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Published on: October 16, 2021
Meta-Analysis of Usefulness of Concomitant Mitral Valve Repair or Replacement for Moderate Ischemic Mitral
Salah E Altarabsheh1, Salil V Deo2, Shannon M Dunlay3
1Division of Cardiovascular Surgery, Queen Alia Heart Institute, Amman, Jordan.
Insights
Repairing moderate ischemic mitral regurgitation (MR) during coronary artery bypass grafting (CABG) improves valve function but does not enhance survival or functional outcomes at 5 years. This combined surgery (MVCABG) offers no clear benefit over isolated CABG for these patients.
Area of Science:
- Cardiology
- Cardiac Surgery
- Medical Meta-Analysis
Background:
- Moderate ischemic mitral regurgitation (MR) frequently co-occurs with coronary artery disease requiring coronary artery bypass grafting (CABG).
- The established clinical benefit of concurrently repairing moderate MR during CABG remains uncertain.
Purpose of the Study:
- To evaluate the clinical efficacy of concomitant mitral valve surgery with coronary artery bypass grafting (MVCABG) compared to isolated CABG.
- To assess the impact of MVCABG on survival and functional status in patients with moderate ischemic MR.
Main Methods:
- A meta-analysis was conducted on 11 studies (7 retrospective, 4 RCTs) involving 547 MVCABG patients and 900 CABG patients.
- Primary endpoints included early and midterm survival, New York Heart Association (NYHA) class, and MR severity.
- Hazard ratios and risk ratios were pooled to compare outcomes between the two groups.
Main Results:
- Concomitant mitral valve repair significantly increased surgical duration.
- Early mortality was comparable between MVCABG (6.9%) and CABG (6%) groups (p=0.11).
- While MVCABG reduced MR at follow-up (p=0.001), there were no significant differences in NYHA class (p=0.11) or midterm survival (p=0.38) at 5 years.
Conclusions:
- Concomitant mitral valve surgery during CABG effectively improves mitral valve competence postoperatively.
- Adding mitral valve repair to CABG for moderate ischemic MR did not translate into improved functional capacity or survival benefits at 5-year follow-up.
Abstract:
Moderate ischemic mitral regurgitation (MR) is often present in patients undergoing coronary artery bypass grafting (CABG). However, the clinical benefit of repairing moderate MR during CABG is unproven. We searched multiple databases to identify original studies comparing isolated CABG versus combined CABG and MR surgery (mitral valve surgery with coronary artery bypass grafting [MVCABG]); survival (either early or midterm) was the primary end point. Risk ratio (RR) or standardize mean difference was selected as the effect estimates; survival was compared by pooling hazard ratios. All results are presented with 95% CIs; p <0.05 is statistically significant. Eleven studies (7 retrospective and 4 randomized controlled trials; 547 MVCABG and 900 CABG patients) were included in our meta-analysis. Concomitant mitral valve repair significantly prolonged surgical duration (p <0.01). Early mortality (MVCABG 6.9% and CABG 6%) was comparable (RR 1.3 [0.9 to 1.8]; p = 0.11). At follow-up, the MVCABG patients had similar New York Heart Association class (standardize mean difference -0.73 (-1.64 to 0.18; p = 0.11). However, patients who underwent concomitant mitral valve surgery had less MR at follow-up (recurrent significant MR, RR 0.37 [0.22 to 0.62]; p = 0.001; mean MR grade, mean difference = 0.39 [0.26 to 0.59]; p <0.001). Midterm survival rate (mean follow-up 5 years) was comparable in both groups (hazard ratio for mortality in the MVCABG cohort 1.1 [0.9 to 1.3]; p = 0.38). In conclusion, concomitant repair of moderate ischemic MR leads to improved mitral valve competence at follow-up; however, this was not translated into any functional or survival benefit for adding valve repair to CABG for these patients at 5 years of follow-up.
