Outcomes of mitral valve repair in ischemic mitral regurgitation: A two-decade experience

The study objective was to evaluate long-term survival outcomes after mitral valve repair in patients with moderate or moderate-to-severe ischemic mitral regurgitation undergoing concomitant coronary artery bypass grafting.

We retrospectively analyzed 212 consecutive patients who underwent mitral valve repair with restrictive annuloplasty and concomitant coronary artery bypass grafting for ischemic mitral regurgitation and coronary artery disease at a tertiary center between January 2005 and May 2025. Survival at 1, 5, 10, 12, and 20 years was assessed using Kaplan-Meier estimates and Cox proportional hazard models. Differential survivals were compared using hazard ratios for the following variables: age more than 65 years, sex, diabetes, residual postoperative mitral regurgitation, incomplete revascularization, left ventricular ejection fraction less than 40%, left ventricular end-systolic diameter 45 mm or greater, and preoperative renal dysfunction (serum creatinine ≥1.5 mg/dL).

Of 212 patients, survival at 1, 5, 10, 12, and 20 years was 97.6%, 94.3%, 88.7%, 87.3%, and 81.1%, respectively. At 12 years, survival was significantly lower in patients with diabetes (82.1% vs 93% in nondiabetic patients; hazard ratio, 2.79 [1.18-6.61], P = .0197), residual mitral regurgitation (51.7% vs 92.9%; hazard ratio, 9.29 [4.30-20.04], P < .0001), and incomplete revascularization (38.9% vs 92.3%; hazard ratio, 11.19 [5.14-24.33], P < .0001). At 20 years, survival remained lower in diabetic patients (71.4% vs 93%; hazard ratio, 3.73 [1.71-8.12], P = .000933), patients with residual mitral regurgitation (51.7% vs 89.1%; hazard ratio, 8.38 [4.46-15.74], P < .0001), patients with incomplete revascularization (33.4% vs 86.1%; hazard ratio, 7.86 [3.97-15.55], P < .0001), and patients with left ventricular end-systolic diameter 45 mm or greater (65.9% vs 88.1%; hazard ratio, 5.29 [2.81-9.96], P < .0001). Age more than 65 years, sex, left ventricular ejection fraction less than 40%, and preoperative renal dysfunction did not significantly affect 12- or 20-year survival. On multivariate analysis, residual mitral regurgitation and incomplete revascularization independently predicted 12-year mortality, whereas at 20 years, residual mitral regurgitation, incomplete revascularization, and left ventricular end-systolic diameter 45 mm or greater were independent predictors.

This 2-decade experience shows that mitral valve repair with restrictive annuloplasty combined with coronary artery bypass grafting yields favorable long-term survival in moderate or moderate-to-severe chronic ischemic mitral regurgitation, particularly when residual mitral regurgitation is avoided, revascularization is complete, and preoperative left ventricular end-systolic diameter is less than 45 mm.