title: Outcomes of coronary artery bypass grafting and reduction annuloplasty for functional ischemic mitral regurgitation: a prospective multicenter study (Randomized Evaluation of a Surgical Treatment for Off-Pump Repair of the Mitral Valve).
abstract: OBJECTIVE
  Functional ischemic mitral regurgitation is a complication of ventricular remodeling; standard therapy is reduction annuloplasty and coronary artery bypass grafting. Unfortunately, outcomes are retrospective and contradictory. We report a multicenter study that documents the outcomes of reduction annuloplasty for functional ischemic mitral regurgitation.
  
  
  METHODS
  Twenty-one centers randomized 75 patients to the coronary artery bypass grafting + reduction annuloplasty subgroup that was the control arm of the Randomized Evaluation of a Surgical Treatment for Off-pump Repair of the Mitral Valve trial. Entry criteria included patients requiring revascularization, patients with severe or symptomatic moderate functional ischemic mitral regurgitation, an ejection fraction 25% or greater, a left ventricular end-diastolic dimension 7.0 cm or less, and more than 30 days since acute myocardial infarction. All echocardiograms were independently scored by a core laboratory. Reduction annuloplasty was achieved by device annuloplasty. Two patients underwent immediate intraoperative conversion to a valve replacement because reduction annuloplasty was unable to correct mitral regurgitation; as-treated results are presented.
  
  
  RESULTS
  Thirty-day mortality was 4.1% (3/73). Patients received an average of 2.8 bypass grafts. Mean follow-up was 24.6 months. Mitral regurgitation was reduced from 2.6 ± 0.8 preoperatively to 0.3 ± 0.6 at 2 years. Freedom from death or valve reoperation was 78% ± 5% at 2 years. There was significant improvement in ejection fraction and New York Heart Association class with reduction of left ventricular end-diastolic dimension. Cox regression analyses suggested that increasing age (P = .001; hazard ratio, 1.16 per year; 95% confidence interval, 1.06-1.26) and renal disease (P = .018; hazard ratio, 3.48; 95% confidence interval, 1.25-9.72) were associated with decreased survival.
  
  
  CONCLUSIONS
  Coronary artery bypass grafting + reduction annuloplasty for functional ischemic mitral regurgitation predictably reduces mitral regurgitation and relieves symptoms. This treatment of moderate to severe mitral regurgitation is associated with improved indices of ventricular function, improved New York Heart Association class, and excellent freedom from recurrent mitral insufficiency. Although long-term prognosis remains guarded, this multicenter study delineates the intermediate-term benefits of such an approach.
authors.affiliation: New York University School of Medicine, New York, NY 10016, USA. Eugene.grossi@nyumc.org
authors.forename: Eugene A
authors.initials: EA
authors.lastname: Grossi
authors.forename: Y Joseph
authors.initials: YJ
authors.lastname: Woo
authors.forename: Nirav
authors.initials: N
authors.lastname: Patel
authors.forename: Judith D
authors.initials: JD
authors.lastname: Goldberg
authors.forename: Charles F
authors.initials: CF
authors.lastname: Schwartz
authors.forename: Valavanur A
authors.initials: VA
authors.lastname: Subramanian
authors.forename: Christopher
authors.initials: C
authors.lastname: Genco
authors.forename: Scott M
authors.initials: SM
authors.lastname: Goldman
authors.forename: Marco A
authors.initials: MA
authors.lastname: Zenati
authors.forename: J Alan
authors.initials: JA
authors.lastname: Wolfe
authors.forename: Yugal K
authors.initials: YK
authors.lastname: Mishra
authors.forename: Naresh
authors.initials: N
authors.lastname: Trehan
mesh_terms: D000368:Aged; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000401:mortality; D057239:Early Termination of Clinical Trials; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D006801:Humans; D008875:Middle Aged; D058386:Mitral Valve Annuloplasty / Q000009:adverse effects / Q000401:mortality; D008944:Mitral Valve Insufficiency / Q000000981:diagnostic imaging / Q000209:etiology / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D017202:Myocardial Ischemia / Q000150:complications* / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology; D016016:Proportional Hazards Models; D011446:Prospective Studies; D020127:Recovery of Function; D012086:Reoperation; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D013318:Stroke Volume; D013997:Time Factors; D016896:Treatment Outcome; D014463:Ultrasonography; D014481:United States; D016277:Ventricular Function, Left; D020257:Ventricular Remodeling