Does coronary artery bypass grafting alone correct moderate ischemic mitral regurgitation?
L Aklog1, F Filsoufi, K Q Flores
1Divisions of Cardiac Surgery and Anesthesiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. laklog@partners.org
Insights
Coronary artery bypass grafting (CABG) alone for moderate ischemic mitral regurgitation (MR) often results in persistent moderate or severe MR. Concomitant mitral annuloplasty may be a better option for these patients.
Area of Science:
- Cardiology
- Cardiac Surgery
- Cardiovascular Imaging
Background:
- Optimal management of moderate ischemic mitral regurgitation (MR) is debated.
- Surgical options include isolated coronary artery bypass grafting (CABG) or CABG with mitral annuloplasty.
Purpose of the Study:
- To evaluate the early impact of isolated CABG on moderate ischemic MR.
- To determine if isolated CABG is sufficient for moderate ischemic MR.
Main Methods:
- Retrospective analysis of 136 patients with moderate ischemic MR undergoing isolated CABG.
- Intraoperative transesophageal echocardiography (TEE) and postoperative transthoracic echocardiography (TTE) were used to assess MR severity.
Main Results:
- 30-day operative mortality was 2.9%.
- Intraoperative TEE underestimated MR severity in 89% of cases.
- Postoperative TTE showed 40% of patients still had moderate or severe MR, 51% had mild MR, and 9% had resolved MR.
Conclusions:
- Isolated CABG alone for moderate ischemic MR often leaves significant residual regurgitation.
- Intraoperative TEE may underestimate MR severity.
- Preoperative diagnosis of moderate MR may indicate the need for concomitant mitral annuloplasty.
Background:
The optimal management of moderate (3+ on a scale of 0 to 4+) ischemic mitral regurgitation (MR) remains controversial. Some advocate CABG alone, whereas others favor concomitant mitral annuloplasty. To clarify the optimal management of these patients, we evaluated the early impact of isolated CABG on moderate ischemic MR.
Methods And Results:
Between January 1992 and August 1999, 136 patients (54% male, mean age 70.5 years, mean New York Heart Association class 2.7, mean ejection fraction 38.1%) with a preoperative diagnosis of moderate ischemic MR, without leaflet prolapse or pathology, underwent isolated CABG. Thirty-eight (28%) of 136 patients had intraoperative transesophageal echocardiography (TEE) before CABG, and 68 (50%) had postoperative transthoracic echocardiography (TTE) within 6 weeks of surgery. The subgroups of patients undergoing intraoperative TEE and postoperative TTE had preoperative characteristics similar to the overall group. The 30-day operative mortality was 2.9% (). Intraoperative TEE downgraded the severity of MR to mild or less (0 to 2+) in 89% (). On postoperative TTE, 40% () continued to have at least moderate MR (3 to 4+), 51% () improved somewhat to mild (2+) MR, and only 9% () had resolution of their MR (0 to 1+). The mean preoperative, intraoperative, and postoperative MR grades were 3.0+/-0.0, 1.4+/-1.0, and 2.3+/-0.8, respectively (P<0.001).
Conclusions:
CABG alone for moderate ischemic MR leaves many patients with significant residual MR and may not be the optimal therapy for most patients. Intraoperative TEE may significantly underestimate the severity of ischemic MR. A preoperative diagnosis of moderate MR may warrant concomitant mitral annuloplasty.
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