Recurrent Mitral Regurgitation and Risk Factors for Early and Late Mortality After Mitral Valve Repair for Functional Ischemic Mitral Regurgitation

doi:10.1016/j.athoracsur.2008.01.079

The Annals of Thoracic Surgery

Volume 85, Issue 5, May 2008, Pages 1537-1543

Presented at the Fifty-fourth Annual Meeting of the Southern Thoracic Surgical Association, Bonita Springs, FL, Nov 7–10, 2007.

https://doi.org/10.1016/j.athoracsur.2008.01.079 Get rights and content

Background

Mortality for patients with coronary artery disease and functional ischemic mitral regurgitation (IMR) remains high regardless of the treatment strategy. Data regarding risk factors, progression of MR, and cause of death in this subgroup are limited.

Methods

A retrospective study was performed on 257 consecutive patients undergoing mitral valve repair exclusively for IMR from 1996 to 2005. Potential preoperative and perioperative risk factors for death and postoperative echocardiographic data were recorded.

Results

Preoperative echocardiography demonstrated 3+ to 4+ MR in 98.4% (252 of 257). Concomitant coronary artery bypass grafting was performed in 80.9% (208 of 257). Operative mortality was 10.1% (26 of 257). Overall survival by Kaplan-Meier analysis was 68.3% at 3 years and 52.0% at 5 years. Factors associated with late mortality by multivariate analysis include advanced age (relative risk [RR], 1.037; 95% confidence interval [CI], 1.016 to 1.059; p ≤ 0.001), preoperative dialysis (RR, 3.504; 95% CI, 1.590 to 7.720; p = 0.008), and diabetes (RR, 2.047; 95% CI, 1.319 to 3.177; p = 0.001). Echocardiographic data at 20 ± 25 months were available in 57% (147 of 257). Their survival by Kaplan-Meier analysis was 76.4% at 3 years and 65.1% at 5 years with 0 to 2+ MR postoperatively (n = 106) vs 61.3% and 35.8% with 3+ to 4+ MR (n = 41; p = 0.003). Cause of death was available in 72.3% (60 of 83) of late deaths, with 42.2% (35 of 83) attributed to cardiac causes and 30.1% (25 of 83) noncardiac.

Conclusions

Mortality for IMR remains high despite surgical management and may be related to risk factors for progression of coronary artery disease. Despite repair, MR progresses in many patients and is associated with poor survival, although more detailed prospective data are needed to characterize this relationship.

Section snippets

Inclusion Criteria

Between January 1996 and December 2005, 257 patients between the age of 18 and 80 years were identified in our prospectively gathered database who had functional IMR and underwent mitral valve repair. All patients included in our study underwent surgical repair with or without a concomitant procedure. A diagnosis of IMR was made in patients in whom MR was present with coronary artery disease accompanied by regional wall motion abnormalities with normal valve leaflets and intact papillary

Preoperative Variables

Demographic data and preoperative risk factors are outlined in Table 1. A total of 189 patients (73.5%) had a previous MI, 113 (44.0%) had three -vessel disease, 42 (16.3%) had previous CABG, and 71 (27.5%) had a previous percutaneous coronary intervention. Pulmonary hypertension, defined by mean pulmonary artery pressure exceeding 30 mm Hg, was present in 119 patients (46.3%). Operations were elective in 199 patients (77.4%). Preoperatively, 252 patients (98.4%) had 3+ to 4+ MR by preoperative

Comment

This study reaffirms the poor prognosis of patients with severe IMR and outlines the often-unpredictable results. Surgical intervention remains the mainstay of therapy in these patients because the results with medical management have been dreadful. Mortality rates at 5 to 7 years with medical management are as high as 60% to 100%, depending on the severity of MR, LV function, and extent of coronary artery disease [9, 10, 11]. Trichon and colleagues [11] reported similar long-term survival in

References (30)

B. Barzilai et al.
Prognostic significance of mitral regurgitation in acute myocardial infarctionThe MILIS Study Group
Am J Cardiol
(1990)
E.A. Grossi et al.
Ischemic mitral valve reconstruction and replacement: comparison of long-term survival and complications
J Thorac Cardiovasc Surg
(2001)
G.G. Pellizzon et al.
Importance of mitral regurgitation inpatients undergoing percutaneous coronary intervention for acute myocardial infarction: the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial
J Am Coll Cardiol
(2004)
P. Buja et al.
Moderate-to-severe ischemic mitral regurgitation and multivessel coronary artery disease: Impact of different treatment on survival and rehospitalization
Int J Cardiol
(2006)
M.D. Diodato et al.
Repair of ischemic mitral regurgitation does not increase mortality or improve long-term survival in patients undergoing coronary artery revascularization: a propensity analysis
Ann Thorac Surg
(2004)
K.M. Harris et al.
Can late survival of patients with moderate ischemic mitral regurgitation be impacted by intervention on the valve?
Ann Thorac Surg
(2002)
A.M. Gillinov et al.
Is repair preferable to replacement for ischemic mitral regurgitation?
J Thorac Cardiovasc Surg
(2001)
T. Mihaljevic et al.
Impact of mitral valve annuloplasty combined with revascularization in patients with functional ischemic mitral regurgitation
J Am Coll Cardiol
(2007)
M.A. Borger et al.
Chronic ischemic mitral regurgitation: repair, replace or rethink?
Ann Thorac Surg
(2006)
E.C. McGee et al.
Recurrent mitral regurgitation after annuloplasty for functional ischemic mitral regurgitation
J Thorac Cardiovasc Surg
(2004)

A.H. Wu et al.

Impact of mitral valve annuloplasty on mortality risk in patients with mitral regurgitation and left ventricular systolic dysfunction

J Am Coll Cardiol

(2005)

M. Pu et al.

Importance of ischemic and viable myocardium for patients with chronic ischemic mitral regurgitation and left ventricular dysfunction

Am J Cardiol

(2003)

H.R. Mallidi et al.

Late outcomes in patients with uncorrected mild to moderate mitral regurgitation at the time of isolated coronary artery bypass grafting

J Thorac Cardiovasc Surg

(2004)

F. Bursi et al.

Heart failure and death after myocardial infarction in the community: the emerging role of mitral regurgitation

Circulation

(2005)

F. Grigioni et al.

Ischemic mitral regurgitation: long-term outcome and prognostic implications with quantitative Doppler assessment

Circulation

(2001)

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Among HF patients with severe SMR in the COAPT trial, those with diabetes had a worse prognosis. Nonetheless, diabetic and nondiabetic patients had consistent reductions in the 2-year rates of death and HFH and improvements in QOL and functional capacity following TMVr treatment using the MitraClip than with maintenance on GDMT alone. (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation [COAPT]; NCT01626079)
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Citation Excerpt :
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The rationale for UA is disputable in view of the physiology of the leak, and its accuracy was largely questioned in the last ACC/AHA guidelines [6]. Actually, high rates of MR recurrence have been reported, in both observational series [8,9] and randomized trials [15,27,28], reaching 33% of patients at 1 year and 60% at 2 years [15,28], which is concerning in view of its logical association with postoperative excess mortality and recurrence of CHF [29]. Our results in the UA group are consistent, by reporting more than half of the patients as having severe MR after UA, and a mean postoperative ERO close to the threshold of severity [5].
Surgical treatment of secondary mitral regurgitation (SMR) is controversial.
To analyse outcome after undersizing annuloplasty (UA) and mitral valve replacement (MVR).
Consecutive patients operated on for severe SMR, with left ventricular ejection fraction (LVEF) < 40% and refractory CHF, were included. Endpoints were in-hospital mortality, mid-term cardiovascular (CV) mortality, evolution of LV variables and recurrence of mitral regurgitation (MR).
59 patients were included (mean age 65 ± 10 years, preoperative LVEF 36 ± 6%; effective regurgitant orifice [ERO] 41 ± 17 mm²), 41 with ischaemic disease: 12 underwent UA and 47 underwent MVR; only eight had concomitant coronary revascularization. In-hospital mortality was 3.3% (8.3% in UA group; 2.1% in MVR group). Eight-year CV mortality was 39 ± 13% (40 ± 18% in UA group; 27 ± 10% in MVR group). Older age (hazard ratio 1.14, 95% confidence interval 1.07 to 1.22; P < 0.001) and LV end-systolic diameter (hazard ratio 1.18, 95% confidence interval 1.09 to 1.27; P < 0.001) independently predicted CV mortality. LVEF did not change between the preoperative and follow-up transthoracic echocardiograms in the MVR group (36 ± 6% vs. 35 ± 10%; P = 0.6) or the UA group (36 ± 5% vs. 31 ± 12%; P = 0.09). Conversely, LV end-diastolic diameter decreased significantly in the MVR group (64 ± 8 m to 59 ± 9 mm; P = 0.002), but not in the UA group (61 ± 7 m to 64 ± 10 mm; P = 0.2). Recurrence of significant MR occurred in 81% of patients in the UA group (mean postoperative ERO 19 ± 6 mm²) versus none in the MVR group.
Surgical treatment of SMR can be performed with acceptable operative risk and mid-term survival in severe heart failure, even if there is no indication for revascularization. MVR is associated with significant reverse remodelling, and UA with prohibitive risk of MR recurrence.
Les indications et modalités de correction chirurgicale de l’insuffisance mitrale secondaire (IMS) sont controversies.
Déterminer l’impact pronostique de l’annuloplastie réductrice(AR) et du remplacement valvulaire mitral (RVM).
Les patients opérés pour IMS avec FEVG < 40 % et insuffisance cardiaque réfractaire ont été inclus. La mortalité hospitalière, la mortalité cardiovasculaire (CV), l’évolution des paramètres VG et la récidive d’IMS ont été analysés après RVM et AR.
59 patients ont été inclus : 12 AR et 47 RVM. Âge moyen = 65 ± 10 ans, FEVG préopératoire = 36 ± 6 % et SOR = 41 ± 17 mm². Mortalité hospitalière = 3,3 % (8,3 % dans groupe AR ; 2,1 % dans groupe RVM). Mortalité cardiovasculaire à 8 ans = 40 ± 18 % après AR et 27 ± 10 % après RVM. L’âge (HR 1,14, IC95 % 1,07 à 1,22 ; P < 0,001) et le DTSVG (HR 1,18, IC95 % 1,09 à 1,27 ; P < 0,001) prédisaient de manière indépendante la mortalité CV. La FEVG restait stable entre la période préopératoire et le dernier suivi dans le groupe RVM (36 ± 6 % vs 35 ± 10 % ; P = 0,6) alors qu’elle tendait à diminuer dans le groupe AR (36 ± 5 % vs 31 ± 12 % ; P = 0,09). Le DTSVG diminuait significativement dans le groupe RVM (64 ± 8 mm à 59 ± 9 mm ; P = 0,002) mais restait stable dans le groupe AR (61 ± 7 mm à 64 ± 10 mm ; P = 0,2). Une récidive d’IMS survenait chez 81 % des patients du groupe AR (SOR moyen = 19 ± 6 mm²). Absence de récidive d’IMS dans groupe RVM.
Le traitement chirurgical de l’IMS peut être réalisé avec un risque opératoire acceptable et une survie satisfaisante même en cas de dysfonction systolique VG profonde et d’absence d’indication de revascularisation myocardique. Le RVM est associé à un remodelage VG inverse significatif alors que l’AR est associée à un risque rédhibitoire de récidive de la fuite.

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Original articleAdult cardiacRecurrent Mitral Regurgitation and Risk Factors for Early and Late Mortality After Mitral Valve Repair for Functional Ischemic Mitral Regurgitation

Background

Methods

Results

Conclusions

Section snippets

Inclusion Criteria

Preoperative Variables

Comment

Am J Cardiol

J Thorac Cardiovasc Surg

J Am Coll Cardiol

Int J Cardiol

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Am Coll Cardiol

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Am Coll Cardiol

Am J Cardiol

J Thorac Cardiovasc Surg

Heart failure and death after myocardial infarction in the community: the emerging role of mitral regurgitation

Circulation

Ischemic mitral regurgitation: long-term outcome and prognostic implications with quantitative Doppler assessment

Circulation

Original article
Adult cardiac
Recurrent Mitral Regurgitation and Risk Factors for Early and Late Mortality After Mitral Valve Repair for Functional Ischemic Mitral Regurgitation