Moderate Ischemic Mitral Regurgitation Research Articles

Ischemic mitral regurgitation: the way ahead is a step back.

Ischemic mitral regurgitation (IMR) has a profound negative effect on survival of patients following myocardial infarction. It occurs when the closing forces are overpowered by the tethering forces as a consequence of ventricular remodeling. Surgeons sought to correct moderate and severe IMR by mitral annuloplasty. Though short-term results were encouraging, survival after 2 years were not so. Higher recurrence rates were also noted with severe mitral regurgitation (MR). Parameters defining severity of IMR were initially formulated in 2003. These were revised enabling intervention in moderate MR in 2014. With the lack of positive medium and long-term evidence, 2017 guidelines have raised the bar, discouraging intervention in moderate IMR. Current guidelines have taken a conservative stance in advocating repair only for severe MR and very symptomatic patients. Till emergence of fresh evidence surgical enthusiasm for repair of IMR has to be restrained.

Assessment of left atrial function in elderly patients with ischemic mitral regurgitation by real-time three-dimensional speckle tracking imaging

Objective To assess left atrial(LA)function by evaluating changes of LA wall movement and volume detected by real-time three-dimensional speckle tracking imaging(RT3D-STI)in elderly patients with ischemic mitral regurgitation(IMR). Methods Eighty-six elderly patients with coronary heart disease(CHD)were enrolled in this study.According to whether or not to have IMR, the patients were divided into the pure CHD group(n=32)and the CHD-induced ischemic mitral regurgitation(IMR)group(n=54, including 20 cases of mild IMR, 18 cases of moderate IMR and 16 cases of severe IMR). Thirty-two healthy elderly volunteers were considered as control group.RT3D-STI was used to evaluate the global atrial longitudinal strain(GLS), global circumferential strain(GCS), global radial strain(GRS)and LA maximal, minimal and pre-systolic volumes(LAVmax, LAVmin, and LAVp). LA ejection fraction(LAEF), LA passive ejection fraction(LApEF)and LA active ejection fraction(LAaEF)were calculated.The relationship of LA volume changes and myocardial strain with LA function was analyzed. Results The left ventricular ejection fraction(LVEF)and LAEF were reduced in CHD group and IMR group as compared with the control group, and were lower in IMR group than in CHD group(P<0.05). Compared with the control group, the LAVmin was increased, and the LAaEF was decreased in the IMR group(P<0.05). Compared with the control group, the GLS, GCS, GRS were declined in the CHD and IMR groups, and were lower in IMR group than in control group(P<0.05). Along with the increased severity of regurgitation, GLS, GCS, and GRS were decreased in varying degrees.The standard deviations of time to peak longitudinal strains(TLS-SD), of time to peak circumferential strains(TCS-SD), and of time to peak radial strain(TRS-SD)rose in the IMR group as compared with the control group(P<0.05). The myocardial motion indicators(GLS, GCS, GRS)had a quite strong correlation with LAEF in the CHD and IMR groups(CHD group: r=-0.745, -0.718 and 0.627, P=0.006, 0.007 and 0.009; IMR group: r=-0.785, -0.781, 0.643, P=0.006, 0.007 and 0.008). The receiver operating characteristic(ROC)curves analysis showed that the sensitivity and specificity of TLS-SD, TCS-SD and TRS-SD were 89.7% and 81.8%, 78.6% and 84.8%, 85.7% and 72.1%, respectively in the evaluation of LA function changes. Conclusions RT3D-STI can precisely and objectively assess the LA function changes by measuring the volume changes and tracing the myocardial motion in elderly IMR patients. Key words: Coronary disease; Mitral valve insufficiency; Echocardiography, three-dimensional; Atrail function, left

P325 Inadequate inhibition of platelet function after exercise in patients with ischemic mitral regurgitation qualified for cardiosurgery treatment

Abstract Purpose Human platelets play a major role in the pathophysiology of cardiovascular diseases. The aim of our study was to determine the relationship between exercise and level of platelet inhibition in patients (pts) after myocardial infarction (MI) with at least moderate ischemic mitral regurgitation (IMR) qualified for cardiosurgical treatment - coronary artery bypass grafting alone (CABG) or CABG with mitral reconstruction (CABGmr). Methods We collected venous blood samples from 70 pts (M 41, 66 ± 9 years) with at least moderate IMR, 3-24 weeks after MI. Platelet reactivity was estimated with the use of rapid, point-of-care platelet analyzer as the time for flowing whole blood to occlude a collagen-epinephrine ring, with shorter closure times (CEPI-CT), indicating greater activity. CEPI-CT was evaluated before (CEPI-CT rest) and 20 min after ExE (CEPI-CT ExE). Inadequate inhibition of the TXA2-dependent activation pathway was defined as CEPI-CT &amp;lt; 193 seconds. All the patients received 75-100 mg of aspirin daily (without clopidogrel treatment). Effective regurgitation orifice (ERO) was used for quantitative IMR assessment (moderate ≥10-20, severe ≥ 20 mm²). In all pts symptom-limited echocardiography (echo) semi-supine exercise test (ExE) was performed with Schiller system. All the pts were referred for CABG (multivessel coronary disease, ejection fraction (EF) 42,6 ± 10,1%, wall motion score index (WMSI) 1.65 ± 0.36). Results We observed inadequate platelet in 26 (37%) pts at rest (CEPI-CT &amp;lt; 193 sec., despite regular aspirin therapy) and in 48 (68%) pts in 20 min. after exercise. We observed a significant decrease in CEPI–CT in all analyzed group (rest vs exe: 202 sec. vs 124 sec., respectively; p &amp;lt; 0,0001) and also in pts with moderate IMR as well as with severe IMR. We didn’t observe a significant change in platelet count and mean platelet volume (MPV) between rest and exercise. Conclusions: 1. Inadequate antiplatelet effect of aspirin at rest was observed in 37% pts after MI with IMR. 2. Symptoms limited exercise test has revealed inadequate platelet inhibition (TXA2 –dependent activation pathway) in 68% of patients after MI with IMR. 3. Aspirin may have a limited antithrombotic effect after physical exercise in patients after MI with significant IMR.

P1786 Impact of exercise on platelet activity in patients with significant ischemic mitral regurgitation qualified for cardiosurgery treatment

Abstract Purpose Platelet activity is believed to play an important role in patients (pts)after myocardial infarction (MI). This study sought to examine a change in platelet activity after 2D echocardiography semi-supine exercise test (ExE) in pts with at least moderate ischemic mitral regurgitation (IMR) qualified for cardiosurgical treatment - coronary artery bypass grafting alone (CABG) or CABG with mitral reconstruction (CABGmr). Methods We collected venous blood samples from 70 patients (M 41, 66 ± 9 years) with at least moderate IMR, 3-24 weeks after MI. Platelet activity was estimated with the use of rapid, point-of-care platelet analyzer as the time (in seconds) for flowing whole blood to occlude a collagen-epinephrine ring, with shorter closure times, indicating greater activity (CEPI-CT- for assessing the thromboxane A2 –dependent activation pathway). CEPI-CT was evaluated before (CEPI-CT rest) and 20 min after ExE (CEPI-CT ExE). All the patients received 75-100 mg of aspirin daily (without clopidogrel treatment). Effective regurgitation orifice (ERO) was used for quantitative IMR assessment (moderate ≥10-20, severe ≥ 20 mm²). All the pts were referred for CABG (multivessel coronary disease, ejection fraction (EF) 42,6 ± 10,1%, wall motion score index (WMSI) 1.65 ± 0.36). Results We observed a significant decrease in CEPI–CT’s in all analyzed group (rest vs exe: 202 sec vs 124 sec, respectively; p &amp;lt; 0,0001) and in pts with moderate IMR as well as in pts with severe IMR, despite aspirin treatment. The results of the analysis of CEPI-CT and IMR size at rest and after ExE in both groups of pts are shown in Table 1. A negative correlation was found between CEPI-CT ExE and ERO ExE (r=-0,752, p = 0,0042). Conclusions 1. Significant increase in platelet activity after exercise was observed in patients after MI with IMR qualified for cardiosurgical treatment. 2. The increase in platelet activity after exercise is correlated with exercise changes of IMR size. 3. Aspirin may have a limited antithrombotic effect after physical exercise in patients after MI with significant IMR. Table 1. CEPI-CT rest CEPI-CT ExE p ERO rest ERO exe p All 202 124 &amp;lt; 0,0001 17 22 &amp;lt;0,001 Moderate IMR 201 124 0,0001 15 20 &amp;lt; 0,0001 Severe IMR 235,5 123,5 &amp;lt; 0,0001 25 31 &amp;lt; 0,0001

P292 The risk of adverse outcome with ischemic mitral regurgitation at 6-month after myocardial infarction: possible benefit of early intervention by transcatheter mitral-valve repair

Abstract Background The latest study has demonstrated the better outcomes of transcatheter mitral-valve repair in patients with decompensated heart failure (HF) and left ventricular (LV) dysfunction. However, it is unknown whether earlier intervention for mitral regurgitation (MR) can improve the outcome of myocardial infarction (MI). Purpose The aim of this study was to investigate the prognostic value of ischemic MR (IMR) at 6-month after MI for the later incidence of HF and death. Methods We retrospectively examined 723 MI patients who were admitted to our hospital. 95.5% of the patients were treated by primary coronary intervention. Patients were clinically followed-up at 6-month after the onset of MI, and divided into 3 groups according to the degree of IMR, i.e. No/Trivial IMR group (n = 528), Mild IMR group (n= 154) and ≥Moderate IMR group (n= 41). We compared the later incidence of hospitalization for HF and all-cause death at 3-year for each group. Results The studied population had preserved ejection fraction (EF) (56.9 ± 10.7%, average) and mostly asymptomatic at 6-month after MI. All-cause mortality within 3-year was higher in patients with ≥Moderate IMR (p &amp;lt; 0.001), and the incidence of hospitalization for HF was significantly higher depends on the degree of IMR at 6-month (p &amp;lt; 0.001). Multivariate analysis showed EF and the degree of IMR were the independent predictor for the hospitalization for HF. Conclusions IMR at 6-month after MI was associated with the later adverse events despite relatively preserved LV contraction without heart failure symptoms at the index examination. Early intervention for IMR potentially benefit for the better outcome. Abstract P292 Figure. Caplan-Meier estimates on adverse events

P1573 Late recovery of left ventricular function in patients with non-severe ischemic mitral regurgitation and multivessel disease qualified to cardiosurgery treatment

Abstract Late recovery of left ventricular function in patients with non-severe ischemic mitral regurgitation and multivessel disease qualified to cardiosurgery treatment. Purpose In patients (pts) after myocardial infarction (MI) with chronic left ventricle (LV) dysfunction, the presence and degree of ischemic mitral regurgitation (IMR) are predominantly related to LV remodelling and mitral valvular deformation. The aim of this study was to compare functional recovery (LVFR) as well as reverse remodelling of the left ventricle (LVRR) in pts with non-severe IMR qualified for cardiosurgical treatment - coronary artery bypass grafting alone (CABGa) or CABG with mitral repair (CABGmr in the 12-month follow-up. Materials and methods A total of 100 pts (mean age 64,4 ± 7,9 years) after MI, eligible for CABG, were included in a prospective study. Echo and clinical assessment were performed before and 12-months after surgery. Pts were referred for CABG a(gr.1; n = 74) or CABGmr (gr.2; n = 26) based on clinical assessment, 2D echo at rest and exercise and myocardial viability assessment (low dose dobutamine - dbx). Effective regurgitation orifice area (EROA) was used for quantitative IMR assessment. An increase in EF≥ 5% (ΔEF) from baseline value was considered as LVFR. A decrease in LV end-systolic volume &amp;gt; 15% from baseline value was considered as LVRR. Multivariable logistic regression analysis was used to identify the strongest factors of lack of LVFR and LVRR. Results An LVFR was observed, at late control, in 35 (49%) of pts in the CABGa group and in 11 (48%) of pts in CABGmr group (p = 0,948). LVRR was observed in 41 (56%) of pts in the CABGa group and in 16 (70%) of pts in CABGmr group 12 months follow-up (p = 0,5). In pts with LVFR, there was a lower incidence of at least moderate IMR at follow-up (ΔEF dbx≥5% vs ΔEFdbx &amp;lt; 5%:11% vs 30% pts; p = 0,05). Multivariable logistic regression analysis revealed that in both CABGa and CABGmr group only preoperative age and EF changes during stress echo remained the independent predictors of the lack of LVFR in 12 months follow-up (table 1). Conclusions 1. LVFR and LVRR were reported in most of the pts in both analyzed groups. 2. Preoperative assessment of changes EF during dbx (ΔEFdbx)can be used to identify pts with IMR at increased risk of lack of improvement in LV function and risk of residual IMRin 12-month f-up after surgery. Parameters Odds ratio (OR) Odds ratio (OR) p CABGa vs CABGmr 0,644 0,215 - 1,927 0,432 Age (increase by every 5 years) 1,11 1,039 - 1,879 0,003 ΔEF dbx (increase by every 5%) 0,21 0,096 - 0,46 &amp;lt;0,001 Table 1. Prognostic factors lack improvement in left ventricle function.

Elderly Patients with Moderate Chronic Ischemic Mitral Regurgitation: Coronary Artery Bypass Grafting Alone or Concomitant Mitral Annuloplasty?

Background An increasing number of elderly patients with ischemic mitral regurgitation (IMR) are referred for coronary artery bypass grafting (CABG). However, data about the management of elderly patients with moderate IMR are scanty. This study evaluates the impacts of two surgical approaches (CABG alone or concomitant mitral annuloplasty (MAP)) on in-hospital and midterm outcomes, to attempt to determine an appropriate treatment option for elderly patients with moderate chronic IMR. Methods All eligible patients over 65 years of age were included and were entered into either a MAP group (patients undergoing CABG plus MAP, n = 96) or a CABG group (patients receiving CABG alone, n = 104). Baseline and surgical characteristics were analyzed, and in-hospital and midterm outcomes between groups were compared after propensity score-matching (1 : 1). Results Using propensity score-matching, 82 pairs of patients were successfully established in a 1 : 1 ratio. No significant differences between the two matched groups were found regarding surgical mortality (4.9% vs. 1.2%, p=0.173) and major postoperative morbidity. 150 patients (76 in the MAP group and 74 in the CABG group) received regular follow-up visit with the median duration of 37 months. Compared with the CABG group, the MAP group received a similar overall survival but a better recurrent MR-free survival (stratified log-rank p, 0.492 and < 0.001, respectively). Using Cox regression, the MAP group as compared with the CABG group did not affect midterm survival probability (propensity score-adjusted hazard ratio, 0.854; 95% confidence interval, 0.571–2.729, p=0.630). Additionally, patients in the MAP group had a significantly lower ratio of NYHA class III-IV at the latest follow-up by comparison with patients in the CABG group (19.7% vs. 35.5%, p=0.033). Conclusion Compared with CABG alone, concomitant mitral annuloplasty is associated with improved midterm outcomes (including reduced IMR recurrence and improved cardiac functional class) but shares similar surgical mortality and major postoperative morbidity and may be a promising treatment option for elderly patients with moderate chronic IMR.

Patients over 70 years of age with moderate ischemic mitral regurgitation undergoing surgical revascularization plus mitral valve repair: insights from a single-center study of propensity-matched data.

Elderly patients, compared with the young, have a higher burden of surgical risk factors with reduced functional capacity and increased comorbidities conditions, and may have worse clinical outcomes. So far, few reports have focused on clinical outcomes of patients over 70 years of age with moderate chronic ischemic mitral regurgitation (IMR) undergoing mitral valve repair at the time of coronary artery bypass grafting (CABG). This single-center study of propensity-matched data attempts to answer a question: compared with patients with age of 70 or less, whether patients over 70 years of age with moderate IMR undergoing CABG plus mitral valve repair receive poor outcomes. All eligible patients were included in this study and were entered into either an elderly group (n=142) or a control group (n=182) according to patients' age. In-hospital outcomes (consisting of surgical mortality and major postoperative morbidity) and midterm clinical outcomes (including all-cause mortality and recurrent mitral regurgitation) were compared after propensity score matching (1:1). Using propensity-score matching, 103 pairs of patients were successfully established in a 1:1 ratio. No significant differences between the two matched groups were found with regard to surgical mortality (5.8% vs. 3.9%, P=0.754) and major postoperative morbidity. A total of 184 patients (91 in the elderly group and 93 in the control group) received regular follow-up visit with the median duration of 38 months [interquartile range (IQR), 27-56 months]. There were not any significant differences between the two matched groups regarding overall survival and recurrent IMR-free survival (stratified log-rank P=0.185 and stratified log-rank P=0.453, respectively). The elderly group as compared to the control group did not affect midterm mortality via cox proportional hazard regression (propensity score adjusted hazard ratio, 1.143; 95% confidence interval, 0.761-1.943; P=0.285). Patients over 70 years of age with moderate chronic IMR undergoing combined CABG and mitral valve repair may receive favorable in-hospital and midterm clinical outcomes.

Risk Factors for Moderate or More Residual Regurgitation in Patients with Moderate Chronic Ischemic Mitral Regurgitation Undergoing Surgical Revascularization Alone.

Few reports have focused on which patients with moderate ischemic mitral regurgitation (IMR) were not good candidates for coronary artery bypass grafting (CABG) alone. This single-center study aimed to assess risk factors for moderate or more residual regurgitation within two years after CABG alone for the treatment of moderate chronic IMR to optimize the operation strategy and prognosis.A total of 189 eligible patients were entered into a failure group (n = 108) or an improved group (n = 81) according to whether moderate or more residual regurgitation occurred within two years after surgery. Baseline and surgical characteristics were analyzed, and clinical outcomes were compared between groups.Prior myocardial infarction (MI)/chronic myocardial ischemia and region wall motion abnormality (anterior/inferior-posterior wall) were two independent risk factors for moderate or more residual regurgitation, following CABG alone, for the treatment of moderate chronic IMR (OR = 3.15, 95% CI 1.66-5.75, and OR = 2.45, 95% CI 1.36-4.84, respectively). During a median follow-up of 40 months, compared with the improved group, the failure group was more likely to present with New York Heart Association (NYHA) class III-IV and cardiac re-hospitalization (57.4% versus 11.1%, P < 0.001, and 13.9% versus 4.9%, P = 0.043, respectively) and had worse cumulative survival (χ2 = 4.259, log-rank P = 0.039).Patients suffering from moderate chronic IMR secondary to prior MI (rather than chronic ischemia) with anterior wall motion abnormalities (rather than inferior-posterior wall motion abnormalities) may not be good candidates for CABG alone, and may have a poor prognosis after CABG alone.

Long-Term Survival of Patients with Ischemic Heart Disease After Surgical Correction of Moderate Ischemic Mitral Regurgitation

to assess effect of correction of moderate ischemic mitral regurgitation (IMR) in patients with ischemic cardiomyopathy(IMC) in immediate and remote period. We included in a single center prospective study 76 patients withIMC, left ventricular ejection fraction ≤35 %, and moderate IMR. Patients with indications to postinfarction aneurism repair werenot included. For randomization we used the method of envelopes. Thirty-eight patients were randomized in the group wherecoronary artery bypass grafting (CABG) was combined with of mitral valve repair (MVR), and 38 patients in the control groupof isolated CABG. Mean age of patients was 57±8 (from 30 to 75 лет) years. For IMR correction we used rigid MEDENG ring.Results. Inhospital mortality was 5.4 % (n=2) after isolated CABG and 10.81 % (n=4) after CABG + MVR. Main cause of death wasacute heart failure. One- and 2‑year survival was 84 and 78 %, respectively, after CABG+MVR, and 84 and 71 % after isolated CABG.There was significant difference in three-year survival between groups (hazard ratio [HR] of death 0.457, p=0.04). Five-year survivalwas 45 and 74 % after isolated CABG and CABG+MVR, respectively (р=0.037). Factors associated with inhospital mortality werepulmonary hypertension (HR 2.177, 95 % confidence interval [CI] 2.299 to 9.831; p=0.043), NYHA class IV chronic heart failure(HR 3.027, 95 % CI 1.605 to 5.707; р=0.001), negative result of stress test echocardiography (HR 0.087, 95 %CI 0.041 to 0.186;р&lt;0.001), atrial fibrillation (HR 4.754, 95 %CI 2.299 to 9.831; р&lt;0.001). Correction of moderate IMR in patients withIMC leads to improvement of parameters of survival in remote period. Five-year survival after isolated CABG was 45 %, while afterCABG+MVR - 74 % (р=0.037).

Moderate Chronic Ischemic Mitral Regurgitation.

The benefits of concomitant mitral valve procedure (MVP) for treating moderate chronic ischemic mitral regurgitation (IMR) during coronary artery bypass grafting (CABG) have not been clearly established. This study aimed to determine the incidence of moderate or more residual mitral regurgitation (MR) following CABG plus MVP for moderate chronic IMR, and to evaluate the impacts of concomitant MVP vs. CABG alone on clinical outcomes based on propensity-matched data.All eligible patients were entered into either the MVP group (CABG plus MVP, n = 184) or CABG group (CABG alone, n = 162). Moderate or more residual MR rate was investigated, and in-hospital and follow-up outcomes between the groups were compared after matching.Moderate or more residual MR rate was 11.4% at 1 year and 22.9% at 2 years after CABG plus MVP, respectively. Patients in the MVP group as compared with the CABG group had significantly lower moderate or more residual MR rates at various postoperative time points (all P < 0.001). Grouping was not an independent risk factor for in-hospital adverse events in multivariate logistic regression analysis. Also, grouping was a significant variable related to moderate or more residual MR rate and NYHA class III-IV at the latest follow-up in Cox regression analysis (HR = 0.391, 95% CI 0.114-0.628; HR = 0.419, 95% CI 0.233-0.819, respectively).Concomitant MVP as compared with CABG alone for treating moderate chronic IMR was associated with a reduction in moderate or more residual MR rate and an improvement in NYHA functional status, with no increase in in-hospital adverse events or follow-up death.

Cost-effectiveness of coronary artery bypass grafting plus mitral valve repair versus coronary artery bypass grafting alone for moderate ischemic mitral regurgitation

ObjectiveThe Cardiothoracic Surgical Trials Network reported that left ventricular reverse remodeling at 2 years did not differ between patients with moderate ischemic mitral regurgitation randomized to coronary artery bypass grafting plus mitral valve repair (n = 150) or coronary artery bypass grafting alone (n = 151). To address health resource use implications, we compared costs and quality-adjusted survival. MethodsWe used individual patient data from the Cardiothoracic Surgical Trials Network trial on survival, hospitalizations, quality of life, and US hospitalization costs to estimate cumulative costs and quality-adjusted life years. A microsimulation model was developed to extrapolate to 10 years. Bootstrap and deterministic sensitivity analyses were performed to address uncertainty. ResultsIn-hospital costs were $59,745 for coronary artery bypass grafting plus mitral valve repair versus $51,326 for coronary artery bypass grafting alone (difference $8419; 95% uncertainty interval, 2259-18,757). Two-year costs were $81,263 versus $67,341 (difference 13,922 [2370 to 28,888]), and quality-adjusted life years were 1.35 versus 1.30 (difference 0.05; −0.04 to 0.14), resulting in an incremental cost-effectiveness ratio of $308,343/quality-adjusted life year for coronary artery bypass grafting plus mitral valve repair. At 10 years, its costs remained higher ($107,733 vs $88,583, difference 19,150 [−3866 to 56,826]) and quality-adjusted life years showed no difference (−0.92 to 0.87), with 5.08 versus 5.08. The likelihood that coronary artery bypass grafting plus mitral valve repair would be considered cost-effective at 10 years based on a cost-effectiveness threshold of $100K/quality-adjusted life year did not exceed 37%. Only when this procedure reduces the death rate by a relative 5% will the incremental cost-effectiveness ratio fall below $100K/quality-adjusted life year. Conclusions:The addition of mitral valve repair to coronary artery bypass grafting for patients with moderate ischemic mitral regurgitation is unlikely to be cost-effective. Only if late mortality benefits can be demonstrated will it meet commonly used cost-effectiveness criteria.

Off-pump mitral valve repair: primary result of treating moderate ischemic mitral regurgitation during off-pump coronary artery bypass grafting.

Treating moderate ischemic mitral regurgitation (IMR) in patients with coronary artery disease (CAD) undergoing off-pump coronary artery bypass grafting (OPCAB) is arguable and difficult. Mitral valve repair (MVP) is the first choice in treating moderate-to-severe IMR under cardiopulmonary bypass (CPB). In last decade, percutaneous treatment of mitral regurgitation was used in clinic (1,2). Now we proposed and used off-pump mitral valve repair to treat moderate IMR. The left ventricular surface just below coronary sinus was folded. This would reshape the annulus and the left ventricle below the mitral annulus. Sixteen patients with moderate mitral regurgitation underwent off-pump MVP mentioned previously during OPCAB. The surgical procedure is simple. The early results showed that this way is safe and effective.

Experience of the management of coronary artery bypass graft only on moderate ischemic mitral regurgitation: A single-center retrospective study.

To summary the impact of off-pump coronary artery bypass grafting (CABG) only on patients with moderate ischemic mitral regurgitation and survival.We retrospectively analyzed 109 patients with coronary artery disease (CAD) complicated by moderate mitral regurgitation, from January, 2008 to December, 2014, in the Department of Cardiovascular Surgery at the No. 2 Hospital of Jilin University undergoing off pump CABG only. Preoperative clinical characteristics, complications after surgery, and outcome (survivor or death) were assessed. We observed the degree of mitral valve regurgitation, left ventricular ejection fraction (LVEF), left ventricular and left atrial size, left ventricular end-diastolic volume (LVEDV) preoperative, and New York Heart Association (NYHA) functional class, postoperative 10 days before discharge, and 6 months and longer after surgery. The statistical data were processed by SPSS 19 software with computer; statistical significant difference with P < .05.Overall in-hospital mortality was 2.75% (3 patients). Patients had lower mean LVEF in the postoperative compared with the preoperative period, but all the patients had higher LVEF since 6 months than preoperative period (P < .001). Compared with the preoperative dates, postoperative valvular regurgitation, left ventricular and atrial size and LVEDV postoperative 10 days before discharge, 6 months and more longer after surgery reduced significantly (P < .001). Rapid atrial fibrillation occurred in 19 cases during perioperative and returned to normal before discharge. The symptom of angina was disappeared in all patients before discharge. The mean follow-up time was 60.16 ± 17.98 months (range 36–96 months). Two patients died of major adverse cardiac events including heart failure and ventricular fibrillation. Three patients died of lung cancer, and 2 patients died of stroke during the longer follow-up.Off-pump CABG can be performed safely in patients with CAD complicated by moderate mitral regurgitation. The efficacy of CABG only is well demonstrated by the significant improvement of LVEF and NYHA functional class, and by the decrease of left ventricular and atrial size, LVEDV, and mitral regurgitation grade.

Clinical implications of moderate ischemic mitral regurgitation in patients undergoing coronary artery bypass grafting

Objective The aim of this study was to explore the fate of moderate ischemic mitral regurgitation (IMR) following isolated coronary artery bypass grafting (CABG). Background IMR is a frequently encountered problem seen in patients with coronary artery disease. A much-debated question is whether surgical revascularization alone will correct moderate (2+) IMR in such patients. Patients and methods The study group included 20 patients with moderate IMR associated with coronary artery disease undergoing isolated CABG. All patients had an ejection fraction of more than 30%. The patients were clinically and echocardiographically evaluated preoperatively, 1 week postoperatively and at 3- and 6-month intervals. Results CABG alone reduced the degree of IMR in 12 (60%) patients, did not improve it in five (25%) patients, and increased its degree to 3–4 + in three (15%) patients at 6-month follow-up echocardiography. Our study showed improved functional capacity of the patients. A significant reduction in the New York Heart Association functional class was observed. The mean preoperative value for New York Heart Association was 2.45 ± 0.51 versus 2.05 ± 0.88 postoperatively (P = 0.042). Some important variables showed a role in the progression of IMR. These were: left ventricular end-systolic dimension, left ventricular end-diastolic dimension, preoperative ejection fraction%, and failure to graft the diseased right coronary system. Conclusion The presence of moderate IMR in patients undergoing revascularization alone does not add additional burden to the operative risk nor does it affect the short-term outcome of these patients.

Chronic ischemic mitral valve regurgitation and surgical perspectives.

Chronic ischemic mitral valve regurgitation is a result of disturbed left ventricular geometry secondary to myocardial ischemia in the absence of intrinsic mitral valve pathology. It is a common complication after myocardial infarction, and patients who have ischemic mitral regurgitation (IMR) have a worse prognosis compared to patients who have ischemic heart disease alone, and this is directly related to the severity of IMR. Medical therapy has limited efficacy, and surgical options including various repair techniques and valve replacement had been tried with variable success. Still there is intense debate among surgeons whether to interfere with moderate degree IMR at the time of coronary artery revascularization.

Three-dimensional mitral valve structure in predicting moderate ischemic mitral regurgitation improvement after coronary artery bypass grafting

ObjectiveFocusing on 3-dimensional mitral valve structure, this study investigated predictors for moderate ischemic mitral regurgitation (IMR) improvement after off-pump coronary artery bypass grafting (OPCAB). MethodsThis study included 143 patients (age 67.6 ± 7.6 years, 32.9% female) with previous myocardial infarction and moderate IMR undergoing OPCAB. Preoperative 3-dimensional echocardiographic data were analyzed, focusing on mitral annular geometry and leaflet tethering model. Patients were grouped according to IMR at 1-year postoperative follow-up into improved (n = 65), with no or mild IMR, and failure (n = 70), with moderate or severe IMR, groups. Groups were compared to identify predictors of IMR improvement after OPCAB. ResultsEight patients died within 1 year. At 1 postoperative year, improved group included 65 patients; failure group included 70. Improved group had less preoperative annular flattening (smaller nonplanar angle) and segmental leaflet tethering (smaller A3, P1, P2, and P3 tethering angles) than failure group. Nonplanar angle (P < .001) and P3 tethering angle (P < .001) were independent predictors of moderate IMR improvement after OPCAB. Receiver operator characteristic curves defined P3 tethering angle of 28.8° (sensitivity of 78.6%, specificity of 84.6%) and nonplanar angle of 158.1° (sensitivity, 64.3% and specificity of 86.2%) as the cutoff values. ConclusionsPreoperative moderate IMR can be improved by OPCAB in selected patients. Less annular flattening and P3 leaflet tethering may predict improvement of moderate IMR after OPCAB, suggesting that the annular nonplanar saddle shape and less leaflet tethering toward P3 segment are important for the prognosis of moderate IMR.

Should the mitral valve be repaired for moderate ischemic mitral regurgitation at the time of revascularization surgery?

Ischemic mitral regurgitation (IMR) is associated with increased mortality and recurrent congestive heart failure following coronary artery bypass graft (CABG) surgery. While mitral surgery should be undertaken for severe MR during CABG, the treatment of moderate IMR remains controversial. We conducted a meta-analysis to determine the outcomes of CABG alone and combine with mitral valve repair (MVr) in moderate IMR. A literature search was conducted by Pubmed, Ovid, and Embase, which included 643 articles. Eleven studies (seven observational studies and four randomized controlled trials) with a total of 1406 patients were included (CABG alone = 864 and CABG plus MVr = 542). There was no difference in operative mortality (odds ratio 1.56, 95% confidence interval [CI] 0.92-2.71) or long-term survival at 1 or 5 years (hazard ratio 0.98, 95%CI 0.71-1.35, P = 0.49) between the two groups, and little evidence of heterogeneity was found in the studies (I2 = 0.0, P = 0.562). There was significantly greater improvement in MR grade (weighted mean difference [WMD] -1.15, 95%CI -1.67 to -0.064, P = < 0.001) and left ventricular systolic diameter (WMD -3.02, 95%CI -4.85 to -1.18, P = 0.001) following CABG and MVr compared to CABG alone. No difference in postoperative functional class or ejection fraction was found. Our results show that in the presence of moderate IMR, adding MVr to revascularization reduces MR grade on follow-up echocardiography and promotes ventricular remodeling, with no improvement in long-term survival or functional class.

Concomitant mitral valve surgery in patients with moderate ischemic mitral regurgitation undergoing coronary artery bypass grafting

The clinical benefits of a concomitant mitral valve (MV) surgery in patients with moderate ischemic mitral regurgitation (iMR) undergoing coronary artery bypass grafting (CABG) remain controversial. The study involved 710 patients (mean age, 65.0±8.9 years; 504 males) with moderate iMR undergoing CABG between 1990 and 2015. Of these, 116 (16.3%) patients underwent a concomitant MV surgery (MVS; replacement in 10, repair in 106) and 594 (83.7%) underwent CABG only. Clinical and echocardiographic outcomes were compared before and after adjustment with the use of propensity score (PS) analyses. Early mortality occurred in 22 (3.7%) and 13 (11.2%) patients in CABG-only and CABG with MVS group, respectively (P=0.001). After adjustment, CABG with MVS group showed significantly increased risks of early death (P<0.001), low cardiac output syndrome (LCOS) (P=0.001) and surgical bleeding (P=0.014). During a median follow-up of 78.0 months (quartile 1-3, 33.6-115.9 months), overall mortality occurred in 286 (40.3%) patients. The addition of an MV surgery showed an increased risk of overall mortality [hazard ratio (HR), 1.34; 95% confidence interval (CI), 0.99-1.80; P=0.055], which became comparable 1 year after surgery on landmark survival analysis (HR, 0.94; 95% CI, 0.64-1.39; P=0.772). Improved left ventricular (LV) ejection fraction and LV reverse remodeling were observed in both groups without significant intergroup differences. The addition of a concomitant MV surgery increased the risk of early mortality and complications in patients with moderate iMR undergoing CABG. In long-term clinical and echocardiographic outcomes, a concomitant MV surgery seemed to confer no significant clinical benefits.

One-year outcomes of concomitant mitral reduction annuloplasty repair with coronary artery bypass grafting for moderate ischemic mitral regurgitation

BackgroundMitral valve repair for chronic ischemic mitral regurgitation (IMR) in the published literature has contradictory outcomes. Here, we report our center outcomes of reduction annuloplasty technique in addition to myocardial revascularization to treat ischemic IMR over a four-year period. MethodsBetween January 2011 and December 2014, a total of 40 patients were identified to have a reduced left ventricular ejection fraction who underwent first-time mitral valve reduction annuloplasty concomitantly with coronary artery bypass grafting to treat moderate IMR. Variations in left ventricular end-systolic volume index (LVESVI), left ventricular ejection fraction (LVEF), functional class, and mitral regurgitation (MR) was followed up after surgery and retrospectively analyzed. ResultsIn our cohort, mitral reduction annuloplasty was successful in helping 33 (82%) patients to have no residual MR and to downgrade their MR from moderate (grade 3+) to trace (grade 1+) in 7 (18%) patients before leaving the operating room. A change from baseline value was observed secondary to correction of MR. At 3-months follow-up time; the mean MR grade that was 0.2 ± 0.1 by the intraoperative assessment post-bypass has increased significantly to be 1.8 ± 0.4 (p < 0.05). Similarly, at one year after surgery it increased to 1.9 ± 0.3, p < 0.05, compared to baseline value.Remarkably, our patients showed a significant increase in the mean LVEF (48 ± 1.1%, p < 0.05), at 3-month visit and 1-year visit post-surgery (47 ± 4.2%), %, p < 0.05) compared to the baseline values (39 ± 2.3%, p < 0.05 for both visits). While our patients showed gradually but non-significantly reduction in the mean LVESVI (57.6 ± 9.0 ml/m2, p > 0.05) at early follow-up time, mean LVESVI improved significantly to be 47.6 ± 11.0 ml/m2, p < 0.05 at the one year. This statistically significant increase in the LVEF% at 3-month visit, in addition to the reduction in the LVESVI after one year were capable to induce substantial clinical change in NYHA functional class, which was observed early (at 3-month visit) where 35 (88%) patients became in NYHA class I and II and later (at 1-year visit post-surgery) where 32 (80%) patients stayed in NYHA class I and II.No deaths were reported during the one-year follow-up resulting in 95% survival rate. During the one-year follow-up time, 7 (18%) were readmitted to the hospital due to non-cardiac indications.Early operative mortality (within 30 days after surgery) was 5%. One-year survival was 95%. The mean duration of follow-up was 1.1 ± 2.4 years (range, 1.0–3.5 years). ConclusionsMitral reduction annuloplasty concomitant to surgical myocardial revascularization may be sufficient to correct moderate IMR. It is associated with substantial improvement in early and intermediate-term survival rates, left ventricular functions, NYHA class and low incidence of recurrent MR.