Michael Y C Tsang1,2, Lilin She3, Fletcher A Miller1, Jin-Oh Choi1,4, Robert E Michler5, Paul A Grayburn6, Robert O Bonow7, Lorenzo Menicanti8, Marek A Deja9, Serenella Castelvecchio8, Vivek Rao10, Peter K Smith3, Tomasz Kukulski11, George Sopko12, David L Prior13, Eric J Velazquez14, Kerry L Lee3, Jae K Oh1,4. 1. Echocardiography Core Laboratory, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA. 2. Division of Cardiology, Department of Medicine, University of British Columbia, BC, Canada. 3. Duke Clinical Research Institute and Departments of Surgery (PKS), Medicine (EJV), and Biostatistics and Bioinformatics (KLL), Duke University School of Medicine, Durham, NC, USA. 4. Division of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. 5. Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York City, NY, USA. 6. Department of Internal Medicine, Cardiology Section, Baylor University Medical Center, Dallas, TX, USA. 7. Northwestern University Feinberg School of Medicine, Chicago, IL, USA. 8. IRCCS Policlinico San Donato, Milan, Italy. 9. Medical University of Silesia, Katowice, Poland. 10. Toronto General Hospital, Toronto, ON, Canada. 11. Department of Cardiology, Congenital Heart Disease and Electrotherapy, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland. 12. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD, USA. 13. Department of Medicine, St. Vincent's Hospital, University of Melbourne, Melbourne, Australia. 14. Section of Cardiovascular Medicine, Yale School of Medicine, Hew Haven, CT, USA.
Abstract
BACKGROUND: This study examined the impact of mitral valve repair (MVRe) on survival of patients with moderate or severe (≥2+) MR and ischemic cardiomyopathy randomized to coronary artery bypass grafting (CABG) versus CABG+surgical ventricular reconstruction (SVR) in the STICH trial. METHODS: Among patients with moderate or severe MR and ischemic cardiomyopathy undergoing CABG or CABG+SVR, the impact of MVRe on mortality between the two treatment arms was compared. RESULTS: Among 867 patients with assessment of baseline MR severity, 211 had moderate or severe MR. After excluding 7 patients who underwent mitral valve replacement, 50, 44, 62, and 48 patients underwent CABG, CABG+MVRe, CABG+SVR, and CABG+SVR+MVRe, respectively. Four-year mortality rates were lower following CABG+MVRe than CABG alone (16% vs. 55%; adjusted hazard ratio [HR] 0.30; 95% CI 0.13-0.71). In contrast, the CABG+SVR+MVRe and CABG+SVR groups had similar 4-year mortality of 39% vs. 39% (adjusted HR 0.88; 95% CI 0.46-1.70). MVRe had a more favorable effect on survival in patients undergoing CABG alone compared to CABG+SVR (p=0.013). Baseline MR severity was similar between patients that received CABG+MVRe and those that underwent CABG+SVR+MVRe. A larger proportion of patients demonstrated a reduction in MR between 4 and 24 months after CABG+MVRe compared to CABG+SVR+MVRe (50.0% versus 25.0%, p=0.023). CONCLUSION: In patients with moderate or severe MR and ischemic cardiomyopathy undergoing CABG, MVRe appears to have a favorable effect on survival. The addition of SVR to CABG may attenuate the anticipated benefits of MVRe by limiting the long-term reduction of MR with MVRe.
BACKGROUND: This study examined the impact of mitral valve repair (MVRe) on survival of patients with moderate or severe (≥2+) MR and ischemic cardiomyopathy randomized to coronary artery bypass grafting (CABG) versus CABG+surgical ventricular reconstruction (SVR) in the STICH trial. METHODS: Among patients with moderate or severe MR and ischemic cardiomyopathy undergoing CABG or CABG+SVR, the impact of MVRe on mortality between the two treatment arms was compared. RESULTS: Among 867 patients with assessment of baseline MR severity, 211 had moderate or severe MR. After excluding 7 patients who underwent mitral valve replacement, 50, 44, 62, and 48 patients underwent CABG, CABG+MVRe, CABG+SVR, and CABG+SVR+MVRe, respectively. Four-year mortality rates were lower following CABG+MVRe than CABG alone (16% vs. 55%; adjusted hazard ratio [HR] 0.30; 95% CI 0.13-0.71). In contrast, the CABG+SVR+MVRe and CABG+SVR groups had similar 4-year mortality of 39% vs. 39% (adjusted HR 0.88; 95% CI 0.46-1.70). MVRe had a more favorable effect on survival in patients undergoing CABG alone compared to CABG+SVR (p=0.013). Baseline MR severity was similar between patients that received CABG+MVRe and those that underwent CABG+SVR+MVRe. A larger proportion of patients demonstrated a reduction in MR between 4 and 24 months after CABG+MVRe compared to CABG+SVR+MVRe (50.0% versus 25.0%, p=0.023). CONCLUSION: In patients with moderate or severe MR and ischemic cardiomyopathy undergoing CABG, MVRe appears to have a favorable effect on survival. The addition of SVR to CABG may attenuate the anticipated benefits of MVRe by limiting the long-term reduction of MR with MVRe.
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Authors: Robert E Michler; Peter K Smith; Michael K Parides; Gorav Ailawadi; Vinod Thourani; Alan J Moskowitz; Michael A Acker; Judy W Hung; Helena L Chang; Louis P Perrault; A Marc Gillinov; Michael Argenziano; Emilia Bagiella; Jessica R Overbey; Ellen G Moquete; Lopa N Gupta; Marissa A Miller; Wendy C Taddei-Peters; Neal Jeffries; Richard D Weisel; Eric A Rose; James S Gammie; Joseph J DeRose; John D Puskas; François Dagenais; Sandra G Burks; Ismail El-Hamamsy; Carmelo A Milano; Pavan Atluri; Pierre Voisine; Patrick T O'Gara; Annetine C Gelijns Journal: N Engl J Med Date: 2016-04-03 Impact factor: 91.245
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