title: Surgical treatment of moderate ischemic mitral regurgitation.
abstract: BACKGROUND
  Ischemic mitral regurgitation is associated with increased mortality and morbidity. For surgical patients with moderate regurgitation, the benefits of adding mitral-valve repair to coronary-artery bypass grafting (CABG) are uncertain.
  
  
  METHODS
  We randomly assigned 301 patients with moderate ischemic mitral regurgitation to CABG alone or CABG plus mitral-valve repair (combined procedure). The primary end point was the left ventricular end-systolic volume index (LVESVI), a measure of left ventricular remodeling, at 1 year. This end point was assessed with the use of a Wilcoxon rank-sum test in which deaths were categorized as the lowest LVESVI rank.
  
  
  RESULTS
  At 1 year, the mean LVESVI among surviving patients was 46.1±22.4 ml per square meter of body-surface area in the CABG-alone group and 49.6±31.5 ml per square meter in the combined-procedure group (mean change from baseline, -9.4 and -9.3 ml per square meter, respectively). The rate of death was 6.7% in the combined-procedure group and 7.3% in the CABG-alone group (hazard ratio with mitral-valve repair, 0.90; 95% confidence interval, 0.38 to 2.12; P=0.81). The rank-based assessment of LVESVI at 1 year (incorporating deaths) showed no significant between-group difference (z score, 0.50; P=0.61). The addition of mitral-valve repair was associated with a longer bypass time (P<0.001), a longer hospital stay after surgery (P=0.002), and more neurologic events (P=0.03). Moderate or severe mitral regurgitation was less common in the combined-procedure group than in the CABG-alone group (11.2% vs. 31.0%, P<0.001). There were no significant between-group differences in major adverse cardiac or cerebrovascular events, deaths, readmissions, functional status, or quality of life at 1 year.
  
  
  CONCLUSIONS
  In patients with moderate ischemic mitral regurgitation, the addition of mitral-valve repair to CABG did not result in a higher degree of left ventricular reverse remodeling. Mitral-valve repair was associated with a reduced prevalence of moderate or severe mitral regurgitation but an increased number of untoward events. Thus, at 1 year, this trial did not show a clinically meaningful advantage of adding mitral-valve repair to CABG. Longer-term follow-up may determine whether the lower prevalence of mitral regurgitation translates into a net clinical benefit. (Funded by the National Institutes of Health and the Canadian Institutes of Health Research; ClinicalTrials.gov number, NCT00806988.).
authors.affiliation: The authors' affiliations are listed in the Appendix.
authors.forename: Peter K
authors.initials: PK
authors.lastname: Smith
authors.forename: John D
authors.initials: JD
authors.lastname: Puskas
authors.forename: Deborah D
authors.initials: DD
authors.lastname: Ascheim
authors.forename: Pierre
authors.initials: P
authors.lastname: Voisine
authors.forename: Annetine C
authors.initials: AC
authors.lastname: Gelijns
authors.forename: Alan J
authors.initials: AJ
authors.lastname: Moskowitz
authors.forename: Judy W
authors.initials: JW
authors.lastname: Hung
authors.forename: Michael K
authors.initials: MK
authors.lastname: Parides
authors.forename: Gorav
authors.initials: G
authors.lastname: Ailawadi
authors.forename: Louis P
authors.initials: LP
authors.lastname: Perrault
authors.forename: Michael A
authors.initials: MA
authors.lastname: Acker
authors.forename: Michael
authors.initials: M
authors.lastname: Argenziano
authors.forename: Vinod
authors.initials: V
authors.lastname: Thourani
authors.forename: James S
authors.initials: JS
authors.lastname: Gammie
authors.forename: Marissa A
authors.initials: MA
authors.lastname: Miller
authors.forename: Pierre
authors.initials: P
authors.lastname: Pagé
authors.forename: Jessica R
authors.initials: JR
authors.lastname: Overbey
authors.forename: Emilia
authors.initials: E
authors.lastname: Bagiella
authors.forename: François
authors.initials: F
authors.lastname: Dagenais
authors.forename: Eugene H
authors.initials: EH
authors.lastname: Blackstone
authors.forename: Irving L
authors.initials: IL
authors.lastname: Kron
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Goldstein
authors.forename: Eric A
authors.initials: EA
authors.lastname: Rose
authors.forename: Ellen G
authors.initials: EG
authors.lastname: Moquete
authors.forename: Neal
authors.initials: N
authors.lastname: Jeffries
authors.forename: Timothy J
authors.initials: TJ
authors.lastname: Gardner
authors.forename: Patrick T
authors.initials: PT
authors.lastname: O'Gara
authors.forename: John H
authors.initials: JH
authors.lastname: Alexander
authors.forename: Robert E
authors.initials: RE
authors.lastname: Michler
mesh_terms: D000368:Aged; D002318:Cardiovascular Diseases / Q000209:etiology / Q000401:mortality; D001026:Coronary Artery Bypass; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D008944:Mitral Valve Insufficiency / Q000209:etiology / Q000601:surgery*; D017202:Myocardial Ischemia / Q000150:complications / Q000601:surgery*; D011183:Postoperative Complications / Q000453:epidemiology; D011788:Quality of Life; D020257:Ventricular Remodeling