title: Mitral valve repair versus replacement in patients with ischaemic mitral regurgitation and depressed ejection fraction: risk factors for early and mid-term mortality†.
abstract: OBJECTIVE
  Mitral valve (MV) surgery for ischaemic mitral regurgitation (IMR) in patients with depressed left ventricular ejection fraction (LVEF) is associated with poor outcomes. The optimal surgical strategy for IMR in these patients remains controversial. The objective of this study was to compare the early mortality and mid-term survival of MV repair versus MV replacement in patients with IMR and depressed LVEF undergoing coronary artery bypass grafting (CABG).
  
  
  METHODS
  A retrospective, observational, cohort study was undertaken of prospectively collected data on 126 consecutive CABG patients with IMR and LVEF <40% undergoing either MV repair (n = 98, 78%) or MV replacement (n = 28, 22%) between July 2002 and February 2011.
  
  
  RESULTS
  The overall mortality rate was 7.9% (n = 10). MV replacement was associated with a 4-fold increase in the risk of death compared with MV repair [17.9%, n = 5 vs 5.1%, n = 5; odds ratio (OR) 4.04, 95% confidence interval (CI) 1.08-15.1, P = 0.04]. However, after adjusting for preoperative risk factors, the type of surgical procedure was not an independent risk factor for early mortality (OR 0.1, 95% CI 0.01-31, P = 0.7). Multivariable analysis showed that preoperative LVEF (OR 0.8, 95% CI 0.6-0.9, P = 0.018), preoperative B-type natriuretic peptide (BNP) levels (OR 1.01, 95% CI 1-1.02, P = 0.025), preoperative left ventricle end-systolic diameter (OR 0.8, 95% CI 0.7-1.0, P = 0.05) and preoperative left atrial diameter (OR 1.3, 95% CI 1.0-1.6, P = 0.015) were independent risk factors of early mortality. At the median follow-up of 45 months (interquartile range 20-68 months), the mid-term survival rate was 74% in the MV repair group and 70% in the MV replacement group (P = 0.08). At follow-up, predictors of worse survival were BNP levels [hazard ratio (HR) 1.0, 95% CI 1.0-1.01, P = 0.047], preoperative renal failure (HR 4.6, 95% CI 1.1-20.3, P = 0.039) and preoperative atrial fibrillation (HR 3.3, 95% CI 1.1-10, P = 0.032).
  
  
  CONCLUSIONS
  MV repair in CABG patients with IMR and depressed LVEF is not superior to MV replacement with regard to operative early mortality and mid-term survival.
authors.affiliation: Department of Adult Cardiac Surgery, Fondazione Toscana G. Monasterio, Massa, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Lio
authors.affiliation: Department of Adult Cardiac Surgery, Fondazione Toscana G. Monasterio, Massa, Italy Bristol Heart Institute, University of Bristol, UK antoniomiceli79@alice.it.
authors.forename: Antonio
authors.initials: A
authors.lastname: Miceli
authors.affiliation: Department of Adult Cardiac Surgery, Fondazione Toscana G. Monasterio, Massa, Italy.
authors.forename: Egidio
authors.initials: E
authors.lastname: Varone
authors.affiliation: Department of Adult Cardiac Surgery, Fondazione Toscana G. Monasterio, Massa, Italy.
authors.forename: Daniele
authors.initials: D
authors.lastname: Canarutto
authors.affiliation: Department of Adult Cardiac Surgery, Fondazione Toscana G. Monasterio, Massa, Italy.
authors.forename: Gioia
authors.initials: G
authors.lastname: Di Stefano
authors.affiliation: Department of Adult Cardiac Surgery, Fondazione Toscana G. Monasterio, Massa, Italy.
authors.forename: Francesca
authors.initials: F
authors.lastname: Della Pina
authors.affiliation: Department of Adult Cardiac Surgery, Fondazione Toscana G. Monasterio, Massa, Italy.
authors.forename: Daniyar
authors.initials: D
authors.lastname: Gilmanov
authors.affiliation: Department of Adult Cardiac Surgery, Fondazione Toscana G. Monasterio, Massa, Italy.
authors.forename: Michele
authors.initials: M
authors.lastname: Murzi
authors.affiliation: Department of Adult Cardiac Surgery, Fondazione Toscana G. Monasterio, Massa, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Solinas
authors.affiliation: Department of Adult Cardiac Surgery, Fondazione Toscana G. Monasterio, Massa, Italy.
authors.forename: Mattia
authors.initials: M
authors.lastname: Glauber
mesh_terms: D000368:Aged; D016009:Chi-Square Distribution; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality*; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000503:physiopathology / Q000601:surgery*; D058386:Mitral Valve Annuloplasty / Q000009:adverse effects / Q000401:mortality*; D008944:Mitral Valve Insufficiency / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D015999:Multivariate Analysis; D017202:Myocardial Ischemia / Q000150:complications* / Q000401:mortality / Q000503:physiopathology; D016017:Odds Ratio; D012189:Retrospective Studies; D012307:Risk Factors; D013318:Stroke Volume; D013997:Time Factors; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000503:physiopathology*; D016277:Ventricular Function, Left
keywords: Ischaemic mitral regurgitation; Left ventricular dysfunction; Mitral valve surgery