title: Ischemic mitral regurgitation: revascularization alone versus revascularization and mitral valve repair.
abstract: BACKGROUND
  In this study we compared the surgical management of ischemic mitral regurgitation (IMR) by revascularization alone and by revascularization combined with mitral valve repair.
  
  
  METHODS
  We studied 355 patients who underwent revascularization alone (n = 168) or revascularization combined with mitral valve repair (n = 187) for IMR from March 1994 to September 2003. Preoperative and operative characteristics, postoperative mitral regurgitation severity, operative mortality, and late survival were examined for each surgical group.
  
  
  RESULTS
  No differences were noted between the two groups in age, sex, history of diabetes or hypertension, and number of bypass grafts. The combined surgical group had a lower preoperative left ventricular ejection fraction (0.38 +/- 0.14 versus 0.44 +/- 0.15), greater severity of IMR, higher frequency of prior myocardial infarction, and longer cross-clamp and pump times (p < 0.01). The combined surgical group had a greater reduction in IMR grade (2.7 +/- 0.1 grades versus 0.2 +/- 0.1 grade), a lower postoperative IMR grade (0.9 +/- 0.1 versus 2.3 +/- 0.1), and a higher success with reduction of IMR by two or more grades (89% versus 11%) (p < 0.001). In patients with 3+ or 4+ IMR, both groups had similar operative mortality (11.0% in the combined group compared with 4.7% for revascularization alone, p = 0.11) and actuarial survival at 5 years (44% +/- 5% versus 41% +/- 7%, p = 0.53). Independently predictive of higher early mortality (< or = 30 days) by Cox analysis were longer pump time (p < 0.001) and older age (p < 0.02). Predictive of late mortality (> 30 days) were older age (p < 0.001), fewer bypass grafts (p < 0.01), and lower ejection fraction (p < 0.01). After adjustment for these variables, there was a trend (p = 0.08) toward a higher late survival with the combined surgical procedure.
  
  
  CONCLUSIONS
  In patients with IMR, combined mitral valve repair and revascularization resulted in less postoperative mitral regurgitation and similar 5-year survival when compared with revascularization alone. Attempts to reduce pump time by using off-pump techniques may reduce early mortality in these high-risk patients.
authors.affiliation: Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California 90048-1865, USA.
authors.forename: Yong-Hwan
authors.initials: YH
authors.lastname: Kim
authors.forename: Lawrence S C
authors.initials: LS
authors.lastname: Czer
authors.forename: Harmik J
authors.initials: HJ
authors.lastname: Soukiasian
authors.forename: Michele
authors.initials: M
authors.lastname: De Robertis
authors.forename: Kathy E
authors.initials: KE
authors.lastname: Magliato
authors.forename: Carlos
authors.initials: C
authors.lastname: Blanche
authors.forename: Sharo S
authors.initials: SS
authors.lastname: Raissi
authors.forename: James
authors.initials: J
authors.lastname: Mirocha
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Siegel
authors.forename: Robert M
authors.initials: RM
authors.lastname: Kass
authors.forename: Alfredo
authors.initials: A
authors.lastname: Trento
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015150:Echocardiography, Doppler; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D008944:Mitral Valve Insufficiency / Q000601:surgery*; D009203:Myocardial Infarction / Q000150:complications; D017202:Myocardial Ischemia / Q000209:etiology*; D009204:Myocardial Revascularization / Q000379:methods*; D012189:Retrospective Studies; D012720:Severity of Illness Index; D016019:Survival Analysis; D016896:Treatment Outcome