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Ann Thorac Surg 2004;78:794-799
© 2004 The Society of Thoracic Surgeons

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Original article: cardiovascular

Repair of ischemic mitral regurgitation does not increase mortality or improve long-term survival in patients undergoing coronary artery revascularization: A propensity analysis

^a Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA

Accepted for publication March 8, 2004.

^* Address reprint requests to Dr Moon, Division of Cardiothoracic Surgery, Queeny Tower, Suite 3108, One Barnes-Jewish Hospital Plaza, St. Louis, MO, USA 63110-1013
moonm{at}msnotes.wustl.edu

Presented at the Fiftieth Annual Meeting of the Southern Thoracic Surgical Association, Bonita Springs, FL, Nov 13–15, 2003.

	Abstract

Top Abstract Introduction Material and methods Results Comment Discussion Acknowledgments References

 
BACKGROUND: The purpose of this study was to compare operative mortality and midterm outcome of patients with ischemic mitral regurgitation (MR) undergoing either coronary artery bypass grafting (CABG) alone or CABG with mitral valve (MV) repair.

METHODS: From 1996 to 2001, 51 consecutive patients underwent CABG with MV repair for ischemic MR. All patients in this group were matched to similar patients with ischemic MR undergoing CABG alone during the same 6-year period using propensity analysis (considering 24 covariates, including severity of MR and New York Heart Association [NYHA] class).

RESULTS: Propensity score matching yielded 51 closely matched control patients. Preoperative MR severity was 3+ or 4+ in 94% of CABG with MV repair and 96% of CABG-alone patients, and 86% of patients in each group were NYHA class III or IV. Operative mortality was 3.9% ± 2.8% in both groups. Survival was also similar between CABG with MV repair and CABG alone at 1 year (84% ± 5% versus 82% ± 5%) and 3 years (70% ± 7% versus 71% ± 7% (p = 0.43). Among survivors, NYHA class improved at follow-up (50 ± 20 months) from 3.4 ± 0.7 to 1.7 ± 1.0 for CABG with MV repair (p < 0.001) and from 3.4 ± 0.7 to 1.8 ± 1.0 for CABG alone (p < 0.001).

CONCLUSIONS: Operative mortality, midterm survival, and late functional class were similar between two well-matched groups of patients undergoing CABG for ischemic MR, differing only in the addition of MV repair. Whereas MV repair can be added safely to CABG in this group of high-risk patients without increasing mortality, its impact on late survival and functional class may be limited.

	Introduction

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The impact of adding mitral valve (MV) repair to coronary artery bypass grafting (CABG) alone for patients with ischemic mitral regurgitation (MR) remains unclear. Several interesting reports have addressed this issue, but study groups have typically been heterogeneous, making interpretation of the resulting statistical analyses difficult [1–6].

The purpose of the current investigation was to compare operative mortality and midterm outcome in matched groups of patients with ischemic MR undergoing either CABG alone or CABG with MV repair. To accomplish this goal, propensity score analysis was performed to best match the two distinct groups and minimize the effect of confounding variables on patient outcome.

	Material and methods

Top Abstract Introduction Material and methods Results Comment Discussion Acknowledgments References

 
From January 1996 to December 2001, 1180 patients underwent CABG at Washington University Medical Center (Barnes-Jewish Hospital), including 71 patients who underwent simultaneous CABG with MV repair. Of these patients, 51 underwent combined CABG with MV repair for "functional" ischemic MR with anatomically normal leaflets and intact papillary muscle (Carpentier I, IIIb). Based on echocardiography, MR severity was graded as absent (0+), trace (1+), mild (2+), moderate (3+), or severe (4+). Left ventricular (LV) function was categorized based on ejection fraction (EF) as normal (0+, LVEF greater than 0.50), mildly impaired (1+, LVEF 0.40 to 0.50), moderately impaired (2+, LVEF 0.25 to 0.40), or severely impaired (3+, LVEF less than 0.25). To select a matched control group of patients who underwent CABG alone despite the presence of an equivalent degree of MR, propensity score analysis was performed [7].

Propensity score analysis
The decision to repair the valve was made by the operating surgeon, often in consultation with the referring cardiologist, based on the patient's preoperative echocardiogram, cardiac catheterization, and clinical status. The resulting selection bias to CABG with MV repair versus CABG alone was addressed by propensity matching. Logistic regression analysis was used to identify covariates, among 24 baseline patient variables, that were imbalanced in the two groups of interest (SPSS 11.0 for Windows, SPSS Inc, Chicago, IL). Fifteen variables were not significant in the logistic regression analysis, including sex, diabetes mellitus, hypercholesterolemia, chronic renal insufficiency, current dialysis requirement, family history of coronary artery disease, pulmonary hypertension, previous cerebrovascular accident, chronic obstructive pulmonary disease, peripheral vascular disease, history of myocardial infarction, congestive heart failure, stable versus unstable angina, LVEF, and cardiogenic shock. In contrast, the logistic regression analysis identified nine variables as significant predictors for the performance of MV repair during CABG, including younger age, smoking history, systemic hypertension, lack of cerebrovascular disease, preoperative intraaortic balloon counterpulsation, New York Heart Association (NYHA) class III or IV, nonurgent/emergent operative status, less than three-vessel disease, and an increased degree of MV insufficiency. Using the significant regression coefficients, a propensity score was calculated for all 1180 patients who underwent CABG at our institution from 1996 to 2001, and patients were closely matched on the basis of this score. This process matched the 51 patients who underwent CABG with MV repair with 51 patients who underwent CABG alone. The resulting 102 matched patients form the focus of the outcomes analysis for this study.

Patient characteristics
Selected preoperative clinical patient characteristics for the CABG alone and CABG with MV repair groups are listed in Table 1. In the CABG with MV repair group, the mean age was slightly lower (p = 0.05), but LVEF tended to be higher (p = 0.07). The CABG with MV repair group included fewer patients with three-vessel disease (p = 0.009) and more smokers (p = 0.07). The groups were similar as far as sex (p = 0.84), emergency procedures (p = 0.152), unstable angina (p = 0.81), history of myocardial infection (p = 0.27), NYHA class (p = 0.77), hypertension (p = 0.17), cerebrovascular disease (p = 0.14), preoperative intraaortic balloon pump use (p = 0.35), and severity of MR (p = 0.99).

The average number of bypass grafts was similar between groups (p = 0.15), but a tendency was noted for greater internal mammary artery use in the CABG-alone group (p = 0.06) (Table 2). As expected, when MV repair was added to CABG the mean cross-clamp time was 25 minutes longer (p < 0.001) and cardiopulmonary bypass time was increased (p < 0.001). In the CABG with MV repair group, all patients underwent annuloplasty alone without an intervention on the leaflets or chords. A partial posterior band was used in 37 patients and a full circumferential ring was used in 14 patients. Ring sizes during the 6-year period were diverse and included 26 mm in 12 patients, 28 mm in 16, 30 mm in 12, and 32 mm in 11, but a significant shift was noted toward smaller annuloplasty sizes during recent years (Fig 1). In 1996 and 1997, 21% of rings were 28 mm or smaller compared with 95% in the years 2000 and 2001 (p < 0.001). Operative year did not influence use of partial versus full annuloplasty (p = 0.95).

View larger version (52K): [in this window] [in a new window]   Fig 1. Influence of operative year on annuloplasty size ( = 26–28 mm; = 30–32 mm; p < 0.001, 2 test).

	Results

Top Abstract Introduction Material and methods Results Comment Discussion Acknowledgments References

 
Operative mortality (30 days or before hospital discharge) occurred in 2 patients in each group, yielding equal mortality rates of 4% ± 3%. At the time of midterm follow-up, an additional 36 patients were no longer alive, leaving 33 patients in the CABG-alone group and 29 patients in the CABG with MV repair group available for midterm functional assessment. Surviving patients were contacted by telephone during a 2-week closing interval ending November 2003. Mean follow-up was 39 ± 25 months in the CABG-alone group and 37 ± 25 months in the CABG with MV repair group (p = 0.70). In the CABG-alone group, survival was 82% ± 5% at 1 year, 71% ± 7% at 3 years, and 65% ± 7% at 5 years (Fig 2). In the CABG with MV repair group, survival was 84% ± 5% at 1 year, 70% ± 7% at 3 years, and 49% ± 9% at 5 years, and was not statistically different than CABG alone (p = 0.43).

View larger version (15K): [in this window] [in a new window]   Fig 2. Postoperative survival estimates (Kaplan–Meier) for patients with ischemic mitral regurgitation undergoing coronary artery bypass grafting (CABG) alone (dark line) or CABG with mitral valve (MV) repair (light line) (n = 51 for each). The numbers of patients at risk are indicated. p = 0.437.

As expected, severity of MR improved significantly after CABG with MV repair from 3.9 ± 0.2 to 1.2 ± 1.2 (p < 0.001), and the number of patients with 3+ to 4+ MR fell from 94% to 10%. However, a significant increase was noted in MR severity when comparing studies performed before hospital discharge (0.7 ± 0.8 in 12 patients) with later studies (1.6 ± 1.0 in 14 patients at 30 ± 19 months) (p = 0.03). This finding may be due, in part, to the fact that the surgeon, as a baseline assessment of the repair, often obtained echocardiograms before hospital discharge, whereas later studies were obtained by the patient's cardiologist to evaluate a change in symptomatology. In the CABG-alone group, improvement in MR severity after surgery was not as dramatic. Severity of MR fell from 3.9 ± 0.3 to 2.3 ± 1.1 with CABG alone (p < 0.001), and the incidence of 3+ to 4+ MR fell from 96% to 42%. Too few patients in the CABG-alone group underwent echocardiograms before hospital discharge to allow a meaningful analysis of early versus midterm results.

Postoperative echocardiography was performed in 29 of 62 patients who were alive at late follow-up and 10 of 40 patients at some point before their death. Interestingly, whereas the difference in LV function between nonsurvivors and survivors was not significant (1.6 ± 1.2 versus 1.7 ± 1.2, p = 0.66), the severity of MR was 30% higher in patients who were no longer alive (2.2 ± 1.0 versus 1.7 ± 1.2, p = 0.05). Among survivors, mean NYHA class improved from 3.4 ± 0.7 to 1.8 ± 1.0 in the CABG-alone group (p < 0.001) and from 3.4 ± 0.7 to 1.7 ± 1.0 in the CABG with MV repair group (p < 0.001). Midterm NYHA class was not significantly different between groups, with 80% of CABG-alone patients and 86% of CABG with MV repair patients in NYHA I or II (p = 0.87).

	Comment

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Elegant experimental work has helped delineate the pathogenesis of ischemic MR [8–10]. Functional MR, as was present in all patients in the current report, appears to be the consequence of a combination of two distinct anatomic abnormalities. Globally, annular dilatation occurs secondary to LV enlargement, which causes incomplete coaptation of the mitral valve despite normal leaflet motion. Locally, remodeling in the inferior wall causes papillary muscle displacement with restricted motion of the mitral leaflets. Novel surgical techniques have been proposed to correct ischemic valvular dysfunction, including infarct restraint, ventricular reconstruction, Paneth suture annuloplasty, and chordal transection [11–14]. However, these methods remain experimental. Since 1996, our approach for patients with ischemic MR has been to leave the mitral leaflets alone and perform a reduction annuloplasty with either a partial posterior band or a full circumferential ring. In recent years, the ring has been "undersized," generally to 26 mm in women and 28 mm in men. This approach effectively relieved MR during the early postoperative period for most patients. The incidence of 3+ to 4+ MR fell from 94% preoperatively to 10% at 21 months postoperatively after CABG with MV repair with a residual nonrestrictive mean gradient of 3.5 mm Hg across the ring.

Several important studies have demonstrated that MR which persists long-term in patients with significant coronary artery disease negatively impacts patient survival [3, 15, 16]. In a multicenter, prospective study, Lamas and coinvestigators [15] followed patients long-term after myocardial infarction and found that 3-year survival decreased significantly from 90% without residual MR to 70% with residual MR. Similarly, at the Cleveland Clinic, Ellis and associates [16] noted a diminution in 3-year survival from 92% to 69% after percutaneous coronary interventions in patients with 2+ or greater MR at the time of catheterization. Thus, if correction of MR can be performed safely at the time of CABG, it would be likely to have long-term benefit.

The goal of the current investigation was to determine whether addition of MV repair for patients with ischemic MR increased mortality compared with CABG alone, and to determine whether repair of significant MR at the time of CABG improved midterm survival and functional status in this high-risk patient population. Using propensity score analysis in an attempt to control selection bias, we found that when MV repair was added to CABG for patients with ischemic MR. Operative mortality was acceptable and identical to case-matched controls undergoing CABG alone. Unfortunately, midterm survival results did not parallel the low initial operative mortality rate, with 3-year survival of 70% in both groups. These data, while generated using propensity analysis to help minimize selection bias, are consistent with previous retrospective studies [2, 4–6]. Some investigators suggest that disappointing midterm survival in these patients reflects the "end-stage" nature of the disease process by the time surgeons are asked to intervene [17, 18]. Indeed, the best hope to improve outcomes in these high-risk patients may be to focus efforts on early intervention to prevent the detrimental myopathic changes consequent to ischemic remodeling.

Historically, MV replacement, when combined with CABG for ischemic MR, has been associated with operative mortality rates of 20% to 50% and poor long-term survival [4, 19, 20], likely due to selection bias. During the 6-year period of the current investigation, 16 additional patients with ischemic MR underwent simultaneous CABG with MV replacement rather than MV repair, all of whom had acute papillary muscle rupture or obvious infarction that was suspicious for impending rupture. We thought that this group represented a different subset of patients and did not think including these patients in the current analysis would be helpful. The overall mortality rate was 50% (8 of 16 patients) for this very high-risk group, including 63% for emergent and 38% for nonemergent cases.

Recent reports have successfully compared late results with repair versus replacement for ischemic MR in a statistically controlled fashion [21, 22]. Both studies suggested that MV repair may be better in low-risk patients, but as expected the patient populations were diverse. One study concluded that 70% of patients with ischemic MR benefit from repair over replacement, but in the high-risk setting, or with complex regurgitant jets, survival was similar with both techniques [22]. In the current report, the only patient in the CABG with MV repair group who underwent an emergent procedure died, as did 5 of 8 patients who underwent emergent CABG with MV replacement. In contrast, for nonemergent cases, the 50:8 ratio of repair to replacement for ischemic MR at our institution was similar to the data presented by other studies [21, 22] and is a consequence of our improved understanding of this complex disease and our belief that repair is preferred in lower-risk patients with functional ischemic MR.

The current study was subject to the limitations inherent to a nonrandomized, nonblinded study, including selection bias as to which patients underwent MV repair during CABG for ischemic MR. Propensity score analysis was used in an attempt to account for selection bias, but such biases are impossible to eliminate completely when the patient analysis is retrospective.

Early postoperative echocardiography was not performed routinely in all patients, especially during the first 3 years of the study. Therefore, follow-up data may have overestimated the severity of residual MR postoperatively, because these data were preferentially collected in patients with signs or symptoms of clinical congestive heart failure. In contrast, midterm NYHA class was likely skewed toward lower scores, because a substantial portion of patients with diminished function and elevated NYHA class postoperatively were among those who died during the follow-up period.

By design, this study encompassed only the most recent 6 years of our clinical experience, with an additional 2 years to increase minimum follow-up. This time period was selected because it was thought to represent a relatively consistent, modern approach to the management of patients with ischemic MR at our institution, most specifically, with a paradigm shift from replacement to repair for patients with functional MR. Thus, whereas maximum follow-up was limited to only 7 years, the prevailing opinion was that this time frame offered us the "cleanest" study groups in which to address the complex issue of ischemic MR.

In summary, the current report demonstrated that the addition of MV repair to CABG for patients with functional ischemic MR did not increase operative mortality. However, midterm survival was disappointing after either CABG alone or CABG with MV repair, and the impact of MV repair on midterm functional status was not evident from our results.

	Discussion

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DR ALAA Y. AFIFI (Albany, NY): I congratulate you on an excellent series, with a low mortality and very good midterm results. The concern of increased morbidity and mortality in the ischemic MR patient has been a profound problem for many of us for years.

The question and the problem that keeps plaguing many of us and that was noted in earlier debates during the postgraduate session was the issue of how to evaluate patients with moderate-to-severe MR. Do you identify them through transthoracic or transesophageal echocardiogram preoperatively or do you identify them through transesophageal echocardiogram after they are intubated in the operating room? In other words, when is the decision made to operate on these patients, that is, to do a concomitant mitral valve procedure in addition to coronary bypass grafting?

DR DIODATO: I can only comment on this series of patients. I cannot comment on the institutional policy at Washington University. All 102 patients of this study were identified to have had MR preoperatively with echocardiography. In the 51 patients not undergoing valve repair in this series, in cases in which the operating surgeon specifically noted the reason for not performing an operation, 66% of the time it was because of an intraoperative downgrading of MR on transesophageal echocardiogram. For the other 33% a cardiologist was consulted during the operation to review the transesophageal echocardiogram, and they concluded that the MR would be repaired with revascularization alone.

DR MOON: As Thor knows, at Washington University, our group is diverse and each surgeon has his own preference as to how he would treat these patients. However, our trend during the last 2 to 3 years has been to base our intraoperative decision on the preoperative evaluation. Preoperatively, most patients with diminished left ventricular function or mitral regurgitation on cardiac catheterization undergo a transthoracic echocardiogram. Patients with moderate-to-severe regurgitation on the transthoracic echocardiogram will then often undergo a transesophageal echocardiogram, with possible stressing, to better delineate the etiology of the regurgitation and determine the need for repair at the time of revascularization. It is rare, at least in my practice these days, that I find a patient with obvious reversible ischemia to the distal circumflex distribution whose regurgitation will be resolved by revascularization alone, at least in my opinion. I think we need to try now not to base the decision to repair the valve on the intraoperative evaluation. We all have learned by Aklog's paper and others [References 3–5 in the manuscript], that the downgrading that occurs during anesthesia may mislead us into making the wrong decision at the time of surgery.

DR ROBERT S. POSTON (Baltimore, MD): There are some data that high-risk patients demonstrate reduced mortality using an off-pump compared with on-pump approach. Yet all of the patients in your CABG-alone group were done on-pump. Have you analyzed the mortality of ischemic MR patients after off-pump CABG alone at Washington University?

DR DIODATO: We did not do that analysis for this study.

	Acknowledgments

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The authors gratefully acknowledge the clinical contributions of William A. Gay, Jr, MD, and Thoralf M. Sundt III, MD.

	References

Top Abstract Introduction Material and methods Results Comment Discussion Acknowledgments References

 

1. Duarte IG, Shen Y, MacDonald MJ, Jones EL, Craver JM, Guyton RA. Treatment of moderate mitral regurgitation and coronary disease by coronary bypass alone: late results. Ann Thorac Surg. 1999;68:426–430[Abstract/Free Full Text]
2. Gangemi JJ, Tribble CG, Ross SD, McPherson JA, Kern JA, Kron IL. Does the additive risk of mitral valve repair in patients with ischemic cardiomyopathy prohibit surgical intervention? Ann Surg. 2000;231:710–714[Medline]
3. Aklog L, Filsoufi F, Flores KQ, et al. Does coronary artery bypass grafting alone correct moderate ischemic mitral regurgitation? Circulation. 2001;104(Suppl 1):I-68–75
4. Harris KM, Sundt TM, Aeppli D, Sharma R, Barzilai B. Can late survival of patients with moderate ischemic mitral regurgitation be impacted by intervention on the valve? Ann Thorac Surg. 2002;74:1468–1475[Abstract/Free Full Text]
5. Tolis GA, Korkolis DP, Kopf GS, Elefteriades JA. Revascularization alone (without mitral valve repair) suffices in patients with advanced ischemic cardiomyopathy, and mild-to-moderate mitral regurgitation. Ann Thorac Surg. 2002;74:1476–1481[Abstract/Free Full Text]
6. Trichon BH, Glower DD, Shaw LK, et al. Survival after coronary revascularization, with and without mitral valve surgery, in patients with ischemic mitral regurgitation. Circulation. 2003;108(Suppl 2):II-103–110
7. Blackstone EH. Comparing apples and oranges. J Thorac Cardiovasc Surg. 2002;123:8–15[Free Full Text]
8. Gorman JH, Gorman RC, Jackson BM, et al. Distortions of the mitral valve in acute ischemic mitral regurgitation. Ann Thorac Surg. 1997;64:1026–1031[Abstract/Free Full Text]
9. Timek TA, Lai DT, Tibayan F, et al. Ischemia in three left ventricular regions: insights into the pathogenesis of acute ischemic mitral regurgitation. J Thorac Cardiovasc Surg. 2003;125:559–569[Abstract/Free Full Text]
10. Tibayan FA, Rodriguez F, Zasio MK, et al. Geometric distortions of the mitral valvular-ventricular complex in chronic ischemic mitral regurgitation. Circulation. 2003;108(Suppl 2):II-116–121
11. Moainie SL, Guy TS, Gorman JH, et al. Infarct restraint attenuates remodeling and reduces chronic ischemic mitral regurgitation after postero-lateral infarction. Ann Thorac Surg. 2002;74:444–449[Abstract/Free Full Text]
12. Menicanti L, Di Donato M, Frigola A, et al. Ischemic mitral regurgitation: intraventricular papillary muscle imbrication without mitral ring during left ventricular restoration. J Thorac Cardiovasc Surg. 2002;123:1041–1050[Abstract/Free Full Text]
13. Tibayan FA, Rodriguez F, Liang D, Daughters GT, Ingels NB, Miller DC. Paneth suture annuloplasty abolishes acute ischemic mitral regurgitation but preserves annular and leaflet dynamics. Circulation. 2003;108(Suppl 2):II-128–133
14. Messas E, Pouzet B, Touchot B, et al. Efficacy of chordal cutting to relieve chronic persistent ischemic mitral regurgitation. Circulation. 2003;108(Suppl 2):II-111–115
15. Lamas GA, Mitchell GF, Flaker GC, et al. Clinical significance of mitral regurgitation after myocardial infarction. Circulation. 1997;96:827–833[Abstract/Free Full Text]
16. Ellis SG, Whitlow PL, Raymond RE, Schneider JP. Impact of mitral regurgitation on long-term survival after percutaneous coronary intervention. Am J Cardiol. 2002;89:315–318[Medline]
17. Miller DC. Ischemic mitral regurgitation redux—to repair or to replace? J Thorac Cardiovasc Surg. 2001;122:1059–1062[Free Full Text]
18. Gorman RC, Gorman JH. Invited commentary on Tolis. Ann Thorac Surg. 2002;74:1481[Free Full Text]
19. Galloway AC, Grossi EA, Spencer FC, et al. Operative therapy for mitral insufficiency from coronary artery disease. Semin Thorac Cardiovasc Surg. 1995;7:227–232[Medline]
20. Cohn LH, Rizzo RJ, Adams DH, et al. The effect of pathophysiology on the surgical treatment of ischemic mitral regurgitation: operative and late risks of repair versus replacement. Eur J Cardiothorac Surg. 1995;9:568–574[Abstract]
21. Grossi EA, Goldberg JD, LaPietra A, et al. Ischemic mitral valve reconstruction and replacement: comparison of long-term survival and complications. J Thorac Cardiovasc Surg. 2001;122:1107–1124[Abstract/Free Full Text]
22. Gillinov AM, Wierup PN, Blackstone EH, et al. Is repair preferable to replacement for ischemic mitral regurgitation? J Thorac Cardiovasc Surg. 2001;122:1125–1141[Abstract/Free Full Text]

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				E. A. Grossi, G. A. Crooke, P. L. DiGiorgi, C. F. Schwartz, U. Jorde, R. M. Applebaum, G. H. Ribakove, A. C. Galloway, J. B. Grau, and S. B. Colvin Impact of Moderate Functional Mitral Insufficiency in Patients Undergoing Surgical Revascularization Circulation, July 4, 2006; 114(1_suppl): I-573 - I-576. [Abstract] [Full Text] [PDF]

				A. Cheng, T. C. Nguyen, M. Malinowski, D. Liang, G. T. Daughters, N. B. Ingels Jr, and D. C. Miller Effects of Undersized Mitral Annuloplasty on Regional Transmural Left Ventricular Wall Strains and Wall Thickening Mechanisms Circulation, July 4, 2006; 114(1_suppl): I-600 - I-609. [Abstract] [Full Text] [PDF]

				M. Di Mauro, G. Di Giammarco, G. Vitolla, M. Contini, A. L. Iaco, A. Bivona, L. Weltert, and A. M. Calafiore Impact of No-to-Moderate Mitral Regurgitation on Late Results After Isolated Coronary Artery Bypass Grafting in Patients With Ischemic Cardiomyopathy Ann. Thorac. Surg., June 1, 2006; 81(6): 2128 - 2134. [Abstract] [Full Text] [PDF]

				Pitfalls and limitations in measuring and interpreting the outcomes of mitral valve repair. J. Thorac. Cardiovasc. Surg., March 1, 2006; 131(3): 523 - 529.

				R. C. Gorman and J. H. Gorman III Why Should We Repair Ischemic Mitral Regurgitation? Ann. Thorac. Surg., February 1, 2006; 81(2): 785 - 785. [Full Text] [PDF]

				C. J. Barreiro, N. D. Patel, T. P. Fitton, J. A. Williams, P. N. Bonde, V. Chan, D. E. Alejo, V. L. Gott, and W. A. Baumgartner Aortic Valve Replacement and Concomitant Mitral Valve Regurgitation in the Elderly: Impact on Survival and Functional Outcome Circulation, August 30, 2005; 112(9_suppl): I-443 - I-447. [Abstract] [Full Text] [PDF]

				W. A. Baumgartner, S. Burrows, P. J. del Nido, T. J. Gardner, S. Goldberg, R. C. Gorman, G. V. Letsou, A. Mascette, R. E. Michler, J. D. Puskas, et al. Recommendations of the National Heart, Lung, and Blood Institute Working Group on Future Direction in Cardiac Surgery Circulation, June 7, 2005; 111(22): 3007 - 3013. [Abstract] [Full Text] [PDF]

				R. H. Jones The Year in Cardiovascular Surgery J. Am. Coll. Cardiol., May 3, 2005; 45(9): 1517 - 1528. [Full Text] [PDF]

				A. M. Calafiore, M. Di Mauro, M. Contini, L. Weltert, and A. Bivona Mitral valve repair in ischemic mitral regurgitation MMCTS, March 24, 2005; 2005(0324): 521. [Abstract] [Full Text] [PDF]

				Y. Enomoto, J. H. Gorman III, S. L. Moainie, T. S. Guy, B. M. Jackson, L. M. Parish, T. Plappert, A. Zeeshan, M. G. St. John-Sutton, and R. C. Gorman Surgical treatment of ischemic mitral regurgitation might not influence ventricular remodeling J. Thorac. Cardiovasc. Surg., March 1, 2005; 129(3): 504 - 511. [Abstract] [Full Text] [PDF]

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