Surgical Treatment of Moderate Ischemic Mitral Regurgitation
This trial compared coronary-artery bypass grafting alone with CABG plus mitral-valve repair in patients with coronary artery disease and moderate ischemic mitral regurgitation. Mitral-valve repair provided no apparent benefit and was associated with more neurologic complications. Each year, approxi...
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| Published in | The New England journal of medicine Vol. 371; no. 23; pp. 2178 - 2188 |
|---|---|
| Main Authors | , , , , , , , , , , , , , , , , , , , , , , , , , , , , |
| Format | Journal Article |
| Language | English |
| Published |
Waltham, MA
Massachusetts Medical Society
04.12.2014
|
| Subjects | |
| Online Access | Get full text |
| ISSN | 0028-4793 1533-4406 1533-4406 |
| DOI | 10.1056/NEJMoa1410490 |
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| Abstract | This trial compared coronary-artery bypass grafting alone with CABG plus mitral-valve repair in patients with coronary artery disease and moderate ischemic mitral regurgitation. Mitral-valve repair provided no apparent benefit and was associated with more neurologic complications.
Each year, approximately 1 million Americans have a myocardial infarction, and nearly 8 million Americans have a history of myocardial infarction.
1
Ischemic mitral regurgitation, which results from functional-valve incompetence due to myocardial injury and adverse left ventricular remodeling, develops in approximately 50% of patients after an infarction, and moderate regurgitation occurs in more than 10% of patients.
2
–
4
Ischemic mitral regurgitation is associated with excess mortality regardless of management.
5
,
6
The valve leaflets and chordal structures in affected patients are “innocent bystanders”; mitral regurgitation results from papillary muscle displacement, leaflet tethering, reduced closing forces, and annular dilatation.
7
–
10
Many patients . . . |
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| AbstractList | BackgroundIschemic 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.MethodsWe 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.ResultsAt 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.ConclusionsIn 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.) 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. 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. 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. 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.). 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.BACKGROUNDIschemic 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.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.METHODSWe 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.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.RESULTSAt 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.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.).CONCLUSIONSIn 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.). This trial compared coronary-artery bypass grafting alone with CABG plus mitral-valve repair in patients with coronary artery disease and moderate ischemic mitral regurgitation. Mitral-valve repair provided no apparent benefit and was associated with more neurologic complications. Each year, approximately 1 million Americans have a myocardial infarction, and nearly 8 million Americans have a history of myocardial infarction. 1 Ischemic mitral regurgitation, which results from functional-valve incompetence due to myocardial injury and adverse left ventricular remodeling, develops in approximately 50% of patients after an infarction, and moderate regurgitation occurs in more than 10% of patients. 2 – 4 Ischemic mitral regurgitation is associated with excess mortality regardless of management. 5 , 6 The valve leaflets and chordal structures in affected patients are “innocent bystanders”; mitral regurgitation results from papillary muscle displacement, leaflet tethering, reduced closing forces, and annular dilatation. 7 – 10 Many patients . . . |
| Author | Argenziano, Michael Acker, Michael A Puskas, John D Parides, Michael K Goldstein, Daniel J Alexander, John H Bagiella, Emilia Jeffries, Neal O'Gara, Patrick T Rose, Eric A Voisine, Pierre Overbey, Jessica R Pagé, Pierre Ailawadi, Gorav Dagenais, François Thourani, Vinod Ascheim, Deborah D Gelijns, Annetine C Hung, Judy W Perrault, Louis P Kron, Irving L Miller, Marissa A Michler, Robert E Smith, Peter K Gammie, James S Moquete, Ellen G Blackstone, Eugene H Moskowitz, Alan J Gardner, Timothy J |
| Author_xml | – sequence: 1 givenname: Peter K surname: Smith fullname: Smith, Peter K organization: The authors' affiliations are listed in the Appendix – sequence: 2 givenname: John D surname: Puskas fullname: Puskas, John D organization: The authors' affiliations are listed in the Appendix – sequence: 3 givenname: Deborah D surname: Ascheim fullname: Ascheim, Deborah D organization: The authors' affiliations are listed in the Appendix – sequence: 4 givenname: Pierre surname: Voisine fullname: Voisine, Pierre organization: The authors' affiliations are listed in the Appendix – sequence: 5 givenname: Annetine C surname: Gelijns fullname: Gelijns, Annetine C organization: The authors' affiliations are listed in the Appendix – sequence: 6 givenname: Alan J surname: Moskowitz fullname: Moskowitz, Alan J organization: The authors' affiliations are listed in the Appendix – sequence: 7 givenname: Judy W surname: Hung fullname: Hung, Judy W organization: The authors' affiliations are listed in the Appendix – sequence: 8 givenname: Michael K surname: Parides fullname: Parides, Michael K organization: The authors' affiliations are listed in the Appendix – sequence: 9 givenname: Gorav surname: Ailawadi fullname: Ailawadi, Gorav organization: The authors' affiliations are listed in the Appendix – sequence: 10 givenname: Louis P surname: Perrault fullname: Perrault, Louis P organization: The authors' affiliations are listed in the Appendix – sequence: 11 givenname: Michael A surname: Acker fullname: Acker, Michael A organization: The authors' affiliations are listed in the Appendix – sequence: 12 givenname: Michael surname: Argenziano fullname: Argenziano, Michael organization: The authors' affiliations are listed in the Appendix – sequence: 13 givenname: Vinod surname: Thourani fullname: Thourani, Vinod organization: The authors' affiliations are listed in the Appendix – sequence: 14 givenname: James S surname: Gammie fullname: Gammie, James S organization: The authors' affiliations are listed in the Appendix – sequence: 15 givenname: Marissa A surname: Miller fullname: Miller, Marissa A organization: The authors' affiliations are listed in the Appendix – sequence: 16 givenname: Pierre surname: Pagé fullname: Pagé, Pierre organization: The authors' affiliations are listed in the Appendix – sequence: 17 givenname: Jessica R surname: Overbey fullname: Overbey, Jessica R organization: The authors' affiliations are listed in the Appendix – sequence: 18 givenname: Emilia surname: Bagiella fullname: Bagiella, Emilia organization: The authors' affiliations are listed in the Appendix – sequence: 19 givenname: François surname: Dagenais fullname: Dagenais, François organization: The authors' affiliations are listed in the Appendix – sequence: 20 givenname: Eugene H surname: Blackstone fullname: Blackstone, Eugene H organization: The authors' affiliations are listed in the Appendix – sequence: 21 givenname: Irving L surname: Kron fullname: Kron, Irving L organization: The authors' affiliations are listed in the Appendix – sequence: 22 givenname: Daniel J surname: Goldstein fullname: Goldstein, Daniel J organization: The authors' affiliations are listed in the Appendix – sequence: 23 givenname: Eric A surname: Rose fullname: Rose, Eric A organization: The authors' affiliations are listed in the Appendix – sequence: 24 givenname: Ellen G surname: Moquete fullname: Moquete, Ellen G organization: The authors' affiliations are listed in the Appendix – sequence: 25 givenname: Neal surname: Jeffries fullname: Jeffries, Neal organization: The authors' affiliations are listed in the Appendix – sequence: 26 givenname: Timothy J surname: Gardner fullname: Gardner, Timothy J organization: The authors' affiliations are listed in the Appendix – sequence: 27 givenname: Patrick T surname: O'Gara fullname: O'Gara, Patrick T organization: The authors' affiliations are listed in the Appendix – sequence: 28 givenname: John H surname: Alexander fullname: Alexander, John H organization: The authors' affiliations are listed in the Appendix – sequence: 29 givenname: Robert E surname: Michler fullname: Michler, Robert E organization: The authors' affiliations are listed in the Appendix |
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| Copyright | Copyright © 2014 Massachusetts Medical Society. All rights reserved. 2015 INIST-CNRS Copyright © 2014 Massachusetts Medical Society. 2014 |
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| Keywords | Medicine Mitral valve Treatment Ischemia Cardiac valvular disease Surgery Mitral regurgitation Cardiovascular disease |
| Language | English |
| License | CC BY 4.0 |
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| Notes | ObjectType-Article-1 SourceType-Scholarly Journals-1 ObjectType-Feature-2 content type line 14 content type line 23 ObjectType-Undefined-3 The Cardiothoracic Surgical Trials Network investigators are listed in the Supplementary Appendix, available at NEJM.org. |
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| PublicationDate | 2014-12-04 |
| PublicationDateYYYYMMDD | 2014-12-04 |
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| PublicationPlace | Waltham, MA |
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| PublicationTitle | The New England journal of medicine |
| PublicationTitleAlternate | N Engl J Med |
| PublicationYear | 2014 |
| Publisher | Massachusetts Medical Society |
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| Snippet | This trial compared coronary-artery bypass grafting alone with CABG plus mitral-valve repair in patients with coronary artery disease and moderate ischemic... Ischemic mitral regurgitation is associated with increased mortality and morbidity. For surgical patients with moderate regurgitation, the benefits of adding... BackgroundIschemic mitral regurgitation is associated with increased mortality and morbidity. For surgical patients with moderate regurgitation, the benefits... |
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| SubjectTerms | Aged Biological and medical sciences Cardiology. Vascular system Cardiovascular disease Cardiovascular Diseases - etiology Cardiovascular Diseases - mortality Cerebrovascular system Coronary artery Coronary Artery Bypass Coronary vessels Endocardial and cardiac valvular diseases Female General aspects Heart Heart surgery Humans Ischemia Male Medical sciences Middle Aged Mitral Valve Insufficiency - etiology Mitral Valve Insufficiency - surgery Morbidity Myocardial Ischemia - complications Myocardial Ischemia - surgery Patients Postoperative Complications - epidemiology Quality of Life Regurgitation Ventricle Ventricular Remodeling |
| Title | Surgical Treatment of Moderate Ischemic Mitral Regurgitation |
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