Original article
Adult cardiac
Survival Prognosis and Surgical Management of Ischemic Mitral Regurgitation

Presented at the Poster Session of the Forty-fourth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2008.
https://doi.org/10.1016/j.athoracsur.2008.05.017Get rights and content

Background

Ischemic mitral regurgitation (IMR) has an adverse prognosis, but survival characteristics and management are controversial. This study reviewed a 20-year series of IMR patients managed with multiple approaches to assess and refine surgical strategies.

Methods

Patients having surgery for primary coronary disease from 1986 to 2006 were divided into group 1 (no IMR; bypass grafting only; n = 16,209), group 2a (IMR; bypass only; n = 3,181), group 2b (IMR; mitral repair; n = 416), and group 2c (IMR; mitral replacement; n = 106). Cox proportional hazards modeling adjusted for baseline differences, and therapeutic adequacy was quantified by area under each survival curve expressed as a percentage of group 1.

Results

Group 2 patients were older than group 1 patients and had worse baseline characteristics. Group 2a had less severe MR and group 2b had the most comorbidity. Assuming group 1 provided the best adjusted outcome at a given baseline risk, group 2a achieved 97.7%, 2b achieved 93.7%, and 2c achieved 79.1% of potential survival (hazard ratio 1.1, 1.4, and 1.6, respectively; p < 0.003). Most of the survival difference was perioperative.

Conclusions

Worse baseline risk is a major factor reducing long-term survival in IMR. Current algorithms in which mild to moderate IMR is managed with bypass only (group 2a) generally produced good late results. In patients with moderate and severe IMR, repair achieved 93.7% of full survival potential; valve replacement was less satisfactory, primarily owing to higher operative mortality. Future therapeutic refinement, emphasizing reparative procedures and better perioperative care, could enhance the surgical prognosis of IMR.

Section snippets

Material and Methods

Institutional Review Board permission was obtained for this study and individual patient consent was waived. The Duke Cardiovascular Disease Databank identified all patients with coronary artery disease who underwent surgical therapy from January 1, 1986, through December 31, 2006. Patients having procedures concomitant with CABG, but not related to IMR, were excluded (aortic valve, tricuspid valve, or MV operations for nonischemic etiologies, repair of postinfarct ventricular septal defect or

Results

Baseline characteristics for the 19,912 patients in group 1 and group 2 are shown in Table 1. Patients with IMR (group 2) demonstrated worse preoperative risk factor profiles than group 1. Specific adverse factors in group 2 included greater age, hyperlipidemia, diabetes, hypertension and renal insufficiency, as well as higher heart failure class, EF reduction, and myocardial infarction history. More female patients existed in group 2, suggesting that IMR disproportionately affected women.

Comment

A high incidence of preoperative risk factors is characteristic of IMR, and these factors influence survival significantly. When differences in baseline characteristics were adjusted statistically, the adverse risk profile of IMR seemed be a major factor limiting survival in IMR, accounting for much of the 58% 5-year survival of IMR patients after repair. Thus, CABG-only patients with the same risk profiles as IMR would have similarly reduced survival, because advanced age and adverse cardiac

References (40)

Cited by (100)

  • Treatment options for ischemic mitral regurgitation: A meta-analysis

    2022, Journal of Thoracic and Cardiovascular Surgery
View all citing articles on Scopus

Authors contributed equally.

View full text