title: Surgical revascularization is associated with maximal survival in patients with ischemic mitral regurgitation: a 20-year experience.
abstract: BACKGROUND
  The optimal treatment for ischemic mitral regurgitation remains actively debated. Our objective was to evaluate the relationship between ischemic mitral regurgitation treatment strategy and survival.
  
  
  RESULTS
  We retrospectively reviewed patients at our institution diagnosed with significant coronary artery disease and moderate or severe ischemic mitral regurgitation from 1990 to 2009, categorized by medical treatment alone, percutaneous coronary intervention, coronary artery bypass grafting (CABG), or CABG plus mitral valve repair or replacement. Kaplan-Meier methods and multivariable Cox proportional hazards analyses were performed to assess the relationship between treatment strategy and survival, with the use of propensity scores to account for nonrandom treatment assignment. A total of 4989 patients were included: medical treatment alone=36%, percutaneous coronary intervention=26%, CABG=33%, and CABG plus mitral valve repair or replacement=5%. Median follow-up was 5.37 years. Compared with medical treatment alone, significantly lower mortality was observed in patients treated with percutaneous coronary intervention (adjusted hazard ratio, 0.83; 95% confidence interval, 0.76-0.92; P=0.0002), CABG (adjusted hazard ratio, 0.56; 95% confidence interval, 0.51-0.62; P<0.0001), and CABG plus mitral valve repair or replacement (adjusted hazard ratio, 0.69; 95% confidence interval, 0.57-0.82; P<0.0001). There was no significant difference in these results based on mitral regurgitation severity.
  
  
  CONCLUSIONS
  Patients with significant coronary artery disease and moderate or severe ischemic mitral regurgitation undergoing CABG alone demonstrated the lowest risk of death. CABG with or without mitral valve surgery was associated with lower mortality than either percutaneous coronary intervention or medical treatment alone.
authors.affiliation: From the Department of Surgery; The Division of Cardiovascular and Thoracic Surgery (A.W.C., J.B.W., M.A.D., C.A.M., P.K.S.); Duke Clinical Research Institute (J.B.W., E.H., L.K.S., R.D.L., J.H.A., E.J.V.); Department of Medicine, Division of Cardiology (Z.S., R.D.L., J.H.A., E.J.V.); and Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Critical Care Medicine (J.P.M.), Duke Medicine, Durham, NC.
authors.forename: Anthony W
authors.initials: AW
authors.lastname: Castleberry
authors.affiliation: From the Department of Surgery; The Division of Cardiovascular and Thoracic Surgery (A.W.C., J.B.W., M.A.D., C.A.M., P.K.S.); Duke Clinical Research Institute (J.B.W., E.H., L.K.S., R.D.L., J.H.A., E.J.V.); Department of Medicine, Division of Cardiology (Z.S., R.D.L., J.H.A., E.J.V.); and Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Critical Care Medicine (J.P.M.), Duke Medicine, Durham, NC.
authors.forename: Judson B
authors.initials: JB
authors.lastname: Williams
authors.affiliation: From the Department of Surgery; The Division of Cardiovascular and Thoracic Surgery (A.W.C., J.B.W., M.A.D., C.A.M., P.K.S.); Duke Clinical Research Institute (J.B.W., E.H., L.K.S., R.D.L., J.H.A., E.J.V.); Department of Medicine, Division of Cardiology (Z.S., R.D.L., J.H.A., E.J.V.); and Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Critical Care Medicine (J.P.M.), Duke Medicine, Durham, NC.
authors.forename: Mani A
authors.initials: MA
authors.lastname: Daneshmand
authors.affiliation: From the Department of Surgery; The Division of Cardiovascular and Thoracic Surgery (A.W.C., J.B.W., M.A.D., C.A.M., P.K.S.); Duke Clinical Research Institute (J.B.W., E.H., L.K.S., R.D.L., J.H.A., E.J.V.); Department of Medicine, Division of Cardiology (Z.S., R.D.L., J.H.A., E.J.V.); and Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Critical Care Medicine (J.P.M.), Duke Medicine, Durham, NC.
authors.forename: Emily
authors.initials: E
authors.lastname: Honeycutt
authors.affiliation: From the Department of Surgery; The Division of Cardiovascular and Thoracic Surgery (A.W.C., J.B.W., M.A.D., C.A.M., P.K.S.); Duke Clinical Research Institute (J.B.W., E.H., L.K.S., R.D.L., J.H.A., E.J.V.); Department of Medicine, Division of Cardiology (Z.S., R.D.L., J.H.A., E.J.V.); and Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Critical Care Medicine (J.P.M.), Duke Medicine, Durham, NC.
authors.forename: Linda K
authors.initials: LK
authors.lastname: Shaw
authors.affiliation: From the Department of Surgery; The Division of Cardiovascular and Thoracic Surgery (A.W.C., J.B.W., M.A.D., C.A.M., P.K.S.); Duke Clinical Research Institute (J.B.W., E.H., L.K.S., R.D.L., J.H.A., E.J.V.); Department of Medicine, Division of Cardiology (Z.S., R.D.L., J.H.A., E.J.V.); and Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Critical Care Medicine (J.P.M.), Duke Medicine, Durham, NC.
authors.forename: Zainab
authors.initials: Z
authors.lastname: Samad
authors.affiliation: From the Department of Surgery; The Division of Cardiovascular and Thoracic Surgery (A.W.C., J.B.W., M.A.D., C.A.M., P.K.S.); Duke Clinical Research Institute (J.B.W., E.H., L.K.S., R.D.L., J.H.A., E.J.V.); Department of Medicine, Division of Cardiology (Z.S., R.D.L., J.H.A., E.J.V.); and Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Critical Care Medicine (J.P.M.), Duke Medicine, Durham, NC.
authors.forename: Renato D
authors.initials: RD
authors.lastname: Lopes
authors.affiliation: From the Department of Surgery; The Division of Cardiovascular and Thoracic Surgery (A.W.C., J.B.W., M.A.D., C.A.M., P.K.S.); Duke Clinical Research Institute (J.B.W., E.H., L.K.S., R.D.L., J.H.A., E.J.V.); Department of Medicine, Division of Cardiology (Z.S., R.D.L., J.H.A., E.J.V.); and Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Critical Care Medicine (J.P.M.), Duke Medicine, Durham, NC.
authors.forename: John H
authors.initials: JH
authors.lastname: Alexander
authors.affiliation: From the Department of Surgery; The Division of Cardiovascular and Thoracic Surgery (A.W.C., J.B.W., M.A.D., C.A.M., P.K.S.); Duke Clinical Research Institute (J.B.W., E.H., L.K.S., R.D.L., J.H.A., E.J.V.); Department of Medicine, Division of Cardiology (Z.S., R.D.L., J.H.A., E.J.V.); and Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Critical Care Medicine (J.P.M.), Duke Medicine, Durham, NC.
authors.forename: Joseph P
authors.initials: JP
authors.lastname: Mathew
authors.affiliation: From the Department of Surgery; The Division of Cardiovascular and Thoracic Surgery (A.W.C., J.B.W., M.A.D., C.A.M., P.K.S.); Duke Clinical Research Institute (J.B.W., E.H., L.K.S., R.D.L., J.H.A., E.J.V.); Department of Medicine, Division of Cardiology (Z.S., R.D.L., J.H.A., E.J.V.); and Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Critical Care Medicine (J.P.M.), Duke Medicine, Durham, NC.
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Velazquez
authors.affiliation: From the Department of Surgery; The Division of Cardiovascular and Thoracic Surgery (A.W.C., J.B.W., M.A.D., C.A.M., P.K.S.); Duke Clinical Research Institute (J.B.W., E.H., L.K.S., R.D.L., J.H.A., E.J.V.); Department of Medicine, Division of Cardiology (Z.S., R.D.L., J.H.A., E.J.V.); and Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Critical Care Medicine (J.P.M.), Duke Medicine, Durham, NC.
authors.forename: Carmelo A
authors.initials: CA
authors.lastname: Milano
authors.affiliation: From the Department of Surgery; The Division of Cardiovascular and Thoracic Surgery (A.W.C., J.B.W., M.A.D., C.A.M., P.K.S.); Duke Clinical Research Institute (J.B.W., E.H., L.K.S., R.D.L., J.H.A., E.J.V.); Department of Medicine, Division of Cardiology (Z.S., R.D.L., J.H.A., E.J.V.); and Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Critical Care Medicine (J.P.M.), Duke Medicine, Durham, NC. peter.smith@dm.duke.edu.
authors.forename: Peter K
authors.initials: PK
authors.lastname: Smith
mesh_terms: D000368:Aged; D001026:Coronary Artery Bypass / Q000401:mortality; D016206:Databases, Bibliographic / Q000706:statistics & numerical data; D005260:Female; D005500:Follow-Up Studies; D019918:Heart Valve Prosthesis Implantation / Q000401:mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000601:surgery; D008944:Mitral Valve Insufficiency / Q000401:mortality* / Q000628:therapy*; D017202:Myocardial Ischemia / Q000401:mortality* / Q000628:therapy*; D009204:Myocardial Revascularization / Q000401:mortality*; D062645:Percutaneous Coronary Intervention / Q000401:mortality; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D015607:Stents / Q000706:statistics & numerical data
keywords: ischemia; mitral valve; revascularization; stent
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