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Mitral valve surgery and coronary artery bypass grafting for moderate-to-severe ischemic mitral regurgitation: Meta-analysis of clinical and echocardiographic outcomes
Address for reprints: Christopher Cao, MBBS, BSc, PhD, The Systematic Review Unit, The Collaborative Research (CORE) Group, Macquarie University, Sydney, NSW 2011, Australia.
The Collaborative Research (CORE) Group, Macquarie University, Sydney, AustraliaDepartment of Cardiothoracic Surgery, St George Hospital, Sydney, Australia
This meta-analysis was conducted to compare clinical and echocardiographic outcomes following isolated coronary artery bypass grafting (CABG) versus CABG and mitral valve (MV) surgery in patients with moderate-to-severe ischemic mitral regurgitation (IMR).
Methods
Seven databases were systematically searched to identify relevant studies. For eligibility, studies were required to report on the primary endpoint of perioperative or late mortality. Data were analyzed according to predefined clinical endpoints.
Results
Four randomized controlled trials (RCTs) (n = 505) and 15 observational studies (OS) (n = 3785) met the criteria for inclusion. Compared with isolated CABG, concomitant CABG and MV surgery was not associated with increased perioperative mortality (RCTs: relative risk [RR] 0.89, 95% confidence interval [CI], 0.26-3.02; OS: RR 1.40, 95% CI, 0.88-2.23). CABG and MV surgery was associated with significantly lower incidence of moderate-to-severe MR at follow-up (RCTs: RR 0.16, 95% CI, 0.04-0.75; OS: RR 0.20, 95% CI, 0.09-0.48). Late mortality was similar between the surgical approaches in RCTs (hazard ratio [HR] 1.20, 95% CI, 0.57-2.53) and OS (HR 0.99, 95% CI, 0.81-1.21). There were no significant differences in echocardiographic outcomes. These results remained consistent in subgroup analyses restricted to patients with strictly moderate IMR.
Conclusions
In patients with moderate-to-severe IMR, the addition of MV surgery to CABG was not associated with increased perioperative mortality. Although concomitant MV surgery reduced recurrence of moderate-to-severe MR at follow-up, this was not associated with a reduction in late mortality. Larger trials with longer follow-up duration are required to further assess long-term survival and freedom from reintervention.
In patients with moderate-to-severe ischemic mitral regurgitation, there was no difference in perioperative or late mortality following isolated CABG versus CABG and mitral valve surgery.
In patients with moderate-to-severe ischemic mitral regurgitation, the addition of mitral valve (MV) surgery to coronary artery bypass grafting was not associated with increased perioperative mortality. Concomitant MV surgery reduced recurrence of moderate-to-severe mitral regurgitation at follow-up, but this was not associated with a reduction in late mortality.
The development of IMR is associated with an increased risk of mortality and heart failure, and this risk increases with the severity of regurgitation.
In IMR, valvular insufficiency is predominantly due to the adverse left ventricular remodeling and annular dilatation that occurs following myocardial injury, resulting in tethered mitral leaflets with poor coaptation.
Isolated coronary artery bypass grafting (CABG) is well-established as the standard treatment for trivial-to-mild IMR.
American College of Cardiology/ American Heart Association Task Force on Practice Guidelines. 2014 AHA/ ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
Revascularization alone may sufficiently restore left ventricular function and dimensions, thereby addressing regurgitation without the potentially increased perioperative risk associated with concomitant mitral valve (MV) surgery.
The aim of the present meta-analysis was to compare clinical and echocardiographic outcomes following isolated CABG and CABG and MV surgery in patients with at least moderate IMR.
Methods
Search Strategy and Study Selection
Electronic searches were performed using Ovid Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register, Database of Abstracts of Reviews of Effects, and ACP Journal Club from their dates of inception to February 2016. The search terms “mitral” AND (“ischemic” OR “ischaemic”) AND (“repair” OR “annuloplasty” OR “replacement”) AND (“mortality” OR “death” OR “survival”) were entered as keywords and MeSH terms. This was supplemented by hand searching the reference lists of key reviews and all potentially relevant studies.
Two reviewers (A.S. and D.D.) independently screened the title and abstract of records identified in the search. Full-text publications were subsequently reviewed separately if either reviewer considered the manuscript as being potentially eligible. Disagreements regarding final study inclusion were resolved by discussion and consensus.
Eligibility Criteria
Eligible studies were those reporting perioperative mortality or late survival following isolated CABG and CABG and MV surgery in patients with at least moderate IMR. Studies were excluded if they included patients with trivial-to-mild IMR without subgroup analysis by IMR severity. Studies with fewer than 10 patients in either the isolated CABG or CABG and MV surgery arm were also excluded.
All publications were limited to those involving human subjects and written in English. Abstracts, conference presentations, editorials, and expert opinions were excluded. Review articles were omitted because of potential publication bias and duplication of results. When institutions published duplicate studies with accumulating numbers of patients or increased lengths of follow-up, only the most complete reports were included for quantitative assessment.
Data Extraction
All data were independently extracted from text, tables, and figures by 2 investigators (A.S. and D.D.). The final results were reviewed by the senior reviewer (C.C.). The predetermined primary endpoints were perioperative mortality and late survival. Perioperative mortality was defined as death within 30 days after surgery or during the same hospitalization. Secondary outcomes included perioperative morbidity, recurrence of moderate-to-severe MR (grade ≥2) at latest follow-up, aortic cross-clamp and cardiopulmonary bypass (CPB) durations, New York Heart Association (NYHA) functional status, and echocardiographic measurements.
Statistical Analysis
Baseline characteristics and operative details were presented as raw values (%), mean ± standard deviation or median (interquartile range [IQR]) unless otherwise indicated. The relative risk (RR), mean difference (MD), or hazard ratio (HR) were used as the summary statistics, and reported with 95% confidence intervals (CIs). When available, adjusted ratios were used from individual studies. Otherwise, unadjusted ratios were computed from the exposure distribution given in the articles. For survival analysis, HRs and associated variance were obtained or calculated from each study by using techniques described by Parmar et al
When direct calculations were not possible due to a lack of presented data, HRs were estimated using Kaplan-Meier graphs. For analysis of continuous data, data presented as median and IQR were converted to mean and standard deviation using the method of Wan et al.
Meta-analyses were performed by using random-effects models to take into account the anticipated clinical and methodological diversity between studies. The I2 statistic was used to estimate the percentage of total variation across studies due to heterogeneity rather than chance, with values exceeding 50% indicative of considerable heterogeneity. Mixed-effects meta-regression models were formed by using follow-up duration as a continuous moderator to assess its impact on the incidence of survival and residual MR.
Subgroup analysis was performed by study design to take into account the different levels of evidence provided by observational studies and randomized trials. Sensitivity analysis was performed by IMR severity to specifically assess the impact of concomitant MV surgery in patients with moderate IMR. Publication bias was assessed by using funnel plots comparing log odds ratios with their standard error. The Egger linear regression method and Begg rank correlation test were used to detect funnel plot asymmetry.
Statistical analysis was conducted with Review Manager Version 5.1.2 (Cochrane Collaboration, Software Update, Oxford, United Kingdom) and publication bias assessed by using Comprehensive Meta-Analysis v2.2 (Biostat Inc, Englewood, NJ). All P values were 2 sided, and values < .05 were considered statistically significant.
Results
A total of 1125 unique records were identified through the database and bibliographic searches. Of these, 1091 were excluded on the basis of title and abstract content. After screening the full text of the remaining 34 articles, 20 studies met the criteria for inclusion.
Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation final results of the Randomized Ischemic Mitral Evaluation (RIME) trial.
POINT: efficacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: a randomized trial.
Early hazards of mitral ring annuloplasty in patients with moderate to severe ischemic mitral regurgitation undergoing coronary revascularization: the importance of preoperative myocardial viability.
Moderate-to-severe ischemic mitral regurgitation and multivessel coronary artery disease: impact of different treatment on survival and rehospitalization.
Repair of ischemic mitral regurgitation does not increase mortality or improve long-term survival in patients undergoing coronary artery revascularization: a propensity analysis.
Of the included studies, 4 were randomized controlled trials (RCTs) and the remainder were observational studies. These included data on a total of 4290 patients, including 3038 who underwent isolated CABG and 1252 patients who underwent combined CABG and MV surgery. For patients who underwent MV surgery, all patients included in the RCTs, and most patients included in the observational studies, underwent mitral valve repair. The mean or median follow-up duration ranged from 12 to 87 months. A full summary of study characteristics is presented in Table 1. Baseline demographic and clinical characteristics of study participants are summarized in Table 2.
Table 1Summary of studies comparing isolated coronary artery bypass graft surgery versus concomitant mitral repair for ischemic mitral regurgitation
Data presented as n (%), mean ± standard deviation, or median [interquartile range], unless stated otherwise. CABG, Coronary artery bypass graft; MVS, mitral valve surgery; MR, mitral regurgitation; RCT, randomized controlled trial; MVr, mitral valve repair; OS, observational study; MVR, mitral valve replacement; NR, not reported; NS, not specified; M, median; m, mean.
Table 2Baseline characteristics of participants in studies comparing isolated coronary artery bypass graft surgery versus concomitant mitral repair for ischemic mitral regurgitation
In 4 RCTs and 11 observational studies including a total of 1963 patients, CABG and MV surgery was associated with significantly longer CPB (MD 48.12; 95% CI, 38.05-58.15; P < .001; Figure 2, A) and aortic cross-clamp (MD 39.13; 95% CI, 32.39-45.86; P < .001; Figure 2, B) durations. These results were consistent in subgroup analyses by study design.
Figure 2Forest plot displaying the mean difference (MD) in aortic cross-clamp (2A) and cardiopulmonary bypass (CPB) durations (2B) for isolated coronary artery bypass graft (CABG) surgery versus CABG and mitral valve (MV) surgery. The MD in each study corresponds to the middle of the squares, the horizontal lines show the 95% confidence intervals (CIs), and the pooled MD is represented by the middle of the solid diamond. A test of heterogeneity between studies is given below the summary statistics. SD, Standard deviation; RCT, randomized controlled trial.
In 3 RCTs including a total of 474 patients, concomitant MV surgery was not associated with significantly increased perioperative mortality compared with CABG alone (RR 0.89; 95% CI, 0.26-3.02; P = .85; I2 = 0%; Figure 3, A). Likewise, in 14 observational studies including a total of 1975 patients, perioperative mortality was not significantly increased with the addition of concomitant MV surgery (RR 1.40; 95% CI, 0.88-2.23; P = .16; I2 = 35%; Figure 3, B).
Figure 3Forest plot displaying relative risk (RR) for perioperative mortality following isolated coronary artery bypass graft (CABG) surgery versus CABG and mitral valve (MV) surgery in randomized controlled trials (3A) and observational studies (3B). The RR of individual studies correspond to the middle of the squares, the horizontal lines show the 95% confidence intervals (CIs), and the pooled RR is represented by the middle of the solid diamond. A test of heterogeneity between studies is given below the summary statistics. RCT, Randomized controlled trial.
In 3 RCTs including a total of 203 patients, CABG and MV surgery was not associated with significantly increased risk of stroke (RR 1.65; 95% CI, 0.27-10.22; P = .53; I2 = 0%).
Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation final results of the Randomized Ischemic Mitral Evaluation (RIME) trial.
POINT: efficacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: a randomized trial.
Likewise, in 2 observational studies including a total of 182 patients, the risk of stroke was not significantly increased with concomitant MV surgery (RR 0.90; 95% CI, 0.23-3.53; P = .70; I2 = 0%).
In 2 RCTs including a total of 173 patients, the incidence of acute renal failure was not significantly increased with the addition of MV surgery (RR 1.38; 95% CI, 0.44-4.31; P = .58; I2 = 0%).
Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation final results of the Randomized Ischemic Mitral Evaluation (RIME) trial.
POINT: efficacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: a randomized trial.
Similarly, in 3 observational studies including a total of 433 patients, there was no significant difference in acute renal failure between the 2 groups (RR 1.08; 95% CI, 0.28-4.19; P = .91; I2 = 79%).
Meta-analyses could not be performed for other morbidity endpoints due to the lack of outcome reporting across studies.
Survival
In 3 RCTs involving a total of 462 patients, there was no difference in survival at follow-up between patients who underwent isolated CABG and those who underwent CABG and MV surgery (HR 1.20; 95% CI, 0.57-2.53; P = .62; I2 = 0%; Figure 4, A). Similarly, in 14 observational studies involving a total of 3828 patients, the 2 surgical cohorts had similar survival at the time of latest follow-up (HR 0.99; 95% CI, 0.81-1.21; P = .92; I2 = 47%; Figure 4, B). Aggregated survival was calculated by using either Kaplan-Meier curves assuming constant censoring
POINT: efficacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: a randomized trial.
Moderate-to-severe ischemic mitral regurgitation and multivessel coronary artery disease: impact of different treatment on survival and rehospitalization.
Early hazards of mitral ring annuloplasty in patients with moderate to severe ischemic mitral regurgitation undergoing coronary revascularization: the importance of preoperative myocardial viability.
Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation final results of the Randomized Ischemic Mitral Evaluation (RIME) trial.
Figure 4Forest plot displaying hazard ratio (HR) for late mortality following isolated coronary artery bypass graft (CABG) surgery versus CABG and mitral valve (MV) surgery in randomized controlled trials (4A) and observational studies (4B). The HR of individual studies correspond to the middle of the squares, the horizontal lines show the 95% confidence intervals (CIs), and the pooled HR is represented by the middle of the solid diamond. A test of heterogeneity between studies is given below the summary statistics. RCT, Randomized controlled trial; SE, standard error.
Recurrence of Moderate-to-Severe Mitral Regurgitation
In 4 RCTs including a total of 459 patients, CABG and MV surgery was associated with significantly lower incidence of moderate-to-severe (grade ≥ 2) regurgitation at latest follow-up (RR 0.16; 95% CI, 0.04-0.75; P = .02; I2 = 68%; Figure 5, A). This result was also demonstrated in an analysis of 4 observational studies including a total of 312 patients (RR 0.25; 95% CI, 0.12-0.50; P < .001; I2 = 21%; Figure 5, B).
Figure 5Forest plot displaying relative risk (RR) for recurrence of moderate-to-severe mitral regurgitation following isolated coronary artery bypass graft (CABG) surgery versus CABG and mitral valve (MV) surgery in randomized controlled trials (5A) and observational studies (5B). The RR of individual studies corresponds to the middle of the squares, the horizontal lines show the 95% confidence intervals (CIs), and the pooled RR is represented by the middle of the solid diamond. A test of heterogeneity between studies is given below the summary statistics. RCT, Randomized controlled trial.
Due to limited data from observational studies, meta-analyses of echocardiographic outcomes were limited to RCTs. In 3 RCTs including 402 patients, CABG and MV surgery was not associated with significantly greater increase in left ventricular ejection fraction (LVEF) at follow-up (MD 0.19; 95% CI, −3.26 to 3.65; P = .91).
POINT: efficacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: a randomized trial.
In 2 RCTs including 339 patients, the decrease in left ventricular end-systolic volume index (LVESVI) was not significantly greater following CABG and MV surgery (weighted mean difference [WMD] −3.59; 95% CI, −17.98 to 10.81; P = .63).
Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation final results of the Randomized Ischemic Mitral Evaluation (RIME) trial.
In 2 RCTs including 88 patients, the decrease in residual regurgitant volume was not significantly different between patients who underwent CABG and MV surgery and those who underwent isolated CABG (WMD −4.78; 95% CI, −26.61 to 17.06; P = .67; I2 = 94%).
Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation final results of the Randomized Ischemic Mitral Evaluation (RIME) trial.
In 3 RCTs including a total of 330 patients, the proportion of patients in NYHA class III/IV at follow-up were similar following isolated CABG or CABG and MV surgery (RR 0.67; 95% CI, 0.25-1.82; P = .43; I2 = 18%).
Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation final results of the Randomized Ischemic Mitral Evaluation (RIME) trial.
This result was also demonstrated in an analysis of 4 observational studies including a total of 292 patients (RR 1.23; 95% CI, 0.78-1.93; P = .37; I2 = 5%).
Factors associated with excessive postoperative blood loss and hemostatic transfusion requirements: a multivariate analysis in cardiac surgical patients.
Subgroup analysis was conducted to assess studies in which all patients had only moderate IMR. This included 4 RCTs and 4 observational studies, reporting on a total of 1155 patients.
Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation final results of the Randomized Ischemic Mitral Evaluation (RIME) trial.
POINT: efficacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: a randomized trial.
Within this group, combined CABG and MV surgery was found to be associated with significantly increased perioperative mortality in observational studies (RR 1.81; 95% CI, 1.03-3.15; P = .02; I2 = 0%) but not within RCTs (RR 0.89; 95% CI, 0.26-3.02; P = .85; I2 = 0%). Patients who underwent combined CABG and MV surgery still had significantly reduced recurrence of MR at latest follow-up in both RCTs (RR 0.16; 95% CI, 0.04-0.75; P < .001; I2 = 68%) and observational studies (RR 0.26; 95% CI, 0.11-0.65; P = .004; I2 = 38%). There remained no difference between the surgical approaches with regard to long-term survival (HR 1.09; 95% CI, 0.84-1.42; P = .53; I2 = 0%) or NYHA functional status (RR 1.16; 95% CI, 0.61-2.21; P = .65; I2 = 37%).
Meta-Regression Analyses
Meta-regression analyses demonstrated that duration of follow-up was not a significant moderator for long-term survival (P = .60) and residual MR (P = .20). Meta-regression analyses could not be performed for other endpoints due to the paucity of studies.
Publication Bias
Neither the Begg rank correlation test (P = .51) nor Egger linear regression method (P = .40) suggested publication bias was a significant factor when perioperative mortality was selected as an endpoint. Likewise, publication bias was not found to significantly influence results for late mortality (Begg rank correlation test, P = .97; Egger linear regression method, P = .51).
Discussion
Despite the prevalence of IMR in patients referred for surgical revascularization and its association with poorer clinical outcomes, the optimal management of moderate-to-severe IMR remains unclear.
The present meta-analysis assessed the safety and efficacy of isolated CABG versus combined CABG and MV surgery in patients with moderate-to-severe IMR. Concomitant MV surgery was not associated with an increase in perioperative mortality. However, the addition of MV surgery to CABG resulted in significantly reduced recurrence of moderate-to-severe MR at latest follow-up. There was no significant difference in late mortality or NYHA functional status between patients who underwent isolated CABG or those who underwent CABG and MV surgery. These findings were replicated in subgroup analysis conducted to assess the impact of concomitant MV surgery in patients with strictly moderate IMR.
CPB and aortic cross-clamp durations were found to be significantly higher in patients undergoing CABG + MV surgery. This is an intuitive finding given the increased complexity of a combined procedure. Longer CPB and aortic cross-clamp durations have been linked with a number of complications, including microemboli, increased transfusion requirements, coagulation defects, and immunosuppression.
Factors associated with excessive postoperative blood loss and hemostatic transfusion requirements: a multivariate analysis in cardiac surgical patients.
In the present meta-analysis, increased operative durations did not translate to an increase in adverse perioperative events. However, it must be emphasized that the present study was unable to assess key perioperative morbidity outcomes, such as major bleeding, reoperation, myocardial infarction, and wound infection. In particular, there were a very limited number of studies assessing neurological events and the event rate may have been too low to enable sufficiently powered analysis. Indeed, in 2 of the included RCTs, the point estimate for stroke suggested a possible trend toward increased risk following combined CABG + MV surgery.
Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation final results of the Randomized Ischemic Mitral Evaluation (RIME) trial.
As such, given the paucity of endpoints reported in current studies, it is not possible to exclude an increased risk of perioperative morbidity with the addition of concomitant MV surgery.
Key findings from the present study demonstrated that the proportion of patients with residual MR of at least moderate severity was significantly lower following concomitant mitral intervention. However, this was not associated with any significant advantage with regard to survival or functional status at the time of latest follow-up. This represents an unexpected finding given the association previously demonstrated between persistent MR and increased mortality.
It is possible the limited sample size and follow-up durations of the included studies, particularly the RCTs, may not have provided sufficient time or statistical power to highlight the clinical benefit of reduced residual MR. Alternatively, surgical revascularization alone may have sufficiently improved adverse left ventricular remodeling and contractility so as to mitigate the adverse impact of residual MR.
The latter suggestion was supported by our meta-analysis of echocardiographic outcomes, which demonstrated similar pooled LVEF and LVESVI in patients who underwent either isolated CABG or CABG and MV surgery. Nonetheless, larger randomized trials with longer follow-up durations are required to clarify this discrepancy between echocardiographic and clinical outcomes.
The present meta-analysis highlighted the considerable variability that exists with regard to the definition of “moderate” IMR. Although the American Society of Echocardiography and American Heart Association/American College of Cardiology have proposed standardized guidelines for the determination of MR grade,
2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease) Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.
Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation final results of the Randomized Ischemic Mitral Evaluation (RIME) trial.
Most included studies graded MR severity according to local institutional criteria, using a wide range of cutoffs for jet regurgitant area, vena contracta diameter, and/or proximal isovelocity surface area. This likely contributed to the considerable heterogeneity present in several of our analyses. To standardize comparative data across institutions, it is imperative that future studies use well-defined echocardiographic grading criteria according to established guidelines.
Results of the present meta-analysis were limited by several restraints, and should be interpreted with caution. First, there were only 4 RCTs, and observational studies provided a significant proportion of clinical data. As observational studies did not use propensity-score matching or report adjusted estimates, it was not possible to account for potential baseline differences between the 2 surgical arms. In recognition of this limitation, we performed subgroup analyses by study design. Second, due to the lack of reporting, it was not possible to assess quality-of-life scores or measures of resource utilization and cost-effectiveness, such as length of intensive care unit stay, despite these being increasingly key considerations in clinical practice. Third, follow-up periods and endpoint definitions differed between institutions, and some studies may have underestimated adverse events due to incomplete follow-up. Although meta-regression analyses did not demonstrate significant interaction between follow-up duration and survival or residual MR, there was not enough data to perform meta-regression for other outcomes such as NYHA functional class. Last, due to the lack of available data, residual MR was assessed using a binary approach rather than through a longitudinal, competing risks method.
In conclusion, available data in the current literature demonstrated that MV surgery in addition to CABG was not associated with increased perioperative mortality in patients with moderate-to-severe IMR. Compared with isolated CABG, concomitant MV surgery was associated with reduced recurrence of moderate-to-severe MR at follow-up. However, there was no significant difference between the 2 treatment approaches with regard to late mortality or NYHA functional status. Larger trials with longer follow-up duration are required to further assess overall survival and freedom from reintervention, as well as the impact of both surgical approaches on quality of life and health care costs.
Conflict of Interest Statement
Authors have nothing to disclose with regard to commercial support.
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Enriquez-Sarano M.
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Roger V.L.
Mitral regurgitation after myocardial infarction: a review.
American College of Cardiology/ American Heart Association Task Force on Practice Guidelines. 2014 AHA/ ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation final results of the Randomized Ischemic Mitral Evaluation (RIME) trial.
POINT: efficacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: a randomized trial.
Early hazards of mitral ring annuloplasty in patients with moderate to severe ischemic mitral regurgitation undergoing coronary revascularization: the importance of preoperative myocardial viability.
Moderate-to-severe ischemic mitral regurgitation and multivessel coronary artery disease: impact of different treatment on survival and rehospitalization.
Repair of ischemic mitral regurgitation does not increase mortality or improve long-term survival in patients undergoing coronary artery revascularization: a propensity analysis.
Factors associated with excessive postoperative blood loss and hemostatic transfusion requirements: a multivariate analysis in cardiac surgical patients.
2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease) Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.
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