Mitral valve relpair and revascularization for ischemic mitral regurgitation: predictors of operative mortality and survival.
OBJECTIVE
Surgery for ischemic mitral regurgitation (IMR) is required in 4-5% of patients subjected to coronary artery surgery, and may be challenging. The study aim was to determine outcome following mitral valve repair and myocardial revascularization for moderate-to-severe IMR.


METHODS
A total of 102 patients (mean age 68+/-7 years) underwent mitral valve repair for IMR between 1998 and 2001 at the authors' unit. Among patients, 28 had acute and 74 chronic mitral regurgitation (MR). Valve repair was achieved with an annuloplasty ring in all 102 patients, while 99 underwent concomitant myocardial revascularization. Preoperatively, 69 patients had MR grade III-IV, 62 had CCS angina class III-IV, 59 were in NYHA class II-IV, 81 had impaired left ventricular function, and 10 were in cardiogenic shock. Follow up was 100% complete (mean 14+/-7 months; range: 0-38 months).


RESULTS
Overall operative mortality was 8.8% (n = 9) (17.8% for acute IMR, 5.4% for chronic, p = 0.048). On multiple logistic regression analysis, cardiogenic shock (p = 0.028) was the only significant risk factor for operative death. There were 11 late deaths. Kaplan-Meier survival at one and three years was 82+/-4% and 79+/-4%, respectively. On Cox proportional hazards regression model, preoperative left ventricular end-systolic diameter (LVESD) >4.5 cm (p = 0.01) and NYHA class III-IV (p = 0.02) were independent adverse predictors of survival. Three patients required reoperation. Kaplan-Meier three-year freedom from reoperation was 97+/-2%.


CONCLUSIONS
Surgery for IMR carries a considerable, but acceptable, operative risk and provides satisfactory freedom from reoperation and mid-term survival. Cardiogenic shock before surgery is the major determinant of an unfavorable in-hospital outcome. LVESD >4.5 cm and poor preoperative NYHA status limit the probability of late survival. The study results support early surgical intervention for IMR, before ventricular dilatation occurs.
Akar
A Ruchan
AR
Department of Cardiothoracic Surgery and Cardiology, University Hospitals of Leicester, UK.
Doukas
George
G
Szafranek
Adam
A
Alexiou
Christos
C
Boehm
Maria C
MC
Chin
Derek
D
Sosnowski
Andrzej
A
Spyt
Tom J
TJ
D000368:Aged; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D000925:Anticoagulants / Q000627:therapeutic use; D002423:Cause of Death; D001026:Coronary Artery Bypass / Q000401:mortality; D005260:Female; D005500:Follow-Up Studies; D019918:Heart Valve Prosthesis Implantation / Q000401:mortality; D006801:Humans; D000960:Hypolipidemic Agents / Q000627:therapeutic use; D007423:Intra-Aortic Balloon Pumping / Q000401:mortality; D007511:Ischemia / Q000188:drug therapy / Q000453:epidemiology / Q000601:surgery*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D008944:Mitral Valve Insufficiency / Q000188:drug therapy / Q000453:epidemiology / Q000601:surgery*; D011183:Postoperative Complications / Q000188:drug therapy / Q000453:epidemiology / Q000209:etiology; D011237:Predictive Value of Tests; D012086:Reoperation; D012307:Risk Factors; D012720:Severity of Illness Index; D013318:Stroke Volume / Q000502:physiology; D013997:Time Factors; D016896:Treatment Outcome; D006113:United Kingdom / Q000453:epidemiology
D000806:Angiotensin-Converting Enzyme Inhibitors; D000889:Anti-Arrhythmia Agents; D000925:Anticoagulants; D000960:Hypolipidemic Agents