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Ann Thorac Surg 2005;79:1895-1901
© 2005 The Society of Thoracic Surgeons
a Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
b Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
c Division of Biostatistics, Cedars-Sinai Medical Center, Los Angeles, California, USA
d Departments of Medicine and Surgery, UCLA School of Medicine, Los Angeles, California
Accepted for publication November 10, 2004.
* Address reprint requests to Dr Czer, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Rm 6215, Los Angeles, CA 90048-1865 (E-mail: czer{at}csmc.edu).
BACKGROUND: In this study we compared the surgical management of ischemic mitral regurgitation (IMR) by revascularization alone and by revascularization combined with mitral valve repair.
METHODS: We studied 355 patients who underwent revascularization alone (n = 168) or revascularization combined with mitral valve repair (n = 187) for IMR from March 1994 to September 2003. Preoperative and operative characteristics, postoperative mitral regurgitation severity, operative mortality, and late survival were examined for each surgical group.
RESULTS: No differences were noted between the two groups in age, sex, history of diabetes or hypertension, and number of bypass grafts. The combined surgical group had a lower preoperative left ventricular ejection fraction (0.38 ± 0.14 versus 0.44 ± 0.15), greater severity of IMR, higher frequency of prior myocardial infarction, and longer cross-clamp and pump times (p < 0.01). The combined surgical group had a greater reduction in IMR grade (2.7 ± 0.1 grades versus 0.2 ± 0.1 grade), a lower postoperative IMR grade (0.9 ± 0.1 versus 2.3 ± 0.1), and a higher success with reduction of IMR by two or more grades (89% versus 11%) (p < 0.001). In patients with 3+ or 4+ IMR, both groups had similar operative mortality (11.0% in the combined group compared with 4.7% for revascularization alone, p = 0.11) and actuarial survival at 5 years (44% ± 5% versus 41% ± 7%, p = 0.53). Independently predictive of higher early mortality (
30 days) by Cox analysis were longer pump time (p < 0.001) and older age (p < 0.02). Predictive of late mortality (>30 days) were older age (p < 0.001), fewer bypass grafts (p < 0.01), and lower ejection fraction (p < 0.01). After adjustment for these variables, there was a trend (p = 0.08) toward a higher late survival with the combined surgical procedure.
CONCLUSIONS: In patients with IMR, combined mitral valve repair and revascularization resulted in less postoperative mitral regurgitation and similar 5-year survival when compared with revascularization alone. Attempts to reduce pump time by using off-pump techniques may reduce early mortality in these high-risk patients.
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