1. 李孟霖, 蔡函衿, 陳瑞雄, 侯紹敏 國泰綜合醫院 心臟血管外科
Surgical outcomes of ischemic mitral regurgitation: experience from one medical center
李孟霖, 蔡函衿, 陳瑞雄, 侯紹敏 國泰綜合醫院 心臟血管外科

2. Introduction Definition:
Ischemic mitral regurgitation (IMR) is mitral regurgitation caused by ischemic heart disease.
NOT mitral regurgitation from other causes that coexist with ischemic heart disease.
Functional valve incompetence due to myocardial injury and adverse left ventricular remodeling.

3. Prevalence Myocardial infarction (MI): one million Americans/ year
8 million Americans have a history of MI.
IMR develops in 50% of patients after MI.
Moderate degree IMR occurs in >10% of patients after MI.
An important predictor of mortality

4. Pathophysiology Central Jet LV dysfunction:
LV dilatation (remodeling, increased sphericity)
Papillary muscle displacement (dysfunction)
Leaflet tethering
Reduced closing forces
Annular dilatation
Papillary muscle ischemia:
Rupture
Necrosis (dysfunction)
Central Jet
The valve leaflets and chordal structures are “ innocent bystanders”.

5. MR severity by echo

6. Prognosis
Grigioni F, Enriquez-Sarano M, Zehr KJ, et al. Ischemic mitral regurgitation: long-term outcome
and prognostic implications with quantitative Doppler assessment. Circulation 2001;103:1759.

7. Treatment --------------Difficult in decision making---------------
When MR is severe: repair or replacement ?
When MR is variable or moderate: mitral valve may be left alone ?

8. Mitral valve anuloplasty
Sorin Memo 3D Ring
St Jude Medical Rigid Saddle Ring
Rigid ring:
Better IMR improvement: (P=0.006)
Lower prevalence of recurrent MR
Restrictive annuloplasty:
2 or more sizes < the size conforms to anterior mitral leaflet and the intertrigonal distance
Silberman S, Klutstein MW, Sabag T, et al. Repair of ischemic mitral regurgitation:
comparison between flexible and rigid annuloplasty rings. Ann Thorac Surg. 2009;87:

9. Mortality Early mortality: Long-term survival: 3-11%
Higher if risk factors (+):
low EF, extensive CAD, old age, CKD, low hematocrit, LVEDD> 65mm, longer CPB, need for inotropic support.
Long-term survival:
In low risk group: 5-year survival: (P=0.08)
Mitral repair: 58%
Mitral replacement: 36%
In high risk group: ( age, NYHA Fc, wall motion abnormality, renal function)
No survival benefit of mitral repair
Gillinov AM, Wierup PN, Blackstone EH, et al. Is repair preferable to replacement
for ischemic mitral regurgitation? J Thorac Cardiovasc Surg 2001;122:1125

10. Experience in our hospital
2008~2015 IMR (n=22)
Gender
M:21(95.5%) F:1(4.5%)
Age(y)
62.1±11.4
BSA
1.76±0.13
BMI
25.5±4.0 ES
1(4.5%)
Procedure
MVR:4(18.2%); MV repair:18(81.8%)
CPB time(min)
165.4±38.4
Cx time(min)
113.8±33.6
Old CVA DM
13(59.1%)
HTN
11(50.0%)
COPD
3(13.6%)
Cr.>2.0
5(22.7%)
Uremia
0(0.0%)
Graft no.
2.0±0.8
Euro Score
7.0±3.7
Logistic Euro Score %
12.3±13.7
pre-LVEF
33.3±15.3
Pre OP IABP

11. In-Hospital Mortality
Result
Ventilator(Hr)
55.2±44.5
Ventilator>7days
1(4.5%)
Drain day1(ml)
951.5±861.6
Drain day2(ml)
428.0±379.8
Transfer to ward Hb
10.9±1.0
LOIS(day)
8.2±9.1
LOHS(day)
25.6±29.7
Inotropic use>2.0
20(90.9%)
last-LVEF
39.9±16.3
Post OP IABP
11(50.0%)
Reopen
0(0.0%)
Newonset Af
6(27.3%)
Phrenic palsy
Valve leakage
TND(ICUsyndrome)
3(13.6%)
PND(CVA,hypoxia)
W'd infection
In-Hospital Mortality

12. Mortality In Hospital Mortality: 3 Late Mortality: 2 MVR: 1
Expire on POD 15 due to pneumonia, sepsis, MOF
MV repair: 2
Expire on the day of operation due to RV failure (pre-op EF 22%)
Expire on the same day of operation in ICU (pre-op EF 18%)
Late Mortality: 2
Prolonged recovery, expire on 8 months after operation as OHCA when arriving at ER
Death due to irrelevant cancer issue 6 years after operation

13. Survival Curve 1年 3年 5年
Survival rate
81.6%
平均追蹤時間：2.9±2.4 years

14. MVR vs. MV repair MVR (N=4) MV repair (N=18) P Gender M:3(75.0%)
MVR
(N=4)
MV repair
(N=18) P
Gender
M:3(75.0%)
F:1(25.0%)
M:18(100.0%) F:0(0.0%)
0.030
Age(y)
63.0±14.8
61.9±11.0
0.871
BSA
1.77±0.14
1.76±0.13
0905
BMI
27.3±5.5
25.1±3.6
0.330 ES
0(0.0%)
1(5.6%)
0.629
CPB time(min)
195.3±65.5
158.7±28.3
0.349
Cx time(min)
148.5±58.7
106.1±28.3
0.244
Old CVA DM
1(25.0%)
12(66.7%)
0.125
HTN
3(75.0%)
8(44.4%)
0.269
COPD
2(50.0%)
0.019
Cr.>2.0
4(22.2%)
0.905
Uremia
Graft no.
1.75±0.96
2.00±0.84
0.604
Euro Score
4.3±2.5
7.6±3.6
0.098
Logistic Euro Score %
4.8±4.8
14.0±14.5
0.236
pre-LVEF
46.0±13.9
30.4±14.4
0.063
Pre OP IABP

15. Result 2008~2015 IMR (n=22) MVR (N=4) MV repair (N=18) P
MVR
(N=4)
MV repair
(N=18) P
Ventilator(Hr)
73.7±68.5
50.6±38.1
0.365
Ventilator>7days
0(0.0%)
1(5.9%)
0.619
Drain day1(ml)
937.5±1025.7
955.0±854.3
0.972
Drain day2(ml)
277.5±161.1
465.6±412.3
0.390
Transfer to ward Hb
10.8±1.1
10.9±1.1
0.798
LOIS(day)
7.0±4.2
8.5±10.0
0.771
LOHS(day)
15.8±10.9
27.9±32.4
0.474
Inotropic use>2.0
4(100.0%)
16(88.9%)
0.484
last-LVEF
38.5±22.6
34.4±17.1
0.693
Post OP IABP
1(25.0%)
10(55.6%)
0.269
Reopen
Newonset Af
6(33.3%)
0.176
Phrenic palsy
1(5.6%)
0.629
Valve leakage
TND(ICUsyndrome)
2(11.1%)
0.464
PND(CVA,hypoxia)
W'd infection
In Hospital Mortality

16. MVR vs. MV repair Survival1年 3年 5年
MVR
75.0%
MV repair
83.0%

17. Discussion What kind of surgical strategy? CABG alone CABG + MV repair

18. Indication of surgery
Ischemic MR

19. Severe IMR There is general agreement to surgically treat severe IMR.
The most effective surgical approach to the treatment of severe IMR remains controversial.
Practice guidelines recommend consideration of MV repair or chordal-sparing MVR.

20. Repair or Replacement? Meta-analysis
22 observational studies (n=3815) and 1 RCT (n=251)

21. Results Reduced perioperative mortality in MV repair
6.6% vs. 11.4%; P<0.001
Reduced late mortality in MV repair
16.8% vs. 22.2% ( F/U duration: months); P=0.002
15.7% vs. 19.4% ( f/U duration: months) ; P=0.20
18.9% vs. 26.7% ( F/U duration > 36 months) ; P=0.006
More recurrence of > moderate MR in MV repair ; P<0.001
Similar MV reoperation rate

22. Perioperative mortality (forest plot)
No favor
Favor MV repair

23. Late mortality (forest plot)
No favor
Favor MV repair

24. Reasons for discrepancy in 30-day and late mortality
Favor MV repair:
Pros:
In clinical practice, high-risk patients with co-morbidities are preferentially allocated to MVR over MV repair
Longer follow-up durations ( mostly beyond 3 years )
Cons:
The meta-analysis included mostly retrospective observational reports (inherent bias)
No favor:
The only RCT
Short follow-up durations ( only 2 years)

25. Repair or replacement? ---the only RCT

26. Summary No significant difference between MV repair and MVR in:
LVESVI improvement ( LV reverse remodeling)
30-day mortality
One-year mortality
Clinical outcomes (functional status, quality of life)
More recurrence of MR ≥2 in the repair group.
32.6% vs. 2.3% ; P< 0.001
MVR provided a more durable correction of MR

27. Two-year follow up

28. Summary At 2 years: No significant difference in:
LVESVI improvement (reverse remodeling)
Survival
Repair group has more:
MR recurrence (58.8% vs. 3.8%; P< 0.001).
HF-related adverse events
Cardiovascular readmissions
Limitations:
Relatively small sample size (250)
Short follow-up time ( Survival in MVR group may become worse after 3 years )

29. Moderate IMR
Controversy surrounds the issue of appropriate surgical management of moderate IMR.
Whether addition of MV repair to CABG improved clinical outcome over CABG-alone in moderate IMR patients?

30. CABG+MV repair or CABG-alone ? Meta-analysis
5 observational studies & 4 RCTs (total 1161 patients)
Mean follow-up duration: 2.7±1.9 years

31. Results Operative risks: Long-term survival:
All studies: higher in CABG+MV repair, 4.7% vs. 4.1% (P=0.01)
RCTs only: equivalent, 2.4% vs. 2.3% (P=0.93)
Long-term survival:
All studies: equivalent (P=0.66)
RCTs only: equivalent (P=0.73)
Residual MR ≥ 2: higher in the CABG-alone group
All studies: 14% vs. 60%(P<0.001)
RCTs only: 8% VS. 39% (P=0.04)

32. Conclusions
Based on RCTs-only data, there is neither increased operative mortality nor survival benefit associated with concomitant CABG and MV repair for IMR of moderate degree over CABG alone.

33. CABG+MV repair or CABG-alone ? ---The largest RCT

34. Summary No significant difference in: (at 1 year)
LVESVI improvement (reverse remodeling)
Survival or MACCE
Functional status or quality of life
Residual MR ≥2: higher in the CABG-alone group (31.0% vs. 11.2%; P<0.001).
More neurologic events in CABG+MV repair group. (P=0.03)
Longer CPB & AXC duration increase risk of embolization
Atrial incision increase supraventricular arrhythmias
This trial did NOT show a clinically meaningful advantage of adding MV repair to CABG.

35. Two-year follow up No difference in mean LVESVI: (P=0.71)
No difference in Mortality: (P=0.78)
CABG-alone: 10.6%
CABG + MV repair: 10.0%
Residual moderate or severe MR: (P<0.001)
CABG-alone: 32.3%
CABG + MV repair: 11.2%
More neurological events and supraventricular arrhythmia: in CABG+MV repair group.

36. Conclusion:
The addition of MV repair did NOT lead to significant differences in LV reverse remodeling at 2 years.
MV repair provided a more durable correction of MR, but did NOT significantly improve survival or reduce overall adverse events or readmissions.
MV repair was associated with more neurologic events and supraventricular arrhythmias.

37. Current suggestions based on evidence
Mild IMR: no surgical treatment
Moderate IMR:
CABG-alone or CABG+MV repair?
Severe IMR:
CABG+MVR or CABG+MV repair?
Less complex operation with
Similar survival and clinical benefit
Similar survival and clinical benefit,
More durable correction, less recurrent MR

38. Thank you for your attention