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N Engl J Med. 2014 Dec 4;371(23):2178-88. doi: 10.1056/NEJMoa1410490. Epub 2014 Nov 18.

Surgical treatment of moderate ischemic mitral regurgitation.

Collaborators (243)

Miller MA, Taddei-Peters WC, Buxton D, Caulder R, Geller NL, Gordon D, Jeffries NO, Lee A, Moy CS, Gombos IK, Ralph J, Weisel R, Gardner TJ, O'Gara PT, Rose EA, Gelijns AC, Parides MK, Ascheim DD, Moskowitz AJ, Moquete E, Chang H, Chase M, Chen Y, Goldfarb S, Gupta L, Kirkwood K, Kumbarce E, Levitan R, O'Sullivan K, Overbey J, Santos M, Weglinski M, Williams P, Wood C, Ye X, Nielsen SL, Wiggers H, Malgaard H, Mack M, Adame T, Settele N, Adams J, Ryan W, Smith RL, Grayburn P, Chen FY, Nohria A, Cohn L, Shekar P, Aranki S, Couper G, Davidson M, Bolman R 3rd, Burgess A, Conboy D, Noiseux N, Stevens LM, Prieto I, Basile F, Dionne J, Fecteau J, Blackstone EH, Gillinov A, Lackner P, Berroteran L, Dolney D, Fleming S, Palumbo R, Whitman C, Sankovic K, Sweeney DK, Pattakos G, Clarke PA, Argenziano M, Williams M, Goldsmith L, Smith CR, Naka Y, Stewart A, Schwartz A, Bell D, Van Patten D, Sreekanth S, Smith PK, Alexander JH, Milano CA, Glower DD, Mathew JP, Harrison J, Welsh S, Berry MF, Parsa CJ, Tong BC, Williams JB, Ferguson T, Kypson AP, Rodriguez E, Harris M, Akers B, O'Neal A, Puskas JD, Thourani VH, Guyton R, Baer J, Baio K, Neill AA, Voisine P, Senechal M, Dagenais F, O'Connor K, Dussault G, Ballivian T, Keilani S, Speir AM, Magee P, Ad N, Keyte S, Dang M, Slaughter M, Headlee M, Moody H, Solankhi N, Birks E, Groh MA, Shell LE, Shepard SA, Trichon BH, Nanney T, Hampton LC, Michler RE, D'Alessandro DA, DeRose JJ Jr, Goldstein DJ, Bello R, Jakobleff W, Garcia M, Taub C, Spevak D, Swayze R, Perrault LP, Basmadjian AJ, Bouchard D, Carrier M, Cartier R, Pellerin M, Tanguay JF, El-Hamamsy I, Denault A, Lacharité J, Robichaud S, Horvath KA, Corcoran PC, Siegenthaler MP, Murphy M, Iraola M, Greenberg A, Sai-Sudhakar C, Hasan A, McDavid A, Kinn B, Pagé P, Sirois C, Latter D, Leong-Poi H, Bonneau D, Errett L, Peterson MD, Verma S, Feder-Elituv R, Cohen G, Joyner C, Fremes SE, Moussa F, Christakis G, Karkhanis R, Yau T, Farkouh M, Woo A, Cusimano RJ, David T, Feindel C, Garrard L, Fredericks S, Mociornita A, Mullen JC, Choy J, Meyer S, Kuurstra E, Gammie JS, Young CA, Beach D, Acker MA, Woo Y, Mayer ML, Bowdish M, Starnes VA, Shavalle D, Matthews R, Javadifar S, Romar L, Kron IL, Ailawadi G, Johnston K, Dent JM, Kern J, Keim J, Burks S, Gahring K, Bull DA, Desvigne-Nickens P, Dixon DO, Haigney M, Holubkov R, Jacobs A, Miller F, Murkin JM, Spertus J, Wechsler AS, Sellke F, McDonald CL, Byington R, Dickert N, Dixon DO, Ikonomidis JS, Williams DO, Yancy CW, Fang JC, Giannetti N, Richenbacher W, Rao V, Furie KL, Miller R, Pinney S, Roberts WC, Walsh MN, Keteyian SJ, Brawner CA, Aldred H, Hung J, Zeng X, Mathew JP, Browndyke J, Toulgoat-Dubois Y.

Author information

1
The authors' affiliations are listed in the Appendix.

Abstract

BACKGROUND:

Ischemic mitral regurgitation is associated with increased mortality and morbidity. For surgical patients with moderate regurgitation, the benefits of adding mitral-valve repair to coronary-artery bypass grafting (CABG) are uncertain.

METHODS:

We randomly assigned 301 patients with moderate ischemic mitral regurgitation to CABG alone or CABG plus mitral-valve repair (combined procedure). The primary end point was the left ventricular end-systolic volume index (LVESVI), a measure of left ventricular remodeling, at 1 year. This end point was assessed with the use of a Wilcoxon rank-sum test in which deaths were categorized as the lowest LVESVI rank.

RESULTS:

At 1 year, the mean LVESVI among surviving patients was 46.1±22.4 ml per square meter of body-surface area in the CABG-alone group and 49.6±31.5 ml per square meter in the combined-procedure group (mean change from baseline, -9.4 and -9.3 ml per square meter, respectively). The rate of death was 6.7% in the combined-procedure group and 7.3% in the CABG-alone group (hazard ratio with mitral-valve repair, 0.90; 95% confidence interval, 0.38 to 2.12; P=0.81). The rank-based assessment of LVESVI at 1 year (incorporating deaths) showed no significant between-group difference (z score, 0.50; P=0.61). The addition of mitral-valve repair was associated with a longer bypass time (P<0.001), a longer hospital stay after surgery (P=0.002), and more neurologic events (P=0.03). Moderate or severe mitral regurgitation was less common in the combined-procedure group than in the CABG-alone group (11.2% vs. 31.0%, P<0.001). There were no significant between-group differences in major adverse cardiac or cerebrovascular events, deaths, readmissions, functional status, or quality of life at 1 year.

CONCLUSIONS:

In patients with moderate ischemic mitral regurgitation, the addition of mitral-valve repair to CABG did not result in a higher degree of left ventricular reverse remodeling. Mitral-valve repair was associated with a reduced prevalence of moderate or severe mitral regurgitation but an increased number of untoward events. Thus, at 1 year, this trial did not show a clinically meaningful advantage of adding mitral-valve repair to CABG. Longer-term follow-up may determine whether the lower prevalence of mitral regurgitation translates into a net clinical benefit. (Funded by the National Institutes of Health and the Canadian Institutes of Health Research; ClinicalTrials.gov number, NCT00806988.).

PMID:
25405390
PMCID:
PMC4303577
DOI:
10.1056/NEJMoa1410490
[Indexed for MEDLINE]
Free PMC Article

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