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. 2014 Jun 17;129(24):2547-56.
doi: 10.1161/CIRCULATIONAHA.113.005223. Epub 2014 Apr 17.

Surgical revascularization is associated with maximal survival in patients with ischemic mitral regurgitation: a 20-year experience

Anthony W Castleberry  1 , Judson B Williams  1 , Mani A Daneshmand  1 , Emily Honeycutt  1 , Linda K Shaw  1 , Zainab Samad  1 , Renato D Lopes  1 , John H Alexander  1 , Joseph P Mathew  1 , Eric J Velazquez  1 , Carmelo A Milano  1 , Peter K Smith  2
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Surgical revascularization is associated with maximal survival in patients with ischemic mitral regurgitation: a 20-year experience

Anthony W Castleberry et al. Circulation. .

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.

Methods and 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.

Keywords: ischemia; mitral valve; revascularization; stent.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr. Milano is a consultant for Thoratec Corporation and HeartWare Inc. Dr Velazquez has received grant funding from Abbott Vascular Structural Heart. Dr. Lopes has received grant funding from Bristol-Myers Squibb. The other authors report no conflicts.

Figures

Figure 1
Figure 1. Study inclusion algorithm
CAD = coronary artery disease; MR = mitral regurgitation; IMR = ischemic mitral regurgitation; CABG = coronary artery bypass grafting; MV = mitral valve.
Figure 2
Figure 2. Summary of treatment modality by year of index cardiac catheterization
Abbreviations: CABG = coronary artery bypass grafting; MVRR = mitral valve repair or replacement; PCI = percutaneous coronary intervention;
Figure 3
Figure 3. Unadjusted Kaplan-Meier survival curves by treatment category
PCI = percutaneous coronary intervention; CABG = coronary artery bypass; MVRR = mitral valve repair or replacement.
Figure 4
Figure 4. Adjusted survival curves by treatment category
PCI = percutaneous coronary intervention; CABG = coronary artery bypass; MVRR = mitral valve repair or replacement.
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