reduced postoperative FMR grade resulted in an incrementally lower risk of death or reoperation after MVr. These results suggest that achieving a durable reduction in FMR burden improves long-term survival.

Whether through minimally invasive or conventional open techniques, thoracic surgery is often reported to be one of the most painful surgical procedures due to the incision of intercostal and respiratory muscles, rib injury or resection, and placement of surgical drains. Some of the more severe complications related to poor analgesia include prolonged intensive care unit (ICU) stay, mechanical ventilation, pneumonia, and the development of chronic postoperative pain syndromes. Over the past few decades, much progress has been made in recognizing the importance of multimodal analgesic techniques. These may include a variety of regional anesthetic techniques such as epidural anesthesia, fascial plane blocks, and intrapleural catheters, as well as the utilization of opioid and opioid-sparing oral regimens. This article provides an up-to-date review of pain management following thoracic surgery, emphasizing multimodal techniques and enhanced recovery pathways. In our review, we included articles published between 2010 and 2022. PubMed and Google Scholar were researched using the keywords thoracic, cardiac, pain control, thoracic epidural analgesia, fascial plane blocks, multimodal analgesia, and ERAS in thoracic surgery. Over 100 articles were then reviewed. We excluded articles not in English and articles that were not pertinent to cardiac or thoracic surgery. Eventually, 53 articles were included in the review, composed of clinical trials, case series, and retrospective cohort studies. A variety of pain control methods employed in thoracic and cardiac surgery range from opioids and opioids sparing medications, such as acetaminophen and gabapentin, to regional techniques, such as fascial plane blocks to epidural anesthesia. Multimodal anesthesia combining regional and opioid-sparing analgesics and their combination in enhanced recovery protocols were shown to provide adequate pain control, decrease opioid consumption and lead to shorter lengths of stay. Postoperative pain control remains one of the biggest challenges in the care of thoracic surgery patients. Analgesic plans must be individualized for each patient. Multimodal analgesia remains the gold standard; however, more studies are still warranted. Finding the optimal combination of opioid and non-opioid pain medication and local anesthetic delivered via suitable regional technique will improve the outcomes and lead to successful patient recovery.