Mitral valve replacement combined with coronary artery operation: determinants of early and late results

Mitral valve replacement combined with coronary artery bypass grafting has been reported as being associated with a higher mortality than either mitral valve replacement or coronary artery bypass grafting alone. Cause of mitral valve disease and severity of mitral regurgitation have been reported as related to mortality. To study the correlation of the cause of mitral valve disease and severity of mitral regurgitation to hospital mortality and long-term survival, we analyzed the results of 135 patients undergoing mitral valve replacement and coronary artery bypass grafting between June 1974 and August 1989. The hospital mortality was 11.8% (16/135). Fifteen preoperative and operative variables were tested for correlation with hospital or late mortality using univariate tests and multivariate regression. Advanced age (greater than 60 years), New York Heart Association functional class, and wall motion score were independently associated with hospital mortality (p less than 0.05). The cause of mitral valve disease and severity of mitral regurgitation were not related to hospital mortality or long-term survival (p greater than 0.05). The follow-up rate was 96.6% for the hospital survivors (115/119). Mean follow-up was 52.6 +/- 4.1 months. There were 35 late deaths. Survival was 91.9%, 89.9%, 78%, and 49.9% at 1, 2, 5, and 10 postoperative years, respectively. Preoperative New York Heart Association functional class and use of catecholamines during the postoperative intensive care period were independently related to late survival (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Treatment of moderate mitral regurgitation and coronary disease by coronary bypass alone

We have favored treatment of moderate mitral regurgitation and coronary disease with coronary bypass alone because of the high operative mortality of combined mitral valve replacement and coronary bypass. Between 1977 and 1983, coronary bypass alone was performed on 58 patients (mean age 63 +/- 8 years). Preoperatively, 90% had Canadian Cardiovascular Society class III or IV angina, and 10% had class III or IV congestive heart failure. In 72% mitral regurgitation had been caused by coronary disease. Hospital mortality was 3.4% (2/58). At follow-up (100% complete, mean 4.3 years) 66% of survivors were functional classes I and II (compared with 7% preoperatively, p less than 0.0001). Of those patients who worked preoperatively, 84% returned to work. There were no reoperations. The 5-year survival was 77%. In the same period combined mitral valve replacement and coronary bypass was required in 20 unmatched patients with moderate mitral regurgitation and coronary disease. Indications for valve replacement included congestive heart failure (10 cases), high left atrial pressure (three cases), and mitral stenosis (four cases). In these patients with more advanced symptoms the hospital mortality was 25%, and the 5-year survival was 31%. Treatment of moderate mitral regurgitation and coronary disease by coronary bypass alone achieved excellent hospital survival and long-term functional stability without a subsequent valve operation.     

Clinical outcomes of surgery of mitral valve regurgitation and coronary artery bypass grafting

The impact of etiology of associated mitral valve regurgitation and a valve procedure on operative and long-term outcomes after coronary bypass grafting surgery is yet to be clearly defined. Results of combined coronary artery bypass grafting and valve procedures for mitral valve regurgitation were retrospectively analyzed in 468 patients. The regurgitation was of ischemic in 45%, degenerative in 55% and 78% valve repairs, 22% valve replacements were performed. Severe coronary artery disease, acute myocardial infarction, low ejection fraction, ischemic mitral regurgitation, advanced heart failure symptoms, failure to use internal mammary artery, valve replacement surgery, and emergency operations are predictors of operative mortality. The 5-year survivals for propensity-matched patients of ischemic and degenerative disease were similar (66%), but 67% vs. 83%, respectively, for unmatched patients. Low ejection fraction (<35%), advanced age (>67 years), valve replacement surgery, residual mitral regurgitation, and severe coronary artery disease were predictors of poor long-term survival. Left ventricular remodeling processes, optimal valve procedure without residual mitral regurgitation and left ventricular function are important determinants of long-term outcome than the etiology of valve regurgitation.     

The results of valve replacement for mitral valve prolapse

Between January, 1975, and December, 1982, 33 patients underwent mitral valve replacement for mitral valve prolapse secondary to myxomatous degeneration. The majority were in the seventh decade of life (median age, 62 years), and all were seen with symptoms of mitral regurgitation. Echocardiography was more accurate in making the diagnosis of mitral valve prolapse more often (75%) than angiography (66%). Thirty-eight percent of the patients who underwent cineangiography had concomitant coronary artery disease and had coronary artery bypass grafting as well as mitral valve replacement. There was 1 operative death, an operative mortality of 3%. There were 6 late deaths, a late mortality of 18%. Of the 26 long-term survivors, 23 (88%) were in New York Heart Association Functional Class I and 3 (12%) were in Class II. The average length of follow-up was 33.25 months, and the 5-year actuarial survival was 76%. There was only one incident of thromboembolism (3%). Short-term and long-term survival were not related to the severity of mitral regurgitation but to the status of the left ventricle and the overall condition of the patient. These data suggest that older patients with severe mitral regurgitation secondary to mitral valve prolapse can undergo valve replacement with low operative mortality and gratifying long-term results.     

Patient survival characteristics after routine mitral valve repair for ischemic mitral regurgitation

BACKGROUND: Ischemic mitral regurgitation has been associated with diminished survival compared with nonischemic mitral regurgitation. Conversion from mitral valve replacement to valve repair has improved prognosis, but it is unclear whether ischemic mitral regurgitation remains an independent predictor of outcome after mitral valve repair. METHODS: Five hundred thirty-five patients undergoing mitral valve repair (primarily rigid ring annuloplasty) with or without coronary bypass from 1993 through 2002 were reviewed retrospectively (ischemic mitral regurgitation, n = 141; nonischemic mitral regurgitation, n = 394). A Cox proportional hazards model evaluated survival as a function of 9 simultaneous covariates: ischemic versus nonischemic mitral regurgitation, age, sex, number of medical comorbidities, ejection fraction, New York Heart Association class, coronary disease, reoperation, and year of operation. RESULTS: According to univariable analysis, patients with ischemic mitral regurgitation had greater age, higher comorbidity, lower ejection fraction, higher New York Heart Association, and higher reoperation rate (all P < .001) compared with those having nonischemic mitral regurgitation. Univariable 30-day mortality was as follows: 4.3% for patients with ischemic mitral regurgitation versus 1.3% for patients with nonischemic mitral regurgitation (P = .01). Unadjusted 5-year mortality was as follows: 44% +/- 5% for patients with ischemic mitral regurgitation versus 16% +/- 3% for patients with nonischemic mitral regurgitation (P < .001). In the multivariable model, however, only the number of preoperative comorbidities and advanced age were independent predictors of survival (P < .0001), whereas ischemic mitral regurgitation, sex, ejection fraction, New York Heart Association class, coronary disease, reoperation, and year of operation did not achieve significance (all P > .19). After being adjusted for differences in all preoperative risk factors, survival was not statistically different between ischemic mitral regurgitation and nonischemic mitral regurgitation (P = .33). CONCLUSIONS: With routine application of rigid ring annuloplasty, long-term patient survival is more influenced by baseline patient characteristics and comorbidity than by ischemic cause of mitral regurgitation per se. Future risk assessment and decision making should be based on patient condition and should not be biased by ischemic cause of mitral regurgitation.     

Can late survival of patients with moderate ischemic mitral regurgitation be impacted by intervention on the valve?

BACKGROUND: Ischemic mitral regurgitation is known to be associated with poor long-term outcome after coronary artery bypass grafting; however, our ability to alter that outcome with intervention on the valve is unclear. The decision to address the valve is most challenging for patients with only moderate mitral regurgitation, particularly with the popularization of off-pump surgery. We therefore reviewed early and late outcomes of patients undergoing revascularization with or without mitral valve surgery. METHODS: Patients with moderate mitral regurgitation undergoing revascularization with and without mitral surgery between January 1991 and September 1996 were identified retrospectively. Operative notes were reviewed and patients with structural valve disease excluded. Perioperative events and late outcomes as determined by telephone contact and search of the social security death index (survival data 97% complete) were compared. RESULTS: One hundred seventy-six patients with moderate mitral regurgitation underwent revascularization alone (n = 142) or with mitral repair or replacement (n = 34). Those undergoing revascularization alone had a higher serum creatinine, somewhat less mitral regurgitation, and lower New York Heart Association functional class preoperatively. Operative mortality was greater with valve surgery (21% vs 9%, p = 0.047). Actuarial survival of both groups at 5 years was similar (52% vs 58%, p = NS); however, when stratified by preoperative functional class, those with more advanced heart failure preoperatively had superior late survival if their mitral valve was intervened upon. CONCLUSIONS: The late survival of patients with ischemic mitral regurgitation undergoing coronary revascularization remains poor; however, intervention on the mitral valve appears to benefit those with symptomatic heart failure.     

Combined valve replacement and myocardial revascularization

Combining valve replacement with coronary artery bypass (CABG) for significant concomitant disease remains a controversial subject. To determine the operative results following combined valve replacement and CABG, we evaluated 201 patients seen consecutively between July 1977 and June 1982. CABG for vessels with greater than 70% stenosis was performed with aortic valve replacement in 106 patients, with mitral valve replacement in 82, and with aortic and mitral valve replacement in 13. There were 143 men and 58 women; the mean age was 67 years. Nine operative deaths (8.5%) occurred with aortic valve replacement and CABG: 5 of 25 (20%) when cardioplegia was not used and 4 of 81 (4.9%) with cardioplegia (p less than 0.01). The operative mortality rate for isolated aortic valve replacement without coronary disease during the same period was 5.9% (10 of 168). The late actuarial survival rate is similar for aortic valve replacement alone or aortic valve replacement and CABG. There were no operative deaths among patients having undergone aortic and mitral valve replacement and CABG; the rate was 15% (9 of 60) in patients having undergone aortic and mitral replacement and CABG. The operative mortality rate was 21.9% for mitral valve replacement and CABG (18 of 82). Rheumatic disease was present in 14 of these patients, two of whom had early deaths (14.3%), both after repeat mitral operations; 11 mitral valve replacements and CABG were done for degenerative mitral regurgitation with no deaths, and the remaining 57 patients had ischemic mitral regurgitation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparative morbidity of mitral valve repair versus replacement for mitral regurgitation with and without coronary artery disease

Mitral valve repair has been increasingly used at our hospital for mitral regurgitation with and without coronary disease. From January, 1984, to June, 1987, of 338 patients undergoing all forms of mitral valve surgery, 140 had first-time surgery for pure mitral regurgitation: 75 had valve repair, and 65 had valve replacement. Thirty-three of 75 (44%) had concomitant coronary bypass in the repair group, while 21 of 65 (32%) had coronary bypass in the replacement group. The mean functional class (3.4 versus 3.5), age (60 versus 61 years), and preoperative hemodynamics were similar in both groups. The cause of mitral regurgitation in the repair group was myxomatous change in 32 patients, ischemia in 27, rheumatic valve disease in 12, and endocarditis in 4. A Carpentier ring was used in 46, a Duran ring was used in 11, and none was used in 18. The operative mortality was 3 of 75 patients (4%) in the repair group, all with coronary artery bypass grafting, versus 2 of 65 patients (3%) in the replacement group, 1 of whom had undergone coronary artery bypass grafting. The mean postoperative functional class 15 months postoperatively was 1.12 in the repair group versus 1.15 in the replacement group. There were 7 late deaths in the replacement group and only 3 late deaths in the repair group. Actuarial survival at 30 months was 85 +/- 6% for the replacement group and 94 +/- 4% for the repair group. There were 5 late emboli (1 fatal, 4 nonfatal) after valve replacement and none after valve repair (p = 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)     

Mitral valve surgery for chronic ischemic mitral regurgitation

BACKGROUND: Early and midterm clinical and echocardiographic results after mitral valve (MV) surgery for chronic ischemic mitral regurgitation were investigated to evaluate the validity of the criteria for repair or replacement applied by us. METHODS: From 1988 to 2002, 102 patients with ischemic mitral regurgitation underwent MV surgery (82 repairs and 20 replacements). End-systolic distance between the coaptation point of mitral leaflets and the plane of mitral annulus was the key factor that allowed either repair (10 mm). Patients who had MV replacement showed higher New York Heart Association class (3.2 +/- 0.5 versus 3.4 +/- 0.5; p = 0.016), lower preoperative ejection fraction (0.33 +/- 0.9 versus 0.38 +/- 0.12; p = 0.034), and higher end-diastolic volume (161 +/- 69 mL versus 109 +/- 35 mL; p < 0.001) compared with repair. Mitral regurgitation was 3.2 +/- 0.7 in both groups. RESULTS: Thirty-day mortality was 3.9% (2.4% MV repair versus 10.0% MV replacement; not significant). During the follow-up 26 patients died. Of the 72 survivors, 55 (76.3%) were in New York Heart Association classes I and II. Five-year survival was 75.6% +/- 4.7% in MV repair and 66.0% +/- 10.5% in MV replacement (not significant). Survival in New York Heart Association classes I and II was 58.9% +/- 5.4% in MV repair and 40.0% +/- 11.0% in MV replacement (not significant). Cox analysis identified preoperative New York Heart Association class, ejection fraction, end-diastolic volume, end-systolic volume, and congestive heart failure as risk factors common to both events. In 46 patients, late echocardiograms showed no volume or ejection fraction modifications. In patients who underwent MV repair, 50% had no or mild mitral regurgitation. CONCLUSIONS: Correction of chronic ischemic mitral regurgitation through either repair or replacement provides a good 5-year survival rate, with more than 75% of the survivors in New York Heart Association classes I and II.     

Late outcome of mitral valve surgery for patients with coronary artery disease

BACKGROUND: We plan to determine whether the cause of mitral valve regurgitation, ischemic or degenerative, affects survival after combined mitral valve repair or replacement and coronary artery bypass grafting (CABG) surgery and to assess the influence of residual mitral regurgitation on late outcome. METHODS: A retrospective study was made of 302 patients having mitral valve repair or replacement and CABG from January 1987 through December 1996. Risk factors for death, for development of New York Heart Association class III or IV congestive heart failure (CHF), and recurrent mitral valve regurgitation were identified by proportional hazards analysis. RESULTS: The cause of mitral regurgitation was ischemic in 137 patients (45%) and degenerative in 165 patients (55%). Valve replacement was performed in 51 patients (17%) and valve repair in 251 patients (83%). Median follow-up was 64 months. Ten-year actuarial survival rates were 33% (95% confidence interval: 22% to 47%) in the ischemic group and 52% (95% confidence interval: 42% to 64%) in the degenerative group. Univariate predictors of death, were entered into a multivariate model. Older age, ejection fraction of 35% or less, three-vessel coronary artery disease, replacement of the mitral valve, and residual mitral regurgitation at dismissal were independent risk factors for death. The cause of mitral valve regurgitation (ischemic or degenerative) was not an independent predictor of long-term survival, class III or IV CHF, or recurrent regurgitation. CONCLUSIONS: Survival after mitral valve surgery and CABG is determined by the extent of coronary disease and ventricular dysfunction and by the success of the valve procedure; etiology of mitral valve regurgitation has relatively little impact on late outcome.     

Early and late risk of mitral valve replacement. A 12 year concomitant comparison of the porcine bioprosthetic and prosthetic disc mitral valves

A consecutive series of 706 mitral valve replacements was performed from January, 1972, to January, 1984. The follow-up ranged from 6 to 150 months with a mean of 50 and a median of 43 months. Seven percent (50) of the patient were lost to follow-up. There were 243 men and 463 women, whose ages ranged from 17 to 86 years (mean 58). A porcine bioprosthetic valve was implanted in 528 patients (514 Hancock and 14 Carpentier-Edwards valves) and a prosthetic disc valve in 178 patients (102 standard disc Bj?rk-Shiley, 34 Beall, and 42 Harken disc valves). Seven patients were in Functional Class II, 325 in Class III, and 374 in Class IV. A concomitant operative procedure was performed in 253 of the 706 patients (36%). Mitral regurgitation was the primary hemodynamic lesion in 363 and mitral stenosis in 343. Operative mortality figures were as follows: 77 of 706 (11%) for the overall group, 34 of 453 (7.5%) for isolated mitral valve replacement, 30 of 169 (17.5%, p = 0.001) for mitral replacement plus coronary bypass, 49 of 528 (9%) for the bioprosthetic valve group, and 28 of 178 (16%) for the prosthetic disc valve group (p = 0.01). After the operation, 262 patients were in Functional Class I, 99 in Class II, and 18 in Class III. The long-term survival rate was significantly lower in patients who had an associated procedure (45% +/- 6%), who had mitral regurgitation rather than mitral stenosis (53% +/- 5% versus 67% +/- 4%) (p = 0.002), who were in Functional Class IV rather than Classes I to III (51% +/- 4% versus 70% +/- 4%) (p = 0.001), and who received a prosthetic disc valve rather than a bioprosthesis (40% +/- 6% versus 67% +/- 4%) (p = 0.001). Thromboembolic rates were significantly higher with prosthetic valves than with bioprosthetic valves (4.6% +/- 0.22% versus 2.4% +/- 0.5% per patient-year of follow-up), and the incidence of anticoagulant-related hemorrhage was significantly higher in the prosthetic valve group (1.65% versus 0.43% per patient-year). Primary valve dysfunction was significantly more common in the bioprostheses (1.23% versus 0.40% per patient-year).(ABSTRACT TRUNCATED AT 400 WORDS)     

Impact of simultaneous myocardial revascularization on operative risk, functional result, and survival following mitral valve replacement

A cohort of 282 patients who underwent mitral valve replacement with a xenograft bioprosthesis was strictly segregated according to etiology of mitral dysfunction and analyzed regarding the impact of arteriographic coronary artery disease (CAD) and concomitant coronary artery bypass grafting (CABG) on operative risk, functional result, and survival. CAD was present in 21% of the 122 patients with predominant mitral stenosis (MS) and 59% of the 155 patients with mitral regurgitation (MR); moreover, discordance between the presence of angina and anatomic CAD was found in 27% (33 of 122) of the MS subgroup and 36% (56 of 155) of the MR subgroup.Etiology of the valvular dysfunction was rheumatic in 148 patients, myxomatous degeneration in 83, and ischemic in 32. Within these subgroups, 41 patients (27%), 40 patients (48%), and 32 patients (100%), respectively, had CAD. Of those patients with CAD, 85% of the rheumatic subgroup, 90% of the degenerative subgroup, and 81% of the ischemic subgroup underwent concomitant CABG at the time of valve replacement. Within each subgroup no statistically significant (P greater than 0.05) differences in operative mortality rate, perioperative myocardial infarction rate, incidence of late angina or late infarction, or late actuarial survival were evident when compared on the basis of CAD, and/or CABG, with one exception. The exception was the 10% incidence of perioperative myocardial infarction in the rheumatic subgrohp with coronary disease versus 2% in the rheumatic subgroup without coronary disease (P = 0.05). Within the time constraints of this study (mean follow-up = 2.3 years; maximum follow-up = 5.9 years), these results support simultaneous MVR and CABG when hemodynamically appreciable CAD is found. Moreover, the overall 43% incidence of arteriographic CAD warrants routine coronary angiography in most adults undergoing preoperative catheterization for mitral valvular disease.     

Treatment of moderate mitral regurgitation and coronary disease by coronary bypass alone: late results.

BACKGROUND: In cases of moderate mitral regurgitation and coronary artery disease operative strategy continues to be debated between coronary artery bypass grafting alone and concomitant valve replacement or repair. We previously reported on 58 patients with moderate mitral regurgitation who had coronary artery bypass grafting between 1977 and 1983. We present the late results for this original cohort (test group), and a matched control group of coronary artery bypass grafting patients without mitral regurgitation (n = 58). METHODS AND RESULTS: In the original cohort, the hospital mortality rate was 3.4% (2 of 58), and 80.4% (45 of 56) of hospital survivors were alive at the time of initial follow-up (mean, 4.3+/-2.3 years). Hospital mortality in the control group was 6.9% (4 of 58 patients). Follow-up was 98.2% (108 of 110 patients) complete, with a mean follow-up time of 10.3+/-5.5 years. Kaplan-Meier curves for hospital survivors showed similar 5- and 10-year survival rates between the two groups (p = 0.59). On multivariate analysis, age 65 years or more, congestive heart failure class III or IV, and pulmonary capillary wedge pressure more than 17 mm Hg were significant (p < 0.05) independent predictors of diminished survival in the test group. CONCLUSIONS: Patients with moderate mitral regurgitation and coronary artery disease treated solely with coronary artery bypass grafting had acceptable early and late results. Moderate mitral regurgitation at the time of revascularization does not always warrant operative correction.     

Preservation of the posterior leaflet during mechanical valve replacement for ischemic mitral regurgitation and complete myocardial revascularization

Between 1980 and 1987, 40 patients with ischemic mitral insufficiency underwent mitral valve replacement (with a mechanical prosthesis) and coronary bypass grafting, 3.5 grafts per patient. The posterior mitral leaflet was preserved in 17 and resected in 23. Five arrived at operation in cardiogenic shock, 15 after recurrent episodes of pulmonary edema, and 20 electively, but in congestive heart failure. Twenty-five had unstable angina, and the remaining had chronic angina. Perioperative and early deaths occurred only in patients with an ejection fraction less than 35%. None of the 21 patients with an ejection fraction greater than 35% died, whereas eight of 19 with an ejection fraction less than 35% died, whereas eight of 19 with an ejection fraction less than 35% died (p less than 0.001). When causes of death in patients with an ejection fraction less than 35% were studied, operative and early mortality was zero of seven with preservation of the posterior mitral leaflet versus eight of 11 with excision of the leaflet (p = 0.035). We concluded that the high mortality in mitral valve replacement for ischemic mitral insufficiency is linked to an ejection fraction less than or equal to 35% and, in this particular group of patients, is due to the surgical destruction of the left ventricular chordae tendineae supportive apparatus. Preservation of this apparatus by preservation of the posterior mitral leaflet drastically reduces operative and early mortality. Preoperative cardiogenic shock, left ventricular aneurysmectomy, and multiple grafting (up to five grafts per patient) did not increase the risk of operation. Extensive revascularization (3.5 grafts per patient) provides improved long-term results.     

Aortic valve replacement in patients with impaired ventricular function

BACKGROUND: Patients with reduced ventricular function undergoing aortic valve replacement have increased operative risks, but the impact of valvular pathophysiology and other risk factors has not been clearly defined. METHODS: From June 1992 through June 2002, 1,402 consecutive patients underwent isolated aortic valve surgery with or without coronary artery bypass grafting; of these patients, 416 had an ejection fraction less than 40% and are the subject of this report. These patients (mean age, 68.6) had severe stenosis (62.5%), severe regurgitation (30.3%), or mixed disease (7.2%). Aortic valve replacement plus coronary artery bypass grafting was performed in 48.4% of patients, and 27% had previous cardiac surgery. Follow-up included echocardiography and survival analysis. RESULTS: Hospital mortality was 10.1% (42 of 416), with no difference between aortic stenosis (9.6%) and regurgitation (11.1%). Multivariate analysis revealed that age (p = 0.002) and renal disease (odds ratio = 4.2; 95% confidence interval, 1.9 to 9.3; p = 0.001) were independently associated predictors of mortality. Valvular pathophysiology had no impact on mortality. Peripheral vascular disease, multivessel coronary disease, and renal disease were associated risks for any postoperative complication. Peripheral vascular disease (odds ratio = 12.3, p = 0.02), history of cerebrovascular disease (odds ratio = 4.8, p = 0.038), and diabetes (odds ratio = 2.7, p = 0.04) were associated risks for stroke. The ejection fraction was more than 40% in 52% of the patients who had postoperative echocardiography (mean follow-up, 6 months). Actuarial survival revealed no difference between pathophysiologic groups. CONCLUSIONS: Aortic valve surgery in patients with impaired ventricular function carries an acceptable operative risk that can be stratified by age and comorbidities. The type of valvular pathophysiology does not significantly affect mortality.     

Incidence, associated factors and evolution of non-severe functional mitral regurgitation in patients with severe aortic stenosis undergoing aortic valve replacement.

INTRODUCTION: In order to improve the prognosis, repair of severe mitral regurgitation should be undertaken at the same time as aortic valve replacement in patients with severe aortic valve stenosis. However, mitral regurgitation may be secondary to pressure overload or ventricular dysfunction and improve after surgery. AIM: To assess the incidence of non-severe functional mitral regurgitation before and after isolated aortic valve replacement and determine its influence on the postoperative course. METHODS: The clinical and surgical characteristics were compared in a cohort of 577 consecutive patients who underwent isolated aortic valve replacement. RESULTS: The mean age was 68.4+/-9.2 years (44% women). Non-severe functional mitral valve regurgitation was detected prior to surgery in 26.5% of the patients. These patients were older (p=0.009), more often had ventricular dysfunction (p=0.005) and pulmonary hypertension (0.002), and had been admitted more frequently for heart failure (0.002), with fewer of them conserving sinus rhythm (p<0.001). Additionally, the pre-surgery existence of mitral regurgitation was associated with greater morbidity and mortality (10.5% vs 5.6%; p=0.025). The mitral regurgitation disappeared or improved prior to hospital discharge in 56.2% and 15.6%, respectively. Independent factors predicting this improvement were the presence of coronary lesions (OR 3.7, p=0.038), and the absence of diabetes (OR 0.28, p=0.011) and pulmonary hypertension (0.33, p=0.046). CONCLUSIONS: The presence of intermediate degree mitral regurgitation in patients undergoing isolated aortic valve replacement increases morbidity and mortality. However, a high percentage of those who do survive experience disappearance or improvement of the mitral regurgitation.     

Use of the intra-aortic balloon pump after valve replacement. Predictive indices, correlative parameters, and patient survival

Intra-aortic balloon pump counterpulsation required as an adjunct during weaning from cardiopulmonary bypass or for circulatory support in the immediate postoperative period was analyzed in 2,498 patients undergoing valve replacement between December, 1972, and September, 1981. A total of 140 successful insertions were performed in 155 attempts. Ninety-five of these patients were from a homogeneous cohort of 1,908 patients undergoing valve replacement with porcine xenografts and were analyzed for factors that might be useful predictors of the need for balloon pump support. Univariate analysis of individual factors delineated preoperative characteristics in patients having mitral valve replacement and intraoperative factors in all patients that correlated with use of the balloon pump. Multivariate analysis revealed a subset of male patients with mitral valve and coronary disease most likely to require counterpulsation. Overall survival rate was markedly reduced at 30 days (balloon counterpulsation plus valve replacement, 50% +/- 5%; valve replacement only, 96% +/- 5%; p less than 0.001) and at 1 year (balloon counterpulsation plus valve replacement, 38% +/- 5%; valve replacement only, 89% +/- 1%, p less than 0.001) if balloon pumping was required. The entire group of 140 patients were retrospectively analyzed for factors predictive of survival. Patients requiring balloon pumping who had a preoperative diagnosis of aortic regurgitation had a lower 1 year survival rate (13% +/- 9%) than the total subgroup undergoing balloon counterpulsation (36% +/- 4.0%) (p = 0.002). Similarly patients treated by balloon counterpulsation who had postoperative renal failure had a significantly lower 1 year survival rate (17% +/- 5%) than those without renal failure (66% +/- 6%) (p = 0.003). The survival rate of patients who required this therapeutic modality after valve replacement is poor. Other methods of hemodynamic support are necessary.     

The influence of coronary artery disease and bypass grafting on early and late survival after valve replacement for aortic stenosis

The influence of coronary artery disease and bypass grafting on survival after valve replacement for aortic stenosis (1975 to 1986, N = 512) was analyzed. Mean follow-up for 30-day survivors was 5.1 years (0.1 to 12.9 years). A total of 205 patients had coronary angiography performed: 122 did not have coronary artery disease, 55 with coronary artery disease underwent bypass grafting, and 28 with coronary artery disease did not. Early mortality rates (less than or equal to 30 days)/5-year cumulative survivals (standard error) were 4.1%/86% (4%), 3.6%/68% (8%), and 17.9%/51% (13%), respectively (p less than 0.05/p less than 0.01). Triple vessel/left main stem disease was more prevalent in patients with coronary disease who underwent bypass grafting (47%) than in those who did not (14%; p less than 0.05). Multivariate analysis revealed that right ventricular failure and omission of bypass grafting in patients with coronary artery disease were independent determinants of early mortality. A Cox regression analysis identified coronary artery disease and aortic valve gradient as determinants of mortality after hospital dismissal, which was not influenced by bypass grafting. On the basis of a coronary artery disease score (positive predictive value for coronary artery disease of 66%) developed on the patients with angiography, 307 patients without angiography were divided into 234 with a low score and 73 with a high score. Early mortality rates/5-year survivals (standard error) were 6.4%/86% (2%) and 16.4%/67% (6%), respectively (p less than 0.01/p less than 0.001). Autopsy revealed stenotic or occlusive coronary artery disease in 92% of 12 early deaths in the group with a high coronary artery disease score and in 33% of 15 in the group with a low score (p less than 0.01). Left ventricular failure and a high coronary artery disease score were independent determinants of early mortality, whereas cardiothoracic index, a high coronary artery disease score, and left ventricular failure were independent predictors of death after hospital dismissal. Despite more severe coronary artery disease, bypass grafting reduced early mortality to a level comparable with that of patients without coronary artery disease, contrasting with a high early mortality rate for unbypassed coronary artery disease. Coronary artery disease increased the late mortality rate, which was not modified by bypass grafting. In the group without angiography, undiagnosed and unbypassed coronary artery disease probably increased both early and late mortality. Coronary angiography should be performed in all adult patients with aortic stenosis, and those with significant coronary artery disease should undergo bypass grafting concomitant with valve replacement.     

Mitral repair is superior to replacement when associated with coronary artery disease

OBJECTIVE: To compare the outcomes of mitral repair and replacement in revascularized patients with ischemic mitral regurgitation. SUMMARY BACKGROUND DATA: Combined coronary bypass (CABG) and mitral procedures have been associated with the highest mortality (>10%) in cardiac surgery. Recent studies have suggested that mitral valve replacement (MVR) with sparing of the subvalvular apparatus had comparable results to mitral repair when associated with CABG. METHODS: Over the past 7 years, 54 patients had CABG/mitral repair versus 56 who had CABG/MVR with preservation of the subvalvular apparatus. The groups were similar in age at 69.2 years in the replacement group versus 67.0 in the repair group. We compared these 2 groups based on hospital mortality, incidence of complications including nosocomial infection, neurologic decompensation (stroke), pulmonary complication (pneumonia, atelectasis, and prolonged ventilation), and renal complications (acute renal failure or insufficiency). RESULTS: The mitral repair group had a hospital mortality of 1.9% versus 10.7% in the replacement group (P = 0.05). Infection occurred in 9% of repairs compared with 13% of replacements (P = 0.59). The incidence of stroke was no different between groups (2 of 54 repairs vs. 2 of 56 replacements, P = 1.00). Pulmonary complication rate was 39% in repairs versus 32% in replacements (P = 0.59). Worsening renal function occurred in 15% of repairs versus 18% of replacements (P = 0.67). CONCLUSIONS: Mitral repair is superior to mitral replacement when associated with coronary artery disease in terms of perioperative morbidity and hospital mortality. Although preservation of the subvalvular apparatus with MVR has a theoretical advantage in terms of ventricular function, mitral repair clearly adds a survival benefit in patients with concomitant ischemic cardiac disease.     

Ischemic mitral regurgitation: intraventricular papillary muscle imbrication without mitral ring during left ventricular restoration

OBJECTIVES: Functional mitral regurgitation in ischemic cardiomyopathy carries a poor prognosis, and its surgical management remains problematic and controversial. The aim of this study was to report the results of our surgical approach to patients who have had myocardial infarctions and have ventricular dilatation, mitral regurgitation, reduced pump function, pulmonary hypertension and coronary artery disease. This surgical approach consists of endoventricular mitral repair without prosthetic ring, ventricular reconstruction with or without patch, and coronary artery bypass grafting. PATIENTS: Forty-six patients (aged 64 +/- 10 years) with previous anterior transmural myocardial infarction and mitral regurgitation comprised the study group. Indication for surgery was heart failure in 93% of cases; 25 patients were in New York Heart Association functional class IV and 17 were in class III. Mitral regurgitation was moderate to severe in 32 cases (69%). RESULTS: All patients underwent coronary artery bypass grafting, with a mean of 3.2 +/- 1.3 grafts. Associated aortic valve replacement was performed in 4 cases. Global operative mortality rate was 15.2%. End-diastolic and end-systolic volumes significantly decreased after surgery (from 140 +/- 40 to 98 +/- 36 mL/m(2) and from 98 +/- 32 to 63 +/- 22 mL/m(2), respectively, P =.001). Systolic pulmonary pressure decreased significantly (from 55 +/- 13 to 43 +/- 16 mm Hg, P =.001). Ejection fraction did not change significantly. Postoperative mitral regurgitation was absent or minimal in 84% of cases; 1 patient had severe mitral regurgitation necessitating valve replacement. New York Heart Association functional class significantly improved. The mean preoperative functional class was 3.4 +/- 0.6 (median 3, range 2-4); after the operation, this decreased to 1.9 +/- 0.7 (median 2, range 1-3, P <.001). Cumulative survival at a 30-month follow-up was 63%. CONCLUSIONS: Our aggressive, combined surgical approach is aimed at correcting the three components of ischemic cardiomyopathy: relieving ischemia, reducing left ventricular wall tension by decreasing left ventricular volumes, and reducing volume overload and pulmonary hypertension by repairing the mitral valve. Despite a relatively high perioperative mortality rate, surviving patients benefitted from the operation, with improved clinical functional class and thus quality of life.