2. Chronic ischemic mitral regurgitation
Chronic ischemic mitral regurgitation is a common complication of
myocardial infarction and severely affects cardiovascular mortality
and morbidity.
Multiple pathophysiologic mechanisms, such as left ventricular (LV)
remodeling and dysfunction, annular dilation/dysfunction, and
mechanical dyssynchrony, are involved in generating IMR, each of
them having different weight.
The aim of medical and/or surgical therapy is to ameliorate heart
failure symptoms, and improve LV remodeling and function and the
intermediate/long-term outcome.
The targets of surgical MV repair involve annulus, leaflets, chordae
and ventricles.
5. Study design
A retrospective study of the early and late results of the
surgical management of chronic IMR over the period of
12 years (1997-2008).
During this period, the 30 day result for 5124 patients
who underwent isolated CABG (control group) were
compared to the results of 157 patients (test group) who
underwent CABG and were suffering from grade II or
more IMR (test group) in the same period.
The late follow-up of the IMR group was then performed
(only for the test group) but was not compared to the
control group (limitation).
6. Pre-operative criteria
Group I Group II p value
Number 157 patients 5124 patients
Age 61 8 years 53 7 years <0.001
Sex 24 (15%) F 1179 (23%) F <0.001
133 (85%) M 3945 (77%) M
E.F. 39 8% 48 7% <0.0001
7. Operative techniques
All patients in the test group were performed by the
same surgical team and same techniques as regard
revascularization and myocardial preservation.
Moderate hypothermia, aortic-cross-clamping, crystalloid
blood-enriched cardioplegia.
Intra-operative TEE is mandatory for every patient.
Complete revascularization with mean number of grafts
3.1 0.9 grafts per patient
8. Surgical repair options adopted
Effective revascularization only expecting reverse
remodeling (17 patients; 11%).
Restrictive annuloplasty alone (94 patients; 60%).
Edge-to-edge technique alone (17 patients; 11%)
Combination of the above both techniques (24 patients;
15%)
Valve replacement (5 patients; 3%)
10. Early results
Test Control P value
Mortality 8 (5.1%) 159 (3.1%) <0.001
Respiratory 9 (5.7%) 108 (2.1%) <0.001
Renal 7 (4.5%) 61 (1.2%) <0.001
LCO 17 (10.8%) 128 (2.5%) <0.001
IABP 9 (5.7%) 46 (0.9%) <0.001
ICU stay 3.6 2.3 days 1.3 1.2 days <0.001
Hospital stay 12.1 2.4 days 7.2 0.9 days <0.001
11. Mortality by procedure
Number Mortality %
Left alone 17 1 5.9%
Restrictive ring 94 3 3.2%
Alfieri 17 3 17.6%
Ring and Alfieri 24 1 4.2%
MV replacement 5 0 0%
12. Predictors of hospital mortality
Odds ratio P value
Residual mitral regurgitation 3.11 <0.001
Alfieri’s repair 2.19 <0.001
Age at surgery 1.49 <0.007
Pre-operative EF 1.34 <0.033
13. Late follow-up
Still undergoing the data collection and completing the analysis.
The follow-up is 91% completed (136 patients).
Late mortality from cardiac and non-cardiac causes is 19% (26 patients).
Of these 26 mortalities 19 (73%) were in patients with residual mitral
regurgitation.
Recurrence rate was 100% in the isolated Edge-to-edge technique group.
Recurrence rate was 17% in the restrictive ring technique.
No mortality or recurrence in the MV replacement group ??.
All (except 3) patients in the revascularization only group suffered from
persistent symptomatic mitral regurgitation.
14. To answer the question
Repair or Not
The Moderate Mitral Regurgitation In Patients
Undergoing CABG (MoMIC) trial is the first international
multi-center, large-scale study to clarify whether
moderate IMR in CABG patients should be corrected.
A total of 550 CABG patients with moderate IMR are to
be randomized to treatment of either CABG alone or
CABG plus mitral valve correction.
The primary end point is a composite end point of
mortality and rehospitalization for heart failure at five
years.
The inclusion and randomization of patients started in
February 2008
15. Conclusions
IMR is still an independent mortality and morbidity
predictor in patients undergoing CABG procedure.
Residual mitral regurgitation should be avoided at all
costs to ensure better-outcome and intra-operative TEE
is mandatory.
A restrictive annuloplasty is now performed in all cases
and could be combined with Alfieri,s suture when
needed.
Alfieri’s suture alone is now abandoned.
The completion of the MoMIC randomized trial is awaited
to determine whether to tackle any MR or just do
revascularization in selected cases.
