Two-Year Outcomes of Surgical Treatment of Severe Ischemic Mitral Regurgitation

Abstract

BACKGROUND In a randomized trial comparing mitral-valve repair with mitral-valve replacement in patients with severe ischemic mitral regurgitation, we found no significant difference in the left ventricular end-systolic volume index (LVESVI), survival, or adverse events at 1 year after surgery. However, patients in the repair group had significantly more recurrences of moderate or severe mitral regurgitation. We now report the 2-year out-comes of this trial. METHODS We randomly assigned 251 patients to mitral-valve repair or replacement. Patients were followed for 2 years, and clinical and echocardiographic outcomes were assessed. RESULTS Among surviving patients, the mean (±SD) 2-year LVESVI was 52.6±27.7 ml per square meter of body-surface area with mitral-valve repair and 60.6±39.0 ml per square meter with mitral-valve replacement (mean changes from baseline, −9.0 ml per square meter and −6.5 ml per square meter, respectively). Two-year mortality was 19.0% in the repair group and 23.2% in the replacement group (hazard ratio in the repair group, 0.79; 95% confidence interval, 0.46 to 1.35; P = 0.39). The rank-based assessment of LVESVI at 2 years (incorporating deaths) showed no significant between-group difference (z score = −1.32, P = 0.19). The rate of recurrence of moderate or severe mitral regurgitation over 2 years was higher in the repair group than in the replacement group (58.8% vs. 3.8%, P<0.001). There were no significant between-group differences in rates of serious adverse events and overall readmissions, but patients in the repair group had more serious adverse events related to heart failure (P = 0.05) and cardiovascular readmissions (P = 0.01). On the Minnesota Living with Heart Failure questionnaire, there was a trend toward greater improvement in the replacement group (P=0.07). CONCLUSIONS In patients undergoing mitral-valve repair or replacement for severe ischemic mitral regurgitation, we observed no significant between-group difference in left ventricular reverse remodeling or survival at 2 years. Mitral regurgitation recurred more frequently in the repair group, resulting in more heart-failure–related adverse events and cardiovascular admissions.

Cardioband for the treatment of secondary mitral regurgitation: a viable percutaneous option?

“…This is similar to the prevalence reported after surgical MV repair, and is a predictor of increased mortality and cardiac complications (6,7). As with surgical mitral restrictive annuloplasty, the Cardioband reduced the septolateral diameter of the mitral annulus (3.67±0.47 vs. 2.41±0.44 cm, P<0.001), but did not address the coexisting geometric subvalvular distortions.…”

Analysing the reasons of failure of surgical mitral repair approaches—do we need to better think in biomechanics?

“…Given the high rate of recurrent mitral regurgitation in patients after RA-repair, surgeons have to consider chordalsparing mitral-valve replacement or combined procedure with subvalvular repair and undersizing mitral annuloplasty to solve ischemic mitral disorder (9)(10)(11)(12)(13)(14). The results of the two-years randomized trial in patients with moderate and severe IMR by the Cardiothoracic Surgical Trials Network (CTSN) imposed the need to revise the surgical dogma regarding the superiority of mitral valve repair over replacement (9,10).…”

“…The results of the two-years randomized trial in patients with moderate and severe IMR by the Cardiothoracic Surgical Trials Network (CTSN) imposed the need to revise the surgical dogma regarding the superiority of mitral valve repair over replacement (9,10). Moreover, we reported the results of a randomized study in patients with severe IMR who received a combined procedure of subvalvular repair [papillary muscle approximation, (PMA)] and undersizing mitral annuloplasty compared to restrictive annuloplasty alone.…”

Percutaneous Treatment of Mitral Regurgitation: Present and Future

“…Due to the progressive nature of the underlying ventricular disease recurrence, an FMR is common after mitral valve repair. 16 The European Heart Survey showed that up to 50% of patients with severe symptomatic MR are not referred for surgery due to advanced age, other comorbidities, and operative risk. 4 Patients with severe MR who are not offered surgery due to high operative risk (STS risk score .12 and logistic EuroScore .20) and are medically treated have a 50% mortality at 5 years.…”