Moderate Ischemic Mitral Regurgitation Research Articles

Mitral valve repair versus replacement in patients with ischemic mitral regurgitation.

The optimal management of ischemic mitral regurgitation (IMR) is controversial. The aim of this study was to examine our eight years' experience of surgical treatment in patients with IMR, and to compare outcomes of mitral valve repair versus replacement with concomitant coronary artery bypass grafting (CABG). A retrospective, observational, cohort study was undertaken to collect data on consecutive patients with IMR and coronary artery disease who received CABG and mitral valve surgery in our hospital between January 2008 and December 2015. Basic patient characteristics, operative data, and postoperative clinical outcomes were examined. The series included 22 consecutive patients (21 male; 1 female). The mean age was 62.1±11.4 years old. The mean preoperative left ventricular ejection fraction (LVEF) was 33.4%±15.4%. The mean cardiopulmonary bypass (CPB) time was 165.4±38.4 minutes, and the mean aortic cross clamp time was 113.8±33.6 minutes. Eighteen patients underwent CABG plus mitral valve repair, and four patients underwent CABG plus mitral valve replacement (MVR). There were three early in-hospital mortalities: two in the mitral valve repair group, and one in the replacement group. The follow-up was complete in all patients, with a mean follow-up duration of 3.1±2.3 years. The mean last LVEF was 35.3%±17.7%. There were 2 late mortalities. Both were from the repair group. The overall late survival rate was 81.6%, with 83.0% in the repair group and 75.0% in the replacement group. In patients with echocardiography follow-up of more than or equal to 1 year duration, the residual or recurrent mitral regurgitation rates were 0.0% in the replacement group and 57.1% in the repair group. One patient in the repair group later underwent MVR due to severe regurgitation postoperatively. Our preliminary findings showed that the surgical outcome of mitral valve repair might be comparable to that of MVR in terms of early mortality and long-term survival. However, mitral valve repair was associated with a higher residual or recurrent mitral regurgitation rate. According to the latest literature, the role of MVR can justifiably be indicated for severe IMR. As for moderate IMR, CABG alone without mitral valve intervention may provide similar clinical outcomes.

Invited Commentary

The inability to predict the response of the left ventricle to myocardial revascularization and mitral valve repair in ischemic mitral regurgitation (MR) patients remains problematic. Morgan and colleagues [1Morgan A.E. Zhang Y. Tartibi M. et al.Ischemic mitral regurgitation: abnormal strain overestimates nonviable myocardium.Ann Thorac Surg. 2018; 105: 1754-1762Abstract Full Text Full Text PDF Scopus (10) Google Scholar] compared the ability of tagged cardiac magnetic resonance imaging (MRI) and late gadolinium-enhanced (LGE) MRI to determine the amount of nonviable myocardium in patients with ischemic MR. Their hypothesis was that strain measurements using tagged cardiac MRI overestimate the amount of nonviable myocardium in ischemic MR when compared with LGE MRI, suggesting that much of the myocardium deemed nonviable by strain measurements is actually viable but nonfunctional (ie, stunned or hibernating). This is a critical issue because it is believed that the degree of stunned myocardium in patients with ischemic MR correlates not only with functional myocardial recovery due to revascularization but also with the degree of ventricular remodeling and, thus, the success or failure of mitral valve surgery in these patients. Although LGE MRI is helpful in identifying nonviable myocardium, it is not necessarily as helpful in determining the response of viable myocardium to surgery for ischemic MR. Gadolinium chelate distributes in the extracellular space but does not cross the intact cell membrane. Through a combination of increased extracellular volume and slower washout kinetics, there is a relative accumulation of gadolinium in areas of necrosis, fibrosis, and inflammation in the late washout phase. LGE MRI depends on this relative accumulation of gadolinium in areas of damaged myocardium, but it may miss areas of diffuse fibrosis and underestimate the true extent of nonviable muscle. Grapsa and colleagues [2Grapsa J. Zimbarra Cabrita I. Jakaj G. et al.Strain balance of papillary muscles as a prerequisite for successful mitral valve repair in patients with mitral valve prolapse due to fibroelastic deficiency.Eur Heart J Cardiovasc Imaging. 2015; 16: 53-61Crossref PubMed Scopus (3) Google Scholar], using 3-D echo speckle-tracking, showed that a disproportionate increase in the deformation of the papillary muscles is a predictor of recurrent MR following mitral valve annuloplasty and that global longitudinal deformation depends on the degree of mitral regurgitation. The amount of deformation of the mitral apparatus in patients with only minor degrees of MR was zero. It would be instructive to include tagged cardiac MRI and LGE MRI in a group of patients with ischemia and no MR to compare with patients with ischemic MR. Pasque and associates used MRI-based multiparametric strain data calculated from 15,300 grid points per patient in normal volunteers and in ischemic patients with and without MR [3Lancaster T.S. Kar J. Cupps B.P. et al.Topographic mapping of left ventricular regional contractile injury in ischemic mitral regurgitation.J Thorac Cardiovasc Surg. 2017; 154: 149-158.e1Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar]. They showed that ischemic MR is caused by dysfunction of the subpapillary ventricular wall and that the free ventricular wall segments outside the subpapillary regions showed the same strain patterns in ischemic MR patients and in ischemic patients without MR. The relationships between nonviability, functional recovery, and response to surgical intervention for ischemic MR are not yet clear. What is needed now are studies comparing these types of preoperative measurements in patients with ischemic MR with similar postoperative measurements on the same patients that might clarify the preoperative parameters that are truly capable of predicting postoperative outcomes. Perhaps we would then have a better understanding of precisely how to treat ischemic MR in individual patients. Ischemic Mitral Regurgitation: Abnormal Strain Overestimates Nonviable MyocardiumThe Annals of Thoracic SurgeryVol. 105Issue 6PreviewTherapy for moderate ischemic mitral regurgitation remains unclear. Determination of myocardial viability, a necessary prerequisite for an improvement in regional contractility, is a likely key factor in determining response to revascularization alone. Myocardial strain has been proposed as a viability measure but has not been compared with late gadolinium enhancement (LGE) cardiac magnetic resonance imaging. We hypothesized that abnormal strain overestimates nonviable left ventricular (LV) segments measured with LGE and that ischemia and mechanical tethering by adjacent transmural myocardial infarction (TMI) also decreases strain in viable segments. Full-Text PDF

Clinical and echocardiographic factors associated with mitral plasticity in patients with chronic inferior myocardial infarction.

Ischaemic mitral regurgitation (IMR) is consequence of left ventricular (LV) remodelling after myocardial infarction. In some cases, the mitral valve enlarges to compensate for LV remodelling and tenting, improving its coaptation; a process termed 'plasticity'. We sought to identify clinical and echocardiographic factors associated with plasticity in patients with chronic inferior myocardial infarction (CII). This study included 91 revascularized CII patients and 46 controls. Plasticity and IMR severity were evaluated by 2D transthoracic echocardiography. Compared with controls, CII patients were older (59 vs. 25 years) and mostly men (80% vs. 46%), both P < 0.001. Chronic inferior myocardial infarction patients also had significant LV remodelling: larger LV volumes, larger mitral tenting areas, larger coaptation depths, longer mitral leaflets and chords, and worse mitral regurgitation (all P ≤ 0.03). Of 91 CII patients, 60 had mitral plasticity (longer anterior and posterior leaflets and longer posterior chords, all P < 0.001), despite not exhibiting significantly larger LV volumes, tenting area or coaptation depth, when compared with patients with no plasticity. Contralateral (anterior) papillary muscle-to-annulus length tended to be increased in CII plasticity patients (P = 0.05). Also they had less moderate and severe IMR (both P < 0.04) compared with non-plasticity CII patients. Multivariate analysis demonstrated independent associations between plasticity and smoking [odds ratio (OR) 0.03, 0.002-0.57; P = 0.019], duration of type-2 diabetes (OR 1.19, 1.007-1.42; P = 0.04) and haemoglobin (OR 2.17, 1.25-3.76; P = 0.005). Mitral plasticity results in less moderate and severe IMR. Longer time-duration of diabetes mellitus and higher haemoglobin level are independently associated with mitral plasticity, while smoking independently associates with no plasticity. Increased anterior papillary muscle-to-annulus length in CII patients with plasticity suggests complex LV remodelling mechanisms are involved in plasticity.

Left ventricular regional dyssynchrony predicts improvements in moderate ischaemic mitral regurgitation after off-pump coronary artery bypass.

The aim of this study was to explore the predictors of the improvement in moderate ischaemic mitral regurgitation (IMR) after off-pump coronary artery bypass grafting (OPCAB) focusing on left ventricular (LV) dyssynchrony. A prospective study was performed among 135 patients (age at surgery, mean ± SD: 67.0 ± 8.2 years, 33.3% women) with prior myocardial infarction and moderate IMR undergoing OPCAB from 2008 to 2015. Preoperative and follow-up clinical and echocardiographic parameters were analysed, focusing on LV global/regional dyssynchrony. Patients were grouped by IMR at 1 year postoperatively: improved group with no or mild IMR (n = 61) and failure group with moderate or severe IMR (n = 67). Data were compared between groups to explore the predictors of IMR improvement after OPCAB. Seven patients who died before the 1-year postoperative assessment were excluded. At the 1-year follow up, there were 61 patients in the improved group and 67 patients in the failure group. Preoperatively, the improved group had smaller LV global dyssynchrony, LV regional dyssynchrony (papillary muscle systolic dyssynchrony; improved group versus failure group: 48.5 ± 4.5 ms vs 57.1 ± 3.9 ms; P < 0.001) and greater LV ejection fraction (improved group versus failure group: 44.7 ± 5.0% vs 36.7 ± 6.7%; P < 0.001) than the failure group. Papillary muscle systolic dyssynchrony (odds ratio 1.556, 95% confidence interval 1.313-1.845; P < 0.001) and preoperative ejection fraction (odds ratio 0.799, 95% confidence interval 0.691-0.924; P = 0.002) were independent predictors of moderate IMR improvement after OPCAB. In the selected patients, preoperative moderate IMR could be relieved by coronary artery bypass grafting. Greater ejection fraction and absence of LV regional dyssynchrony may predict the improvement in moderate IMR after coronary artery bypass grafting, suggesting that LV dyssynchrony especially regional dyssynchrony and preserved ventricular function would be important to the outcome of patients with moderate IMR.

Ischemic Mitral Regurgitation: Abnormal Strain Overestimates Nonviable Myocardium

Therapy for moderate ischemic mitral regurgitation remains unclear. Determination of myocardial viability, a necessary prerequisite for an improvement in regional contractility, is a likely key factor in determining response to revascularization alone. Myocardial strain has been proposed as a viability measure but has not been compared with late gadolinium enhancement (LGE) cardiac magnetic resonance imaging. We hypothesized that abnormal strain overestimates nonviable left ventricular (LV) segments measured with LGE and that ischemia and mechanical tethering by adjacent transmural myocardial infarction (TMI) also decreases strain in viable segments. Sixteen patients with mild or greater ischemic mitral regurgitation and 7 healthy volunteers underwent cardiac magnetic resonance imaging with noninvasive tags (complementary spatial modulation of magnetization [CSPAMM]), LGE, and stress perfusion. CSPAMM images were post-processed with harmonic phase and circumferential and longitudinal strains were calculated. Viability was defined as the absence of TMI on LGE (hyperenhancement >50% of wall thickness). The borderzone was defined as any segment bordering TMI. Abnormal strain thresholds (±1 to 2.5 SDs from normal mean) were compared with TMI, ischemia, and borderzone. 7.4% of LV segments had TMI on LGE, and more than 14.5% of LV segments were nonviable by strain thresholds (p < 0.005). In viable segments, ischemia impaired longitudinal strain (least perfused one-third of LV segments:-0.18 ± 0.08 versus most perfused:-0.22 ± 0.1, p = 0.01) and circumferential strain (-0.12 ± 0.1 versus-0.16 ± 0.08, p < 0.05). In addition, infarct proximity impaired longitudinal strain (-0.16 ± 0.11 borderzone versus-0.18 ± 0.09 remote, p= 0.05). Impaired LV strain overestimates nonviable myocardium compared with TMI on LGE. Ischemia and infarct proximity also decrease strain in viable segments.

Isolated coronary artery bypass surgery in patients with mild to moderate ischemic mitral regurgitation: Early results

The optimal management of moderate ischemic mitral regurgitation (MR) remains controversial. Some surgeons advocate coronary artery bypass alone, while others suggest concomitant mitral valve annuloplasty. We aimed to evaluate the early results of isolated coronary artery bypass operation on the cases with mild-to-moderate ischemic MR. Between May 2010 and May 2011, 59 patients (64% male, mean age: 50.5 years) with a preoperative diagnosis of mild-to-moderate ischemic MR underwent a coronary bypass operation. Patients evaluated with preoperative and postoperative (in twelve-month period with an average of five months) transthoracic echocardiogram (TTE). Postoperative mortality was not observed in study group. The preoperative functional capacity of the patients as well as the variables of mild MR and moderate MR showed a statistically significant difference in a positive way when compared with the postoperative functional capacity and MR variables. Postoperative TTE evaluation revealed that only 2 cases have severe MR (3,4%) also 62,7 % of patients have mild and 33.9% of patients have moderate MR. While there was a significant difference in a positive way between the preoperative and postoperative period in terms of left atrial diameter, no significant difference was found for the variables of ejection fraction and pulmonary artery pressure. Among the patients whom undergoing coronary bypass surgery, if there is mild or moderate MR revealed with the TTE prior to the operation, performing only coronary bypass operation will be adequate, and our early results in this matter are satisfactory. But, if severe MR revealed with TTE, performance of mitral valve repair or replacement should be evaluated additional to coronary bypass operation.

P6154The relationship between NT-proBNP due to exercise and echocardiographic parameters in patients with moderate ischemic mitral regurgitation

P6154The relationship between NT-proBNP due to exercise and echocardiographic parameters in patients with moderate ischemic mitral regurgitation

Surgical management of ischemic mitral regurgitation

Ischemic mitral regurgitation (IMR) portends a dismal survival rate for the afflicted irrespective of the type of surgical intervention. The treatment of moderate IMR has been a subject of debate with recent evidence citing similar survival statistics with revascularisation alone/revascularisation with mitral valve surgery approaches. The recognition of left ventricular (LV) reverse remodelling as the key factor determining the progression of IMR has resulted in a paradigm shift in the surgical management of IMR. Literature review was done in Pubmed and Scopus to identify relevant articles pertaining to the pathophysiology, diagnosis and treatment of IMR with the view of writing a narrative review on the subject. The similar long-term outcomes following mitral valve repair/replacement strategies for IMR has led to a resurgence of interest in primarily replacing the valve employing chordal preservation techniques especially in the setting of high probability of repair failure. Although mitral valve annuloplasty remains the most utilised surgical technique in IMR correction, several ingenious techniques tackling the various components of the valve apparatus continue to evolve. From the current understanding, IMR is primarily a valvular manifestation of ischemic ventricular disease and hence, myocardial revascularisation forms the key element in the surgical treatment of IMR with or without adjunctive mitral valve repair/replacement.

The Role for Cardiovascular Remodeling in Cardiovascular Outcomes.

Ischemic and non-ischemic injury to the heart causes deleterious changes in ventricular size, shape, and function. This adverse remodeling is mediated by neurohormonal and hemodynamic alterations and is reflected in non-invasive measures of left ventricular ejection fraction (LVEF), left ventricular end-systolic volume (LVESV), and left ventricular end-diastolic volume (LVEDV). These measures are closely linked to cardiovascular outcomes and have become key surrogate endpoints for evaluating the therapeutic efficacy of contemporary treatments for heart failure with reduced ejection fraction (HFrEF). In this review, we critically evaluate recent published data (2015-2016) from randomized clinical trials (RCTs) and observational studies of HFrEF therapies to assess the role of ventricular remodeling on outcomes. These data highlight the benefits of certain guideline-directed medical therapies (GDMT) such as cardiac resynchronization therapy, surgical revascularization, and mechanical circulatory support on remodeling, while revealing the limitations of other therapies-routine mitral valve repair for patients with moderate ischemic mitral regurgitation and adjuncts to percutaneous coronary intervention in patients with ST elevation myocardial infarction (cyclosporine A and bioabsorbable cardiac matrix). The new angiotensin receptor blocker/neprilysn inhibitor, sacubitril/valsartan, demonstrates convincing improvements in clinical outcomes with a study of remodeling parameters to follow; the new cardiac myosin activator, omecamtiv mecarbil, demonstrates improvement in remodeling parameters without a clear early clinical benefit. The concepts and contemporary trials reviewed in this paper reinforce the value of non-invasive measures of ventricular remodeling (LVEF, LVESV, and LVEDV) as important metrics across a range of cardiovascular therapies. Global non-invasive measures of cardiovascular remodeling have roughly paralleled or preceded hard clinical outcomes. Additionally, the capacity for reverse remodeling in HFrEF with GDMT motivates continued research in the fields of implementation science, diagnostic imaging, and gene-based therapeutics.

Mitral valve surgery and coronary artery bypass grafting for moderate-to-severe ischemic mitral regurgitation: Meta-analysis of clinical and echocardiographic outcomes

ObjectiveThis meta-analysis was conducted to compare clinical and echocardiographic outcomes following isolated coronary artery bypass grafting (CABG) versus CABG and mitral valve (MV) surgery in patients with moderate-to-severe ischemic mitral regurgitation (IMR). MethodsSeven databases were systematically searched to identify relevant studies. For eligibility, studies were required to report on the primary endpoint of perioperative or late mortality. Data were analyzed according to predefined clinical endpoints. ResultsFour randomized controlled trials (RCTs) (n = 505) and 15 observational studies (OS) (n = 3785) met the criteria for inclusion. Compared with isolated CABG, concomitant CABG and MV surgery was not associated with increased perioperative mortality (RCTs: relative risk [RR] 0.89, 95% confidence interval [CI], 0.26-3.02; OS: RR 1.40, 95% CI, 0.88-2.23). CABG and MV surgery was associated with significantly lower incidence of moderate-to-severe MR at follow-up (RCTs: RR 0.16, 95% CI, 0.04-0.75; OS: RR 0.20, 95% CI, 0.09-0.48). Late mortality was similar between the surgical approaches in RCTs (hazard ratio [HR] 1.20, 95% CI, 0.57-2.53) and OS (HR 0.99, 95% CI, 0.81-1.21). There were no significant differences in echocardiographic outcomes. These results remained consistent in subgroup analyses restricted to patients with strictly moderate IMR. ConclusionsIn patients with moderate-to-severe IMR, the addition of MV surgery to CABG was not associated with increased perioperative mortality. Although concomitant MV surgery reduced recurrence of moderate-to-severe MR at follow-up, this was not associated with a reduction in late mortality. Larger trials with longer follow-up duration are required to further assess long-term survival and freedom from reintervention.

Noteworthy Literature Published in 2016 for the Cardiothoracic Anesthesiologist

Clinical research and outcome studies dominated the publication spectrum for the cardiothoracic anesthesiologist in 2016. Echocardiography is an important tool in the armamentarium of the cardiothoracic anesthesiologist. Technology is advancing at a fast pace: A new method to quantify the regurgitant volume in mitral regurgitation has been described in an experimental model and been validated in humans. Interesting studies on key elements of our daily practice have been published: Does tranexamic acid decrease the transfusion requirements after cardiac surgery? Are patients with a postoperative cognitive deficit at risk for dementia 7.5 years after surgery? What is the best strategy for post-cardiac surgery atrial fibrillation? What is the mechanism of preconditioning with remifentanil? Large multicenter looked at the treatment strategies for moderate and severe ischemic mitral regurgitation and benefits of transcatheter aortic valve replacement versus the surgical approach. These studies may give us ideas on how to tailor treatment to optimize the patients' outcome and to minimize the associated risks.

Surgical Repair of Moderate Ischemic Mitral Regurgitation-A Systematic Review and Meta-analysis.

Introduction Moderate mitral regurgitation (MR) of ischemic etiology has been associated with worse outcomes after coronary artery bypass grafting (CABG). Studies comparing concomitant mitral valve replacement/repair (MVR/Re) with CABG and standalone CABG have reported conflicting results. We performed a systematic review and meta-analysis of the published literature. Patients and Methods We searched using PubMed, Cochrane, EMBASE, CINAHL, and Google scholar databases from January 1960 to June 2016 for clinical trials comparing CABG to CABG + MVR/Re for moderate MR. Pooled risk ratio or mean difference (MD) with 95% confidence intervals (CI) for individual outcomes were calculated using random effects model and heterogeneity was assessed using Cochrane's Q-statistic. Results A total of 11 studies were included. Mean follow-up was 35.3 months. All-cause mortality (Mantel-Haenszel [MH] risk ratio [RR]: 0.96, 95% CI: 0.75-1.24, p = 0.775), early mortality (MH RR: 0.65, 95% CI: 0.39-1.07, p = 0.092), and stroke rates (MH RR 0.65, 95% CI: 0.21-2.03, p = 0.464) were similar between CABG and CABG + MVR/Re groups. Adverse event at follow-up was lower with CABG (MH RR: 0.90, 95% CI: 0.61-1.32, p = 0.584). MD of change from baseline in left ventricular (LV) end-systolic dimension (MD: - 2.50, 95% CI: - 5.21 to - 0.21, p = 0.071) and LV ejection fraction (MD: 0.48, 95% CI: - 2.48 to 3.44, p = 0.750) were not significantly different between the groups. Incidence of moderate MR (MH RR: 3.24, 95% CI: 1.79-5.89, p < 0.001) was higher in the CABG only group. Conclusion Addition of MVR/Re to CABG in patients with moderate ischemic MR did not result in improvement in early or overall mortality, stroke risk, or intermediate markers of LV function when compared with CABG alone.

Management of moderate ischemic mitral regurgitation: revascularization alone versus revasularization and mitral valve repair

Background Ischemic mitral regurgitation (IMR) is a frequent condition post-myocardial infarction. Management of moderate myocardial infarction is still debatable, with adding mitral valve repair (MVR) to coronary artery bypass grafting (CABG) being questionable. Aim To compare echocardiographic and clinical outcome of moderate IMR treated by revascularization alone versus another group of patients treated by revascularization and MVR. Patients and methods Forty consecutive patients with ischemic heart disease with moderate IMR undergoing on-pump CABG are randomly selected. They were divided into two groups: group I (20) had CABG+MVR, group II (20) had only CABG; echocardiography was done postoperatively and after 6 months for both groups. Results Our study revealed improvement in the grade of mitral regurgitation (MR) in both groups which was more evident and significant in group I than II with 11 (61%) of group I showing complete resolution of MR versus 0 patients in group II which was highly statistically significant (P=0.0001). Follow-up after 6 months, there were significant reduction in the New York Heart Association functional class as well as the mean grade of MR in group I versus group II, (P=0.004), with nine (50%) patients in group I against two (11%) patients in group II had complete resolution (P=0.004). We found also significant reduction in left ventricular dimensions and function. Conclusion MVR can be performed safely, concomitantly with coronary artery bypass grafting in patients who have moderate IMR.

Качество жизни пациентов после хирургического лечения умеренной ишемической митральной недостаточности

Качество жизни пациентов после хирургического лечения умеренной ишемической митральной недостаточности

Meta-Analysis of Usefulness of Concomitant Mitral Valve Repair or Replacement for Moderate Ischemic Mitral Regurgitation With Coronary Artery Bypass Grafting

Moderate ischemic mitral regurgitation (MR) is often present in patients undergoing coronary artery bypass grafting (CABG). However, the clinical benefit of repairing moderate MR during CABG is unproven. We searched multiple databases to identify original studies comparing isolated CABG versus combined CABG and MR surgery (mitral valve surgery with coronary artery bypass grafting [MVCABG]); survival (either early or midterm) was the primary end point. Risk ratio (RR) or standardize mean difference was selected as the effect estimates; survival was compared by pooling hazard ratios. All results are presented with 95% CIs; p <0.05 is statistically significant. Eleven studies (7 retrospective and 4 randomized controlled trials; 547 MVCABG and 900 CABG patients) were included in our meta-analysis. Concomitant mitral valve repair significantly prolonged surgical duration (p <0.01). Early mortality (MVCABG 6.9% and CABG 6%) was comparable (RR 1.3 [0.9 to 1.8]; p= 0.11). At follow-up, the MVCABG patients had similar New York Heart Association class (standardize mean difference-0.73 (-1.64 to 0.18; p= 0.11). However, patients who underwent concomitant mitral valve surgery had less MR at follow-up (recurrent significant MR, RR 0.37 [0.22 to 0.62]; p= 0.001; mean MR grade, mean difference= 0.39 [0.26 to 0.59]; p <0.001). Midterm survival rate (mean follow-up 5years) was comparable in both groups (hazard ratio for mortality in the MVCABG cohort 1.1 [0.9 to 1.3]; p= 0.38). In conclusion, concomitant repair of moderate ischemic MR leads to improved mitral valve competence at follow-up; however, this was not translated into any functional or survival benefit for adding valve repair to CABG for these patients at 5years of follow-up.

Coronary artery bypass grafting versus concomitant mitral valve annuloplasty in moderate ischemic mitral regurgitation: 4-year follow-up

Objective In severe ischemic mitral regurgitation (IMR), there is benefit evidence for mitral valve repair with coronary artery bypass grafting (CABG). However, there is still a debate around combined repair and CABG for moderate IMR. We evaluate our results over 4-year follow-up for patients with moderate IMR who underwent isolated CABG and combined with mitral ring annuloplasty.

Impact of Left Ventricular to Mitral Valve Ring Mismatch on Recurrent Ischemic Mitral Regurgitation After Ring Annuloplasty.

In ischemic mitral regurgitation (IMR), ring annuloplasty is associated with a significant rate of recurrent MR. Ring size is based on intertrigonal distance without consideration of left ventricular (LV) size. However, LV size is an important determinant of mitral valve (MV) leaflet tethering before and after repair. We aimed to determine whether LV-MV ring mismatch (mismatch of LV size relative to ring size) is associated with recurrent MR in patients with IMR after restrictive ring annuloplasty. Patients with moderate or severe IMR from the 2 Cardiothoracic Surgical Trials Network IMR trials who received MV repair were examined at 1 year after surgery. Baseline LV size was assessed by LV end-diastolic dimension and LV end-systolic dimension (LVESd). LV-MV ring mismatch was calculated as the ratio of LV to ring size (LV end-diastolic dimension/ring size and LVESd/ring size). At 1 year after ring annuloplasty, 45 of 214 patients with MV repair (21%) had moderate or greater MR. In univariable logistic regression analysis, larger LVESd (P=0.02) and LVESd/ring size (P=0.007) were associated with recurrent MR. In multivariable models adjusted for age, sex, baseline LV ejection fraction, and severe IMR, only LVESd/ring size (odd ratio per 0.5 increase, 2.20; 95% confidence interval, 1.05-4.62; P=0.038) remained significantly associated with 1-year MR recurrence. LV-MV ring size mismatch is associated with increased risk of MR recurrence. This finding may be helpful in guiding choice of ring size to prevent recurrent MR in patients undergoing MV repair and in identifying patients who may benefit from MV repair with additional subvalvular intervention or MV replacement rather than repair alone. URL:http://clinicaltrials.gov. Unique identifiers: NCT00806988 and NCT00807040.

Coronary artery bypass grafting (CABG) alone in moderate ischemic mitral regurgitation: is CABG really enough?

The randomized study described by Michler and co-authors recently appeared in NEJM reports the results of the 2-year outcomes of surgical treatment of moderate ischemic mitral regurgitation (IMR) (1). This paper nourishes and expands the discussion about functional or “secondary” mitral regurgitation occurring as a consequence of an active reversible ischemia or a complete infarction and reopens the debate arisen in the previous study of the Cardiothoracic Surgical Trials Network (CTSN) about the optimal treatment of IMR. Advances in the management of cardiovascular risk factors and acute coronary syndromes permit to effectively identify around 1.6 to 2.8 million patients in the United States suffering by functional IMR after a heart attack; about 10% of these patients suffer from an IMR of moderate entity. Despite the increase in the immediate survival, the lack of an optimized surgical treatment is responsible for a high rate of IMR recurrence (2) after surgery, transforming this pathological phenomenon into a chronic disease, with enormous societal implications.

DETERMINATION OF DELAY FREQUENCY IN REFERRAL AND ITS RELATED FACTORS IN PATIENTS WITH STEMI, WHO REFERRED TO IMAM REZA HOSPITAL EMERGENCY IN 93-92

Objectives & ( hypothesis OR questions) : Ischemic mitral regurgitation (IMR) is a major source of morbidity and mortality of myocardial infarction. Although mitral valve repair has become recently popularized for the treatment of IMR, select patients may derive benefits from replacement. The purpose of this study is to describe current surgical options for IMR and to discuss when mitral valve repair (MVR) by KAY method may be favored over mitral valve replacement. Materials & Methods: This clinical study was conducted from 28 may 2014 to 2016-05-28 ,in cardiac surgery ward of Imam Reza Hospital of Mashhad University of Medical Sciences retrospectively. All of patients with ischemic mitral regurgitation (moderate or severe) who needs CABG planned CABG +Mitral Repair and KAY method had been chosen .and all patients follow –up for One year by admission and echocardiography in day of discharge -3 months and 1 year ago. Operation and echocardiography was done by same cardiac surgeon and cardiologist. Results: We found 12 patients (male=5,femal=8) that operated by CABG AND KAY METHOD ,IN 75% of them was a history of previous myocardial infarction and in remainder there was acute ischemia of myocardium. In 91/7% patients there was inferior myocardial infarction and dominant coronary vessel was RCA.ALL of patient had significant MR that resolved in all of them (p-value. (0.05> there isn’t any preoperative and post operative mortality. The main time of CPB was 150 minute and in t2 test revealed 10% increased ejection fraction of left ventricle (p value <0/0005).no further postoperative reported in 1 year follow-up patients. Conclusion :Although surgical CABG alone may benefit patients with mild–moderate IMR, most surgeons advocate the performance of CABG in combination with either mitral valve repair or replacement. In the current era, and in Iran mitral valve repair specially KAY method has proven to offer improved short-term and long-term survival, decreased valve-related morbidity, and improved left ventricular function and it is cost effective procedure. Future randomized, prospective clinical trials are needed to compare this surgical technique.

33. Moderate ischemic mitral regurgitation: Revascularization alone versus revascularization and mitral valve repair

Ischemic mitral regurgitation (IMR) can be defined as mitral valve (MV) insufficiency caused by coronary artery disease and excluding other causes of mitral pathology as rheumatic, myxomatous, infectious, congenital, or connective tissue diseases ,it usually occurs with right or circumflex coronary infarction that involves the posterior ventricular wall, posterior papillary muscle, and adjacent mitral annulus (1). The management of IMR represents a therapeutic challenge. Although most patients are treated medically, many patients are referred for surgery. Some authors claimed that revascularization alone is sufficient for managing those patients (3), whereas others have recommended revascularization combined with mitral valve repair (2). There is a general agreement that patients with mild mitral regurge (1+) are treated with coronary artery bypass surgery (CABG) alone and those with severe (3+ or 4+) IMR should undergo mitral valve surgery at the time of CABG surgery. However, the importance of moderate IMR (2+) is still controversial. A prospective controlled randomized study includes (60 patients with IHD undergoing CABG with ischemic mitral regurge aged from 40 to 65 years of both sexes). They will be divided into two groups of patients: Group I: 30 patients with IHD and moderate IMR undergoing on pump CABG for revascularization only. Group II: A 30 patients with IHD and moderate IMR undergoing on pump CABG for revascularization and mitral valve repair. Study made from January, 2014 to August, 2015, at Medina Cardiac Centre that the presence of moderate (2+) ischaemic mitral regurgitation in ischaemic heart disease patients undergoing revascularization alone does not add any additional burden to the operative risk nor does it affect the immediate and early outcome of these patients. That revascularization alone can ameliorate moderate ischaemic mitral regurgitation in most patients postoperatively. This improvement is translated into an improvement in the functional class and the quality of life postoperatively there is no statistical difference between two groups.Also a procedure to address the mitral valve in moderate IMR should be considered in patients with a worse preoperative left ventricular profile.