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Ann Thorac Surg 1999;68:426-430
© 1999 The Society of Thoracic Surgeons

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Original Articles

Treatment of moderate mitral regurgitation and coronary disease by coronary bypass alone: late results

^a Carlyle Fraser Heart Center, Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA

Address reprint requests to Dr Guyton, Division of Cardiothoracic Surgery, Department of Surgery, Crawford Long Hospital, Emory University School of Medicine, 550 Peachtree St, NE, Atlanta, GA 30365-2225

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. In cases of moderate mitral regurgitation and coronary artery disease operative strategy continues to be debated between coronary artery bypass grafting alone and concomitant valve replacement or repair. We previously reported on 58 patients with moderate mitral regurgitation who had coronary artery bypass grafting between 1977 and 1983. We present the late results for this original cohort (test group), and a matched control group of coronary artery bypass grafting patients without mitral regurgitation (n = 58).

Methods and Results. In the original cohort, the hospital mortality rate was 3.4% (2 of 58), and 80.4% (45 of 56) of hospital survivors were alive at the time of initial follow-up (mean, 4.3 ± 2.3 years). Hospital mortality in the control group was 6.9% (4 of 58 patients). Follow-up was 98.2% (108 of 110 patients) complete, with a mean follow-up time of 10.3 ± 5.5 years. Kaplan-Meier curves for hospital survivors showed similar 5- and 10-year survival rates between the two groups (p = 0.59). On multivariate analysis, age 65 years or more, congestive heart failure class III or IV, and pulmonary capillary wedge pressure more than 17 mm Hg were significant (p < 0.05) independent predictors of diminished survival in the test group.

Conclusions. Patients with moderate mitral regurgitation and coronary artery disease treated solely with coronary artery bypass grafting had acceptable early and late results. Moderate mitral regurgitation at the time of revascularization does not always warrant operative correction.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Patients with coronary artery disease and severe mitral regurgitation (MR) are typically treated with coronary artery bypass grafting (CABG) and concomitant mitral valve replacement or repair [1, 2]. In contrast, patients with mild MR and coronary artery disease are generally offered CABG alone, with acceptable early and late results [2, 3]. The mild degree of concomitant mitral valve dysfunction in this group of patients does not justify the increased operative risks associated with simultaneous mitral valve correction. In addition, there are long-term risks inherent in mitral valve replacement, including anticoagulation for mechanical prostheses and the possibility of bioprosthetic valve degeneration requiring subsequent replacement.

The treatment of moderate mitral regurgitation in association with coronary artery disease however, remains controversial: should CABG alone be used or should CABG and concomitant mitral valve correction be used? In particular, as techniques of valvular repair continue to be refined, many surgeons have advocated mitral valve repair and concomitant CABG for these patients [4–8]. Others however, have continued to treat these patients with revascularization alone and close postoperative observation of the mitral valve [2, 3].

We previously reported on 58 patients with moderate MR and coronary artery disease treated with CABG alone between 1977 and 1983 [9]. That cohort has remained the largest series of its kind in the literature. The hospital mortality rate was 3.4% (n = 2), and the initial 5-year survival estimate was 77%, with a mean follow-up 4.3 ± 2.3 years. In contrast, 20 patients with moderate MR and coronary artery disease who had combined mitral valve replacement and CABG during a similar time period had a hospital mortality rate of 25% (n = 5), and 5-year survival was limited to approximately 31%. As a result, our institution adopted a policy of treating patients with moderate MR and coronary artery disease with CABG alone.

In this study, we evaluated the long-term results of CABG alone for moderate MR and coronary artery disease by updating the follow-up for the original 58 patients. In addition, we compared these results to those of 58 matched patients with coronary artery disease but without evidence of MR preoperatively who also had CABG during the same time period.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
As described in the original report, patients with moderate MR and coronary artery disease who had CABG between 1977 and 1983 were originally identified from the Emory University Cardiac Data Bank (test group, n = 58) [9]. The data bank was also used to identify patients without preoperative evidence of MR who had CABG during the same time period (control group, n = 58). These control patients were matched to those in the test group on the basis of age, sex, and preoperative ejection fraction, and they were reviewed for follow-up data only.

Moderate mitral regurgitation was defined as 3+ opacification (on a scale of 0 to 4+) of the left atrium during left ventriculography, or complete filling of the left atrium to the same density as the ventricle for two or three cardiac cycles. Patients who had undergone previous mitral valve operation or who required aortic valve operation were excluded. Coronary bypass reoperations and concomitant aneurysmectomy or aneurysm plication were included.

Variables registered
All preoperative data were recorded previously for the 58 original test group patients [9]. Routine demographic data included age, gender, preoperative heart medications, the incidence and number of previous myocardial infarctions, and the occurrence of infarction within 3 months of operation. Symptoms of angina and congestive heart failure were scored according to the Canadian Cardiovascular Society and New York Heart Association classifications [10, 11].

Data obtained from the preoperative cardiac catheterization included ejection fraction and assessment of left ventricular wall motion as normal, hypokinetic, or akinetic. Preoperative pulmonary capillary wedge pressure was also documented.

The cause of MR was determined from historical and physical examination data and the cardiac catheterization. A history of rheumatic fever, a long-standing murmur unrelated to myocardial infarction, and preserved wall motion led to the diagnosis of rheumatic valve disease. Prior myocardial infarction and associated wall motion abnormality suggested an ischemic basis for MR. Prolapse was assumed to be the cause when there was no evidence of rheumatic disease or ischemic etiology. Some patients had MR associated with idiopathic hypertrophic subaortic stenosis, and mixed etiology was assigned in cases where no single cause could be identified.

Follow-up
Follow-up, conducted between January and March 1997, was complete for 98.2% (108 of 110) of all hospital survivors in both groups. Patients were interviewed by telephone. The date and cause of death were noted in cases where the patient had died.

Statistical analysis
Continuous data were displayed as a mean ± standard deviation. The ² or Fisher’s exact test was used to determine significance of differences for categoric variables, and the t test or Wilcoxon two-sample test was used for continuous variables [12]. Univariate correlates of late survival were identified with the log-rank test, and univariate (unadjusted) Kaplan-Meier curves were derived using S-Plus statistical software (MathSoft, Inc, Seattle, WA) [12]. The multivariate (adjusted) correlates of late survival were identified by Cox proportional hazards regression analysis, where the hazard of death was modeled from all preoperative characteristics identified. The results are given as hazard ratios, ie, ratios of the hazard of death for patients with and without a characteristic present, with 95% confidence intervals. All tests were two-tailed, and a p value of 0.05 or less was considered statistically significant.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Patient demographics and preoperative data are presented in Table 1. With respect to the cause of MR in the test group, ischemia accounted for most (74%) of MR because many patients had prior myocardial infarction (76%) and wall motion abnormalities (71%). Mitral valve prolapse was identified in an additional 16% of cases, idiopathic hypertrophic subaortic stenosis in 3%, rheumatic valve disease in 2%, and 5% of MR cases were of mixed etiology.

Follow-up
One hundred ten patients survived the initial hospitalization, and follow-up was complete for 98.2% of all patients (108 of 110). Mean length of follow-up was 10.3 ± 5.1 years in the test group and 10.4 ± 5.9 years in the control group (p = 0.79). Of the hospital survivors, 15 (26%) in the test group and 19 (34%) in the control group were alive at the time of follow-up (p = 0.42). With regard to the cause of death among the deceased patients, there was a larger proportion of cardiac deaths in the test group compared with the control group, 61% versus 30%, respectively. This comparison, however, is limited, as a significantly larger number of deaths in the control group were of undetermined origin, 30% versus 17%, respectively.

Angina and congestive heart failure classification for patients alive at follow-up are shown in Table 2. There was no significant difference in the number of patients with angina or congestive heart failure classification I or II versus III or IV between the two groups. Most patients in both groups who are alive had relatively mild, compensated symptoms.

View larger version (21K): [in this window] [in a new window]   Fig 1. Kaplan-Meier actuarial survival curves for the two groups of hospital survivors.

View larger version (24K): [in this window] [in a new window]   Fig 2. Kaplan-Meier survival curves for hospital survivors in the test group: (A) pulmonary capillary wedge pressure (PCWP); (B) congestive heart failure (CHF) class; and (C) age (in years).

	Comment

Top Abstract Introduction Patients and methods Results Comment References

The approach to patients with moderate MR and coronary artery disease, however, continues to be debated. Since our initial report of 58 patients with coronary artery disease and moderate MR treated with CABG alone with acceptable early results, we have approached such patients with revascularization alone. Pinson and associates [3] similarly presented good estimated 5-year survival results (72%) for 14 patients with moderate MR treated with CABG alone, but that study was limited by the small sample size and brief follow-up (mean, 3.5 years). The current review evaluated the late survival statistics of our original cohort and assessed the impact on survival of moderate MR left untreated at the time of CABG.

Our 5- and 10-year survival results (81% and 52%, respectively) compared favorably with those of matched patients who had CABG without preoperative MR (control group). The moderate MR treated by CABG alone did not appear to confer an added deleterious risk with respect to late survival. Indeed, it was also similar to previous studies of patients who had CABG and mitral valve repair or replacement. Akins and associates [5] recently reported a 75% 5-year survival rate for 233 patients with MR (all severe cases) treated with mitral valve repair and CABG and 68% survival at 5 years if they had concomitant mitral valve replacement and CABG. Our hospital mortality rate of 3.4% in the test group was significantly less than the 15% rate of He and colleagues [15], who studied 40 patients with moderate MR treated with CABG and mitral valve replacement [15]. In addition, because these patients were treated with CABG alone, they avoided the morbidity associated with anticoagulation for mechanical prostheses or risk of reoperation for bioprosthetic valve degeneration.

With respect to the origin of mitral valve disease, several investigators have found diminished survival in patients treated for ischemic MR and CABG [16, 17]. Those descriptions however, included patients with severe MR and coronary artery disease who clearly were at increased risk of early or late death as previously mentioned. In our cohort of patients with moderate MR, the cause of valvular dysfunction, ischemic versus other, was not a significant independent predictor of outcome.

Multivariate analysis of preoperative demographic and clinical data did identify patients within the test group who were at increased risk of diminished late survival. Elevated pulmonary capillary wedge pressure, increased age, and advanced congestive heart failure classification were the only independent predictors of outcome in this group.

In their review, Rankin and associates [6] called for a more liberal application of mitral valve repair for patients with coronary artery disease and moderate-to-severe MR. This approach subsequently has been supported by several reports describing refinements in the technique of mitral valve repair with improved outcomes [4, 8, 18]. However, several studies have also documented higher early mortality rates among these patients, with limited late survival data. Cohn and colleagues [19] presented a review of 94 patients with ischemic MR who had CABG and mitral valve repair between 1984 and 1994. The operative mortality rate was 9.5%, and the estimated 5-year survival rate was 56% [19]. Our own institution’s preliminary results for combined CABG and mitral valve repair in 164 patients (MR and mitral stenosis), between 1980 and 1996, revealed a hospital mortality rate of 11% among this cohort [20]. As a result of these initial findings, the most common indication for mitral valve repair at our institution remains primarily in cases of myxomatous degeneration of the mitral valve as the cause of severe regurgitation where repair is technically feasible. In cases of coronary artery disease and severe MR, mitral valve replacement is typically offered, although the choice of mitral valve reconstruction versus replacement is at the surgeon’s discretion.

To further place these findings in perspective, 58 individuals were chosen at random from the pool of the general population census in the S-Plus statistical software package (MathSoft, Inc, Seattle, WA). These individuals were matched to the gender and age of patients in the test and control groups at the year of their operation. When the survival curves for these three groups were compared, there was equally diminished late survival in both operative groups compared with the general population, beginning at approximately 8 years after operation (Fig 3). The similar test and control group survival curves suggest that coronary artery disease was the principal cause of their diminished survival and that moderate mitral regurgitation left untreated did not further limit late outcome in the test group.

View larger version (15K): [in this window] [in a new window]   Fig 3. Comparison of Kaplan-Meier survival curves for the test group and control group of patients as well as that of 58 individuals chosen from the general population and matched for gender and age. Both patient groups revealed an equally diminished late survival compared with that of the general population.

	Footnotes

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. Cohn L.H., Allred E.N., Cohn L.A., et al. Early and late risk of mitral valve replacement. J Thorac Cardiovasc Surg 1985;90:872-881.[Abstract]
2. Connolly M.W., Gelbfish J.S., Jacobowitz, et al. Surgical results for mitral regurgitation from coronary artery disease. J Thorac Cardiovasc Surg 1986;91:379-388.[Abstract]
3. Pinson C.W., Cobanoglu A., Metzdorff M.T., Grunkemeier G.L., Kay P.H., Starr A. Late surgical results for ischemic mitral regurgitation. J Thorac Cardiovasc Surg 1984;88:663-672.[Abstract]
4. Yun K.L., Miller D.C. Mitral valve repair versus replacement. Cardiac Clinics 1991;9:315-327.
5. Akins C.W., Hilgenberg A.D., Buckley M.J., et al. Mitral valve reconstruction versus replacement for degenerative or ischemic mitral regurgitation. Ann Thorac Surg 1994;58:668-676.[Abstract]
6. Rankin J.S., Hickey M.S., Smith L.R., et al. Current management of mitral valve incompetence associated with coronary artery disease. J Cardiac Surg 1989;4:25-42.[Medline]
7. Hickey MS, Smith LR, Muhlbaier LH, et al. Current prognosis of ischemic mitral regurgitation. Circulation 1988;78:I51–9.
8. Bolling S.F., Deeb G.M., Bach D.S. Mitral valve reconstruction in elderly ischemic patients. Chest 1996;109:35-40.[Abstract/Free Full Text]
9. Arcidi J.M., Hebeler R.F., Craver J.M., Jones E.L., Hatcher C.R., Guyton R.A. Treatment of moderate mitral regurgitation and coronary disease by coronary bypass alone. J Thorac Cardiovasc Surg 1988;95:951-959.[Abstract]
10. Campeau L. Grading of angina pectoris [Letter]. Circulation 1976;54:522-523.[Medline]
11. Criteria Committee of the New York Heart Association, Inc. Diseases of the heart and blood vessels (nomenclature and criteria for diagnosis), 6th ed. Boston: Little, Brown and Company, 1964.
12. Fisher L.D., Belle G.V. Biostatistics. A methodology for the health sciences. New York: John Wiley, 1993.
13. Flameng W., Szecsi J., Sergeant P., Daenen W., Herijgers P., Scheys I. Combined valve and coronary artery bypass surgery. Eur J Cardiothorac Surg 1994;8:410-419.[Abstract]
14. Czer L.S.C., Gray R.J., DeRobertis M.A., et al. Mitral valve replacement. Circulation 1984;70:I198-I207.
15. He G.W., Hughes C.F., McCaughan B. Mitral valve replacement combined with coronary artery operation. Ann Thorac Surg 1991;51:916-923.[Abstract]
16. Minale C., Messmer B.J. Combination of mitral and coronary artery surgery. J Cardiovasc Surg 1986;27:480-487.[Medline]
17. Lytle B.W., Cosgrove D.M., Gill C.C., et al. Mitral valve replacement combined with myocardial revascularization. Circulation 1985;71:1179-1190.[Abstract/Free Full Text]
18. Miller D.C., Stinson E.B., Rossiter S.J., Oyer P.E., Reitz B.A., Shumway N.E. Impact of simultaneous myocardial revascularization on operative risk, functional result, and survival following mitral valve replacement. Surgery 1978;84:848-857.[Medline]
19. Cohn L.H., Rizzo R.J., Adams D.H., et al. The effect of pathophysiology on the surgical treatment of ischemic mitral regurgitation. Eur J Cardiothorac Surg 1995;9:568-574.[Abstract]
20. Craver J.M., Jones E.L., Guyton R.A. Short and long term outcome after mitral valve repair. Circulation 1997;96:I731.

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				J. X. Qin, T. Shiota, P. M. McCarthy, C. R. Asher, M. Hail, D. A. Agler, Z. B. Popovic, N. L. Greenberg, N. G. Smedira, R. C. Starling, et al. Importance of Mitral Valve Repair Associated With Left Ventricular Reconstruction for Patients With Ischemic Cardiomyopathy: A Real-Time Three-Dimensional Echocardiographic Study Circulation, September 9, 2003; 108(90101): II-241 - 246. [Abstract] [Full Text] [PDF]

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				G. A. Tolis Jr, D. P. Korkolis, G. S. Kopf, and J. A. Elefteriades Revascularization alone (without mitral valve repair) suffices in patients with advanced ischemic cardiomyopathy and mild-to-moderate mitral regurgitation Ann. Thorac. Surg., November 1, 2002; 74(5): 1476 - 1481. [Abstract] [Full Text] [PDF]

				L. Aklog, F. Filsoufi, K. Q. Flores, R. H. Chen, L. H. Cohn, N. S. Nathan, J. G. Byrne, and D. H. Adams Does Coronary Artery Bypass Grafting Alone Correct Moderate Ischemic Mitral Regurgitation? Circulation, September 18, 2001; 104(90001): I-68 - 75. [Abstract] [Full Text] [PDF]

				T. Ryden, O. Bech-Hanssen, G. Brandrup-Wognsen, F. Nilsson, S. Svensson, and A. Jeppsson The importance of grade 2 ischemic mitral regurgitation in coronary artery bypass grafting Eur. J. Cardiothorac. Surg., August 1, 2001; 20(2): 276 - 281. [Abstract] [Full Text] [PDF]