CLINICAL PERSPECTIVE
WHAT IS NEW?
- This study describes the occurrence of more than moderate ischemic mitral regurgitation (IMR) in patients undergoing left ventricular reconstruction (LVR) for heart aneurysm.
- In this study, comparable overall and event-free outcomes were observed after mitral valve repair and replacement concomitant to LVR, while mitral valve replacement showed superiority on persistent correction of IMR.
WHAT ARE THE CLINICAL IMPLICATIONS?
- Regarding the overall and event-free survival, both mitral valve repair and mitral valve replacement might be reasonable in patients undergoing LVR complicated by more than moderate IMR.
- Mitral valve replacement may be a better choice to achieve persistent correction of IMR than mitral valve repair.
1. Introduction
Up to 60% of patients with myocardial infarction develop various degree of ischemic mitral regurgitation (IMR),[1] which is primarily attributable to remodeling of the left ventricle, generating reduced closing forces and increased tethering forces on the mitral valve.[2] IMR can compromise patient prognosis,[3] depending on the severity of the level of regurgitation. Compared with patients who undergo no mitral valve intervention, evidence from existing studies shows that concomitant mitral valve surgery, most of which is mitral valve repair, during coronary artery bypass grafting (CABG) is associated with less mitral regurgitation recurrence, without increasing perioperative mortality in patients with more than moderate IMR[4]; unfortunately however, concomitant mitral valve surgery fails to provide survival benefits during late follow-up. Furthermore, randomized clinical trials support chordal-sparing mitral valve replacement over mitral valve repair,[5,6] since the latter is related to an increased rate of recurrent IMR.
Heart aneurysm, the majority of which is left ventricular aneurysm, is another severe complication of acute myocardial infarction. While previous studies have demonstrated that left ventricular reconstruction (LVR) can improve patient outcomes,[7,8] several investigations also indicated that IMR of more than moderate level is an independent risk factor that negatively affects event-free survival of these patients.[7,9] Therefore, the need for simultaneous mitral valve surgery should be carefully evaluated. While clinical guidelines recommend chordal-sparing mitral valve replacement for patients undergoing CABG, whether repair or replacement of the mitral valve is preferable in patients undergoing surgical LVR for ischemic ventricular aneurysm followed by more than moderate IMR is unknown.
In this study, we aimed to evaluate the effect of concomitant mitral valve surgery, including mitral valve repair and replacement, on the prognosis of patients with more than moderate IMR undergoing LVR.
2. Materials and methods
2.1. Study design
In this single-center cohort study, patients who underwent LVR followed by concomitant mitral valve repair or replacement for more than moderate (including moderate-to-severe and severe) IMR between March 2000 and March 2021 were retrospectively recruited. The effect of 2 different surgical methods, namely LVR + mitral valve repair and LVR + mitral valve replacement, on patient outcome was compared. This study was performed in accordance with the Declaration of Helsinki, and the institutional review board at Fuwai Hospital approved the use of clinical data for this study and waived individual informed consent.
2.2. Surgical techniques
LVR included 3 different surgical methods: linear ventriculoplasty, modified LVR, and endocardial patch reconstruction. The option used for LVR depended mainly on the personal preference of the surgeons. The surgical technique and the indications for the procedures were described in detail previously.[10,11]
2.3. Study population, definitions, data collection, and follow-up
Patients who fulfilled all of the following criteria were included: (1) >18 years of age, (2) underwent LVR for left ventricular aneurysm, and (3) received either mitral valve repair or replacement for more than moderate IMR. Patients who were <18 years old, or who received CBAG alone without LVR, were excluded. Patients were divided into repair (LVR + mitral valve repair) and replacement (LVR + mitral valve replacement) groups, according to the treatment of the mitral valve. All patients received guideline-directed medical treatment before and after the operation.
The primary outcome was the occurrence of major adverse cardiovascular and cerebrovascular events (MACCE), which was defined as the composite of all-cause death, non-fatal myocardial infarction, stroke, repeat revascularization or repeat valvular surgery, or heart failure leading to rehospitalization. Secondary outcomes were all-cause death and perioperative complications, as well as changes in ejection fraction (EF), left ventricular end-diastolic diameter (LVEDD), and level of IMR.
IMR was determined preoperatively using transthoracic echocardiography by examining the vena contracta and the regurgitant jet area at least for twice. Furthermore, all patients received transesophageal echocardiography for further evaluation of the level of IMR in the operating room before surgery. IMR was graded as described previously,[11] namely: 1+ = mild, 2+ = moderate, 3+ = moderate-to-severe, and 4+ = severe. More than moderate IMR was defined as a regurgitant level of 3+ or 4+. Operative death was defined as postoperative in-hospital death, or death within 30 d from surgery after discharge. Baseline and operative characteristics, as well as the early postoperative outcomes of patients, were obtained from electronic hospital records, while the follow-up results were derived from routine postoperative outpatient visit or telephone interviews.
2.4. Statistical analysis
The normality of continuous variables was confirmed by Shapiro-Wilk test, and continuous variables are presented as mean ± standard deviation (SD) and the significance of differences between groups tested by student t test if they follow a normal distribution, otherwise, they are presented as medians (Q1, Q3) and were tested by Wilcoxon rank-sum test. Categorical variables are presented as numbers (%) and the significance of differences between groups tested by Chi-square or Fisher exact test, as appropriate. Survival rates were calculated using the Kaplan-Meier method and compared using the log-rank test. Univariate Cox regression was performed to evaluate possible confounders of survival outcomes, followed by multivariate analysis. P value <0.05 was considered statistically significant. Statistical analyses were performed using Stata 17.0 (StataCorp, College Station, Texas, USA).
3. Results
3.1. Patient demographic and intraoperative data
A total of 74 patients were enrolled in this study, 59 of whom underwent LVR + mitral valve repair (repair group), while the remaining 15 received LVR + mitral valve replacement (replacement group). Patient baseline demographic characteristics are summarized in Table 1. There were no significant differences between the 2 groups in age, sex, body mass index, body surface area, smoking, or preoperative comorbidities. More patients in the repair group than the replacement group were complicated with triple vessel disease (64.4% vs. 33.3%, P = 0.029), while the proportion of left main disease was comparable between the groups (16.9% vs. 6.7%, P = 0.318). In addition, more patients in the repair group exhibited moderate-to-severe IMR than those in the replacement group (83.1% vs. 33.3%, P < 0.001), whereas EF and LVEDD were similar in the 2 groups (both P > 0.05).
Table 1 -
Baseline characteristics of
mitral valve repair and replacement groups in patients who underwent LVR complicated by more than moderate IMR.
| Variable |
Repair group (n = 59) |
Replacement group (n = 15) |
P
|
| Age (years), mean ± SD |
58.6 ± 11.1 |
58.5 ± 8.2 |
0.968 |
| Sex (male), n (%) |
50 (84.7) |
13 (86.7) |
0.852 |
| Body mass index (kg/m2), median (Q1, Q3) |
24.2 (22.1, 25.8) |
24.7 (23.0, 27.3) |
0.350 |
| Body surface area (m2), median (Q1, Q3) |
1.8 (1.7, 1.9) |
1.8 (1.7, 1.9) |
0.861 |
| Smoking, n (%) |
40 (67.8) |
10 (66.7) |
0.864 |
| Hypertension, n (%) |
30 (50.8) |
6 (40.0) |
0.453 |
| Dyslipidemia, n (%) |
32 (54.2) |
9 (64.3) |
0.496 |
| Diabetes mellitus, n (%) |
19 (32.2) |
4 (26.7) |
0.679 |
| Stroke, n (%) |
7 (11.9) |
3 (20.0) |
0.411 |
| Renal failure, n (%) |
4 (6.8) |
1 (6.7) |
>0.99 |
| Atrial fibrillation, n (%) |
2 (3.4) |
1 (6.7) |
0.499 |
| History of PCI, n (%) |
11 (18.6) |
1 (6.7) |
0.261 |
| NYHA III or IV, n (%) |
34 (57.6) |
12 (80.0) |
0.111 |
| Left main disease, n (%) |
10 (16.9) |
1 (6.7) |
0.318 |
| Triple vessel disease, n (%) |
38 (64.4) |
5 (33.3) |
0.029 |
| Position of aneurysm, n (%) |
|
|
0.836 |
| Anterior wall |
44 (74.6) |
11 (73.3) |
|
| Lateral wall |
2 (3.4) |
0 |
|
| Posterior-inferior wall |
13 (22.0) |
4 (26.7) |
|
| Left ventricular thrombus, n (%) |
12 (20.3) |
1 (6.7) |
0.189 |
| Ejection fraction (%), median (Q1, Q3) |
40.0 (35.0, 45.0) |
41.0 (35.0, 50.0) |
0.412 |
| LVEDD (mm), median (Q1, Q3) |
64.0 (60.0, 70.0) |
65.0 (61.0, 69.0) |
0.968 |
| Mitral regurgitation, n (%) |
|
|
<0.001 |
| Moderate-to-severe |
49 (83.1) |
5 (33.3) |
|
| Severe |
10 (16.9) |
10 (66.7) |
|
IMR: Ischemic mitral regurgitation; LVEDD: Left ventricular end-diastolic diameter; LVR: Left ventricular reconstruction; NYHA: New York Heart Association; PCI: Percutaneous coronary intervention; SD: Standard deviation.
Intraoperative characteristics of patients are presented in Table 2. The duration time of cardiopulmonary bypass, cross-clamp time, and the technique of LVR were comparable between the 2 groups. The rate of concomitant CABG was higher in the repair group than the replacement group, although the difference was not statistically significant (94.9% vs. 80.0%, P = 0.093). Furthermore, 2 patients switched from mitral valve repair to mitral valve replacement before leaving the operating room, due to failure to fully correct the IMR.
Table 2 -
Intraoperative characteristics of
mitral valve repair and replacement groups in patients who underwent LVR complicated by more than moderate IMR.
| Variable |
Repair group (n= 59) |
Replacement group (n = 15) |
P
|
| CPB duration (min), median (Q1, Q3) |
155.0 (121.0, 197.0) |
186.0 (96.0, 216.0) |
0.514 |
| Cross-clamp time (min), median (Q1, Q3) |
110.0 (76.0, 143.0) |
126.0 (60.0, 148.0) |
0.563 |
| LVR, n (%) |
|
|
0.813 |
| Linear ventriculoplasty |
48 (81.4) |
12 (80.0) |
|
| Modified ventricular reconstruction |
9 (15.3) |
3 (20.0) |
|
| Endocardial patch reconstruction |
2 (3.4) |
0 |
|
| Concomitant CABG, n (%) |
56 (94.9) |
12 (80.0) |
0.093 |
CABG: Coronary artery bypass grafting; CPB: Cardiopulmonary bypass; IMR: Ischemic mitral regurgitation; LVR: Left ventricular reconstruction.
3.2. Early postoperative results
Operative death of 1 patient in the repair group occurred. More patients in the repair group than the replacement group received ventricular assist therapy (22.0% vs. 0, P = 0.045), including intra-aortic balloon pumps (15.3%), ventricular assist device (3.4%), and extracorporeal membrane oxygenation (3.4%). Nevertheless, there were no significant differences in intubation time, intensive care unit stay, or rates of adverse events, including secondary thoracotomy for bleeding, new-onset stroke, and peak creatinine levels, between the 2 groups. Postoperative echocardiography showed that parameters, including EF and LVEDD as well as changes in these parameters when compared to the preoperative echocardiography, and the level of IMR, were comparable between the 2 groups. Early postoperative results are summarized in Table 3.
Table 3 -
Early postoperative results of
mitral valve repair and replacement groups in patients who underwent LVR complicated by more than moderate IMR.
| Variable |
Repair group (n = 59) |
Replacement group (n = 15) |
P
|
| Intubation (hours), median (Q1, Q3) |
24.0 (19.0, 45.0) |
39.0 (18.0, 43.0) |
0.753 |
| ICU stay (hours), median (Q1, Q3) |
112.5 (64.5, 159.0) |
91.5 (84.0, 130.0) |
0.495 |
| Assist devices, n (%) |
13 (22.0) |
0 |
0.045 |
| IABP usage |
9 (15.3) |
0 |
0.107 |
| ECMO |
2 (3.4) |
0 |
>0.990 |
| Ventricular assist device (other) |
2 (3.4) |
0 |
>0.990 |
| Thoracotomy for bleeding, n (%) |
3 (5.1) |
2 (13.3) |
0.265 |
| New-onset stroke, n (%) |
1 (1.7) |
2 (13.3) |
0.103 |
| Creatinine peak value, median (Q1, Q3) |
136.1 (106.5, 173.3) |
125.5 (114.1, 144.7) |
0.773 |
| Dialysis for renal dysfunction, n (%) |
3 (5.1) |
2 (13.3) |
0.256 |
| Operative death, n (%) |
1 (1.7) |
0 |
>0.990 |
| Ejection fraction (%), median (Q1, Q3) |
43.0 (38.0, 50.0) |
41.0 (40.0 45.0) |
0.803 |
| ∆ Ejection fraction (%), median (Q1, Q3) |
2.0 (–2.4, 10.0) |
3.0 (–4.4, 5.0) |
0.412 |
| LVEDD (mm), median (Q1, Q3) |
55.0 (51.0, 62.0) |
60.0 (52.0, 63.0) |
0.623 |
| ∆ LVEDD (mm), median (Q1, Q3) |
–8.0 (–13.0, –2.0) |
–6.0 (–12.0, –2.0) |
0.741 |
| Mitral regurgitation, n (%) |
|
|
0.096 |
| No or trace |
38 (64.4) |
13 (86.7) |
|
| Mild or moderate |
21 (35.6) |
2 (13.3) |
|
“∆” represents changes in parameters before and after the operation.
ECMO: Extracorporeal membrane oxygenation; IABP: Intra-aortic balloon pump; ICU: Intensive care unit; IMR: Ischemic mitral regurgitation; LVEDD: Left ventricular end-diastolic diameter; LVR: Left ventricular reconstruction.
Before and after comparative analysis indicated that postoperative EF was improved in the whole cohort (∆EF, 2.0 (–3.0, 7.0); P = 0.009), and that there was a significant reduction in LVEDD (∆LVEDD, –8.0 (–13.0, –2.0); P < 0.001) compared with preoperative parameters. When stratified by surgical procedure for mitral valve treatment, postoperative improvement of EF (∆EF, 2.0 (–2.4, 10.0); P = 0.011) and reduction of LVEDD (∆LVEDD, –8.0 (–13.0, –2.0)) differed significantly from preoperative echocardiography data in the mitral valve repair group, while only the reduction of LVEDD (∆LVEDD, –6.0 (–12.0, –2.0); P < 0.001) was statistically significant in the replacement group, while the improvement of EF was not (∆EF, 3.0 (–4.4, 5.0); P = 0.458). Changes in EF and LVEDD are illustrated in Figure 1.
;)
Figure 1:: Comparison of the trends in echocardiographic parameters of mitral valve repair and replacement groups in patients who underwent LVR complicated by more than moderate IMR. (A) Comparison of the change in ejection fraction. (B) Comparison of the change in left ventricular end-diastolic diameter. *P < 0.05 compared with preoperative parameters. IMR: Ischemic mitral regurgitation; LVR: Left ventricular reconstruction.
3.3. Follow-up results
Median follow-up time was 59.4 (34.0, 96.5) months. During follow-up, all-cause death was observed in 15 patients, 1 from hepatorenal failure and the remaining from cardiac death or for unknown reasons. Twenty-nine patients suffered from MACCE. The details of follow-up events are shown in Table 4. Overall survival rates at 1, 3, and 5 years were 90.3%, 87.0%, and 79.9% among the whole cohort, while MACCE-free survival rates were 87.5%, 81.3%, 62.9%, respectively. No difference in overall survival was observed between the 2 groups (HR, 1.10; 95% CI, 0.31–3.93; Plogrank = 0.888); however, the rate of MACCE-free survival was lower in the replacement group, although the difference did not reach the statistical significance (HR, 1.54; 95% CI, 0.65–3.65; Plogrank = 0.319). Comparisons of the survival outcomes are presented in Figure 2.
Table 4 -
Follow-up events of
mitral valve repair and replacement groups in patients who underwent LVR complicated by more than moderate IMR.
| Variable |
Repair group (n = 59) |
Replacement group (n = 15) |
P
|
| All-cause death |
12 (20.3) |
3 (20.0) |
0.888 |
| Myocardial infarction |
1 (1.7) |
0 |
– |
| Stroke |
3 (5.1) |
1 (6.7) |
– |
| Hospitalization for heart failure |
8 (13.6) |
3 (20.0) |
– |
| Repeat heart surgery |
1 (1.7) |
0 |
– |
| MACCE |
22 (37.3) |
7 (46.7) |
0.319 |
Values are presented as n (%). P calculated by log-rank test. “–” indicates the data are not available.
IMR: Ischemic mitral regurgitation; LVR: Left ventricular reconstruction; MACCE: Major adverse cardiovascular and cerebrovascular events.
Figure 2:: Cumulative survival during the follow-up of mitral valve repair and replacement groups in patients who underwent LVR complicated by more than moderate IMR. (A) Overall survival. (B) MACCE-free survival. IMR: Ischemic mitral regurgitation; LVR: Left ventricular reconstruction; MACCE: Major adverse cardiovascular and cerebrovascular events.
The results of univariate and multivariate Cox analysis are provided in Supplementary Table 1 (https://links.lww.com/CD9/A28) and Supplementary Table 2 (https://links.lww.com/CD9/A28). Variables with P < 0.05 in univariate analysis were considered potential confounders and included in the multivariate Cox analysis. After adjusting for confounders, there was no difference in overall survival (HR, 1.35; 95% CI, 0.37–4.88; PCox = 0.646) or the MACCE-free survival (HR, 1.41; 95% CI, 0.57–3.44; PCox = 0.455) between the 2 groups.
3.4. Follow-up echocardiography
Median echocardiographic follow-up time was 22.6 months. During follow-up, complete echocardiographic results were available from 46 (62.2%) patients. While no significant differences were observed in EF (repair group, 45.0 (39.0, 50.0); replacement group, 47.0 (30.0, 62.0); P = 0.825), LVEDD (repair group, 59.0 (56.0, 64.0); replacement group, 56.0 (53.0, 65.0); P = 0.579), or the changes in these parameters between the 2 groups, the replacement group was associated with greater improvement in mitral valve regurgitation (P = 0.041). Follow-up echocardiographic results are presented in Table 5.
Table 5 -
Follow-up echocardiography of
mitral valve repair and replacement groups in patients who underwent LVR complicated by more than moderate IMR.
| Variable |
Repair group (n = 37) |
Replacement group (n = 9) |
P
|
| Ejection fraction (%), median (Q1, Q3) |
45.0 (39.0, 50.0) |
47.0 (30.0, 62.0) |
0.825 |
| ∆Ejection fraction (%), median (Q1, Q3) |
1.0 (–3.0, 10.2) |
2.0 (–11.0, 2.0) |
0.542 |
| LVEDD (mm), median (Q1, Q3) |
59.0 (56.0, 64.0) |
56.0 (53.0, 65.0) |
0.579 |
| ∆LVEDD (mm), median (Q1, Q3) |
–4.0 (–7.0, 1.0) |
–1.0 (–11.0, 2.0) |
0.782 |
| Mitral regurgitation, n (%) |
|
|
0.041 |
| No or trace |
11 (29.7) |
7 (77.8) |
|
| Mild or moderate |
24 (64.9) |
2 (22.2) |
|
| More than moderate |
2 (5.4) |
0 |
|
IMR: Ischemic mitral regurgitation; LVEDD: Left ventricular end-diastolic diameter; LVR: Left ventricular reconstruction.
4. Discussion
In this retrospective cohort study, we observed that, in patients undergoing LVR for ventricular aneurysm, the effects of concomitant mitral valve repair and mitral valve replacement were comparable regarding MACCE-free and overall survival; however, mitral valve replacement was associated with a lower rate of use of perioperative ventricular assist device and greater improvement of IMR than mitral valve repair.
Treatment of IMR has been a great concern for cardiac surgeons in recent years. As ventricular remodeling caused by ischemia plays an important role in IMR development, myocardial revascularization to reverse the remodeling process is among the most important therapies for this population of patients; however, even complete revascularization of the culprit coronary artery may not always result in improvement of IMR, particularly in those with moderate or more than moderate regurgitation, compromising patient outcome.[12] Therefore, it is important to evaluate the necessity of concomitant mitral valve surgery. Studies on the surgical treatment of severe and moderate IMR have been published. Michler et al[13] reported in their randomized controlled trial that concomitant mitral valve repair increased the risk of neurological adverse events, while it did not improve the survival outcomes of patients undergoing CABG complicated by moderate IMR. In a prospective study, Goldstein et al[6] observed that chordal-sparing mitral valve replacement was superior to mitral valve repair for reducing mitral regurgitation, whereas no between-group differences in left ventricular reverse remodeling or 2-year survival were detected. Current clinical guidelines for the treatment of IMR are based primarily on randomized controlled trials,[5,14] and recommend chordal-sparing mitral valve replacement for severe IMR in patients undergoing CABG.
Ventricular aneurysm, which primarily occurs in the anterior area of the left ventricle, is among the most severe complications of myocardial infarction, and a substantial proportion of patients with ventricular aneurysm are complicated by IMR. Nevertheless, while there is evidence regarding the treatment of severe IMR during CABG, as mentioned elsewhere in this article, and studies show potential advantages (although without survival benefit) of additional mitral valve surgery in patients with moderate IMR undergoing CABG,[4,15–17] there is paucity of data on the treatment of more than moderate IMR during LVR. In our prior study, we reported comparable clinical outcomes between LVR and LVR plus mitral valve surgery.[11] Here, we conducted further investigation of the effect of mitral valve repair vs. replacement on patient prognosis. Our findings indicate that the effect of mitral valve repair and replacement concomitant to LVR on perioperative and late survival were comparable, as was event-free survival, defined as MACCE in this study. These results are consistent with those of previous studies, in which only patients undergoing CABG without LVR were included. Unlike organic mitral regurgitation, early studies reported that mitral valve repair, fails to show survival benefits in patients with IMR compared with mitral valve replacement.[18–20] Later, in a randomized controlled trial, Acker et al[21] observed that patients who underwent mitral valve repair showed comparable survival outcomes to those receiving mitral valve replacement at 1 year, which was sustained at later follow-up (2 years).[6] Therefore, in terms of survival, mitral valve repair and replacement might yield comparable outcomes in patients undergoing LVR and complicated by more than moderate IMR.
Studies demonstrate that persistent mitral regurgitation after LVR combined with CABG is a strong predictor of poor follow-up prognosis,[22] while other researchers report that concomitant mitral valve replacement is associated with reduced survival.[23] Menicanti et al[7] also reported that operative mortality was increased by 10% in patients requiring mitral valve repair or replacement, compared with those who did not require mitral valve surgery during LVR. Therefore, the decision on whether to repair or replace the mitral valve in this population of patients is critical. In our study, we observed that mitral valve replacement was associated with a lower rate of perioperative use of ventricular assist device. Furthermore, we found that mitral valve replacement reduced the recurrence rate of follow-up moderate or more than moderate IMR. These results are also consistent with those of prior studies on patients undergoing mitral valve surgery for more than moderate IMR, but without LVR.[6,20,21,24] A possible explanation for these results is the mechanism underlying IMR—left ventricular adverse remodeling. In primary mitral regurgitation, organic lesions of the mitral valve play an important role in the development of valvular dysfunction, causing remodeling of the left ventricle; however, in the development of the IMR, left ventricular remodeling, which is due to myocardial ischemia, is the cause, rather than the result, of mitral valve dysfunction. Even after complete revascularization, diseased coronary arteries cannot completely return to normal. Therefore, achievement of left ventricle reverse remodeling may be more difficult in patients with IMR than in those with primary mitral regurgitation. Consequently, while mitral valve repair is preferred for the treatment of primary mitral regurgitation,[25] mitral valve replacement may be more advantageous for preserving mitral valve function in patients with IMR of more than moderate level, which also seems to apply to patients undergoing LVR. Unfortunately, however, follow-up echocardiography was not available for all individuals who survived in this study, which may have compromised the representativeness of the population.
5. Limitations
First, this was a single-center retrospective cohort study; hence, bias caused by the study design could not be avoided. Second, our study was limited by a relatively small sample size, which may have compromised the power of statistical tests. Third, echocardiography results were not available for all patients in this study. In addition, follow-up echocardiography was not completed at the same time point for all patients, taking place at times ranging from a few months to several years; therefore, the comparability of the echocardiographic results may have been compromised to some extent. Finally, although we attempted to account for between-group confounding factors by conducting multivariate analysis, unknown bias may still have been present. Therefore, more studies with prospective design, larger sample size, and complete echocardiographic follow-up are needed.
6. Conclusions
In patients undergoing LVR and complicated by more than moderate IMR, both concomitant mitral valve repair and replacement can be successful, with comparable overall and MACCE-free survival. Furthermore, mitral valve replacement may be preferable over mitral valve repair for persistent correction of mitral dysfunction.
Funding
This work was supported by the National High Level Hospital Clinical Research Funding of the People’s Republic of China (2022-GSP-GG-30).
Author contributions
Xieraili Tiemuerniyazi conceptualized ideas, performed the study, conducted the analysis, and drafted the manuscript; Yangwu Song performed the study and revised the manuscript; Hanping Ma directed the analytic strategy and revised the manuscript; Fei Xu supervised the study from conception to completion; Wei Zhao supervised the study from conception to completion and revised drafts of the manuscript.
Conflicts of interest
None.
References
[1]. Bursi F, Enriquez-Sarano M, Jacobsen SJ, et al. Mitral regurgitation after myocardial infarction: a review. Am J Med. 2006;119(2):103–112. doi:10.1016/j.amjmed.2005.08.025.
[2]. Piérard LA, Carabello BA. Ischaemic mitral regurgitation: pathophysiology, outcomes and the conundrum of treatment. Eur Heart J. 2010;31(24):2996–3005. doi:10.1093/eurheartj/ehq411.
[3]. Bursi F, Enriquez-Sarano M, Nkomo VT, et al. Heart failure and death after myocardial infarction in the community: the emerging role of mitral regurgitation. Circulation. 2005;111(3):295–301. doi:10.1161/01.CIR.0000151097.30779.04.
[4]. Virk SA, Tian DH, Sriravindrarajah A, et al. Mitral valve surgery and coronary artery bypass grafting for moderate-to-severe
ischemic mitral regurgitation: meta-analysis of clinical and echocardiographic outcomes. J Thorac Cardiovasc Surg. 2017;154(1):127–136. doi:10.1016/j.jtcvs.2017.03.039.
[5]. Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2021;77(4):e25–25e197. doi:10.1016/j.jacc.2020.11.018.
[6]. Goldstein D, Moskowitz AJ, Gelijns AC, et al. Two-year outcomes of surgical treatment of severe
ischemic mitral regurgitation. N Engl J Med. 2016;374(4):344–353. doi:10.1056/NEJMoa1512913.
[7]. Menicanti L, Castelvecchio S, Ranucci M, et al. Surgical therapy for ischemic heart failure: single-center experience with surgical anterior ventricular restoration. J Thorac Cardiovasc Surg. 2007;134(2):433–441. doi:10.1016/j.jtcvs.2006.12.027.
[8]. Castelvecchio S, Garatti A, Gagliardotto PV, et al. Surgical ventricular reconstruction for ischaemic heart failure: state of the art. Eur Heart J Suppl. 2016;18(Suppl E):E8–8E14. doi:10.1093/eurheartj/suw028.
[9]. Petrus A, Klein P, Tops LF, et al. 10-year outcomes after
left ventricular reconstruction: rethinking the impact of mitral regurgitation. Ann Thorac Surg. 2019;108(1):81–88. doi:10.1016/j.athoracsur.2019.01.003.
[10]. Zheng Z, Fan H, Feng W, et al. Surgery of left ventricular aneurysm: a propensity score-matched study of outcomes following different repair techniques. Interact Cardiovasc Thorac Surg. 2009;9(3):431–436. doi:10.1510/icvts.2009.207134.
[11]. Song Y, Hu S, Sun H, et al. Results of
left ventricular reconstruction with and without mitral valve surgery. Ann Thorac Surg. 2020;109(3):753–761. doi:10.1016/j.athoracsur.2019.07.026.
[12]. Di Donato M, Frigiola A, Menicanti L, et al. Moderate
ischemic mitral regurgitation and coronary artery bypass surgery: effect of mitral repair on clinical outcome. J Heart Valve Dis. 2003;12(3):272–279.
[13]. Michler RE, Smith PK, Parides MK, et al. Two-year outcomes of surgical treatment of moderate
ischemic mitral regurgitation. N Engl J Med. 2016;374(20):1932–1941. doi:10.1056/NEJMoa1602003.
[14]. Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2022;43(7):561–632. doi:10.1093/eurheartj/ehab395.
[15]. Altarabsheh SE, Deo SV, Dunlay SM, et al. Meta-analysis of usefulness of concomitant
mitral valve repair or replacement for moderate
ischemic mitral regurgitation with coronary artery bypass grafting. Am J Cardiol. 2017;119(5):734–741. doi:10.1016/j.amjcard.2016.11.024.
[16]. Wang L, Li B, Liu C, et al. Short- and medium-term effects of combined mitral valve surgery and coronary artery bypass grafting versus coronary artery bypass grafting alone for patients with moderate
ischemic mitral regurgitation: a meta-analysis. J Cardiothorac Vasc Anesth. 2016;30(6):1578–1586. doi:10.1053/j.jvca.2016.06.032.
[17]. Zhang Y, Ma L, Zhao H. Efficacy of
mitral valve repair as an adjunct procedure to coronary artery bypass grafting in moderate
ischemic mitral regurgitation: a meta-analysis of randomized trials. J Card Surg. 2015;30(8):623–630. doi:10.1111/jocs.12585.
[18]. Magne J, Girerd N, Sénéchal M, et al. Mitral repair versus replacement for
ischemic mitral regurgitation: comparison of short-term and long-term survival. Circulation. 2009;120(11 Suppl):S104–S111. doi:10.1161/CIRCULATIONAHA.108.843995.
[19]. Lorusso R, Gelsomino S, Vizzardi E, et al.
Mitral valve repair or replacement for
ischemic mitral regurgitation? The Italian Study on the Treatment of
Ischemic Mitral Regurgitation (ISTIMIR). J Thorac Cardiovasc Surg. 2013;145(1):128–139; discussion 137-138. doi:10.1016/j.jtcvs.2012.09.042.
[20]. Chan V, Ruel M, Mesana TG.
Mitral valve replacement is a viable alternative to
mitral valve repair for
ischemic mitral regurgitation: a case-matched study. Ann Thorac Surg. 2011;92(4):1358–1365; discussion 1365–1366. doi:10.1016/j.athoracsur.2011.05.056.
[21]. Acker MA, Parides MK, Perrault LP, et al. Mitral-valve repair versus replacement for severe
ischemic mitral regurgitation. N Engl J Med. 2014;370(1):23–32. doi:10.1056/NEJMoa1312808.
[22]. Qin JX, Shiota T, McCarthy PM, et al. Importance of
mitral valve repair associated with
left ventricular reconstruction for patients with ischemic cardiomyopathy: a real-time three-dimensional echocardiographic study. Circulation. 2003;108(Suppl 1):II241–II246. doi:10.1161/01.cir.0000087653.99527.50.
[23]. Athanasuleas CL, Stanley AW Jr, Buckberg GD, et al. Surgical anterior ventricular endocardial restoration (SAVER) in the dilated remodeled ventricle after anterior myocardial infarction. RESTORE group. Reconstructive endoventricular surgery, returning torsion original radius elliptical shape to the LV. J Am Coll Cardiol. 2001;37(5):1199–1209. doi:10.1016/s0735-1097(01)01119-6.
[24]. Wang Y, Shi X, Wen M, et al. Repair or replace
ischemic mitral regurgitation during coronary artery bypass grafting? A meta-analysis. J Cardiothorac Surg. 2016;11(1):141. doi:10.1186/s13019-016-0536-6.
[25]. Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;143(5):e72–72e227. doi:10.1161/CIR.0000000000000923.
