Mitral-valve repair versus replacement for severe ischemic mitral regurgitation

Michael A. Acker, Michael K. Parides, Louis P. Perrault, Alan J. Moskowitz, Annetine C. Gelijns, Pierre Voisine, Peter K. Smith, Judy W. Hung, Eugene H. Blackstone, John D. Puskas, Michael Argenziano, James S. Gammie, Michael Mack, Deborah D. Ascheim, Emilia Bagiella, Ellen G. Moquete, T. Bruce Ferguson, Keith A. Horvath, Nancy L. Geller, Marissa A. MillerY. Joseph Woo, David A. D'Alessandro, Gorav Ailawadi, Francois Dagenais, Timothy J. Gardner, Patrick T. O'Gara, Robert E. Michler, Irving L. Kron

Research output: Contribution to journalArticle

381 Citations (Scopus)

Abstract

BACKGROUND: Ischemic mitral regurgitation is associated with a substantial risk of death. Practice guidelines recommend surgery for patients with a severe form of this condition but acknowledge that the supporting evidence for repair or replacement is limited. METHODS: We randomly assigned 251 patients with severe ischemic mitral regurgitation to undergo either mitral-valve repair or chordal-sparing replacement in order to evaluate efficacy and safety. The primary end point was the left ventricular end-systolic volume index (LVESVI) at 12 months, as assessed with the use of a Wilcoxon rank-sum test in which deaths were categorized below the lowest LVESVI rank. RESULTS: At 12 months, the mean LVESVI among surviving patients was 54.6±25.0 ml per square meter of body-surface area in the repair group and 60.7±31.5 ml per square meter in the replacement group (mean change from baseline, -6.6 and -6.8 ml per square meter, respectively). The rate of death was 14.3% in the repair group and 17.6% in the replacement group (hazard ratio with repair, 0.79; 95% confidence interval, 0.42 to 1.47; P = 0.45 by the log-rank test). There was no significant between-group difference in LVESVI after adjustment for death (z score, 1.33; P = 0.18). The rate of moderate or severe recurrence of mitral regurgitation at 12 months was higher in the repair group than in the replacement group (32.6% vs. 2.3%, P<0.001). There were no significant between-group differences in the rate of a composite of major adverse cardiac or cerebrovascular events, in functional status, or in quality of life at 12 months. CONCLUSIONS: We observed no significant difference in left ventricular reverse remodeling or survival at 12 months between patients who underwent mitral-valve repair and those who underwent mitral-valve replacement. Replacement provided a more durable correction of mitral regurgitation, but there was no significant between-group difference in clinical outcomes.

Original languageEnglish (US)
Pages (from-to)23-32
Number of pages10
JournalNew England Journal of Medicine
Volume370
Issue number1
DOIs
StatePublished - 2014

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Mitral Valve Insufficiency
Mitral Valve
Stroke Volume
Nonparametric Statistics
Ventricular Remodeling
Body Surface Area
Practice Guidelines
Quality of Life
Confidence Intervals
Safety
Recurrence
Survival
Mortality

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Acker, M. A., Parides, M. K., Perrault, L. P., Moskowitz, A. J., Gelijns, A. C., Voisine, P., ... Kron, I. L. (2014). Mitral-valve repair versus replacement for severe ischemic mitral regurgitation. New England Journal of Medicine, 370(1), 23-32. https://doi.org/10.1056/NEJMoa1312808

Mitral-valve repair versus replacement for severe ischemic mitral regurgitation. / Acker, Michael A.; Parides, Michael K.; Perrault, Louis P.; Moskowitz, Alan J.; Gelijns, Annetine C.; Voisine, Pierre; Smith, Peter K.; Hung, Judy W.; Blackstone, Eugene H.; Puskas, John D.; Argenziano, Michael; Gammie, James S.; Mack, Michael; Ascheim, Deborah D.; Bagiella, Emilia; Moquete, Ellen G.; Ferguson, T. Bruce; Horvath, Keith A.; Geller, Nancy L.; Miller, Marissa A.; Woo, Y. Joseph; D'Alessandro, David A.; Ailawadi, Gorav; Dagenais, Francois; Gardner, Timothy J.; O'Gara, Patrick T.; Michler, Robert E.; Kron, Irving L.

In: New England Journal of Medicine, Vol. 370, No. 1, 2014, p. 23-32.

Research output: Contribution to journalArticle

Acker, MA, Parides, MK, Perrault, LP, Moskowitz, AJ, Gelijns, AC, Voisine, P, Smith, PK, Hung, JW, Blackstone, EH, Puskas, JD, Argenziano, M, Gammie, JS, Mack, M, Ascheim, DD, Bagiella, E, Moquete, EG, Ferguson, TB, Horvath, KA, Geller, NL, Miller, MA, Woo, YJ, D'Alessandro, DA, Ailawadi, G, Dagenais, F, Gardner, TJ, O'Gara, PT, Michler, RE & Kron, IL 2014, 'Mitral-valve repair versus replacement for severe ischemic mitral regurgitation', New England Journal of Medicine, vol. 370, no. 1, pp. 23-32. https://doi.org/10.1056/NEJMoa1312808
Acker, Michael A. ; Parides, Michael K. ; Perrault, Louis P. ; Moskowitz, Alan J. ; Gelijns, Annetine C. ; Voisine, Pierre ; Smith, Peter K. ; Hung, Judy W. ; Blackstone, Eugene H. ; Puskas, John D. ; Argenziano, Michael ; Gammie, James S. ; Mack, Michael ; Ascheim, Deborah D. ; Bagiella, Emilia ; Moquete, Ellen G. ; Ferguson, T. Bruce ; Horvath, Keith A. ; Geller, Nancy L. ; Miller, Marissa A. ; Woo, Y. Joseph ; D'Alessandro, David A. ; Ailawadi, Gorav ; Dagenais, Francois ; Gardner, Timothy J. ; O'Gara, Patrick T. ; Michler, Robert E. ; Kron, Irving L. / Mitral-valve repair versus replacement for severe ischemic mitral regurgitation. In: New England Journal of Medicine. 2014 ; Vol. 370, No. 1. pp. 23-32.
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abstract = "BACKGROUND: Ischemic mitral regurgitation is associated with a substantial risk of death. Practice guidelines recommend surgery for patients with a severe form of this condition but acknowledge that the supporting evidence for repair or replacement is limited. METHODS: We randomly assigned 251 patients with severe ischemic mitral regurgitation to undergo either mitral-valve repair or chordal-sparing replacement in order to evaluate efficacy and safety. The primary end point was the left ventricular end-systolic volume index (LVESVI) at 12 months, as assessed with the use of a Wilcoxon rank-sum test in which deaths were categorized below the lowest LVESVI rank. RESULTS: At 12 months, the mean LVESVI among surviving patients was 54.6±25.0 ml per square meter of body-surface area in the repair group and 60.7±31.5 ml per square meter in the replacement group (mean change from baseline, -6.6 and -6.8 ml per square meter, respectively). The rate of death was 14.3{\%} in the repair group and 17.6{\%} in the replacement group (hazard ratio with repair, 0.79; 95{\%} confidence interval, 0.42 to 1.47; P = 0.45 by the log-rank test). There was no significant between-group difference in LVESVI after adjustment for death (z score, 1.33; P = 0.18). The rate of moderate or severe recurrence of mitral regurgitation at 12 months was higher in the repair group than in the replacement group (32.6{\%} vs. 2.3{\%}, P<0.001). There were no significant between-group differences in the rate of a composite of major adverse cardiac or cerebrovascular events, in functional status, or in quality of life at 12 months. CONCLUSIONS: We observed no significant difference in left ventricular reverse remodeling or survival at 12 months between patients who underwent mitral-valve repair and those who underwent mitral-valve replacement. Replacement provided a more durable correction of mitral regurgitation, but there was no significant between-group difference in clinical outcomes.",
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TY - JOUR

T1 - Mitral-valve repair versus replacement for severe ischemic mitral regurgitation

AU - Acker, Michael A.

AU - Parides, Michael K.

AU - Perrault, Louis P.

AU - Moskowitz, Alan J.

AU - Gelijns, Annetine C.

AU - Voisine, Pierre

AU - Smith, Peter K.

AU - Hung, Judy W.

AU - Blackstone, Eugene H.

AU - Puskas, John D.

AU - Argenziano, Michael

AU - Gammie, James S.

AU - Mack, Michael

AU - Ascheim, Deborah D.

AU - Bagiella, Emilia

AU - Moquete, Ellen G.

AU - Ferguson, T. Bruce

AU - Horvath, Keith A.

AU - Geller, Nancy L.

AU - Miller, Marissa A.

AU - Woo, Y. Joseph

AU - D'Alessandro, David A.

AU - Ailawadi, Gorav

AU - Dagenais, Francois

AU - Gardner, Timothy J.

AU - O'Gara, Patrick T.

AU - Michler, Robert E.

AU - Kron, Irving L.

PY - 2014

Y1 - 2014

N2 - BACKGROUND: Ischemic mitral regurgitation is associated with a substantial risk of death. Practice guidelines recommend surgery for patients with a severe form of this condition but acknowledge that the supporting evidence for repair or replacement is limited. METHODS: We randomly assigned 251 patients with severe ischemic mitral regurgitation to undergo either mitral-valve repair or chordal-sparing replacement in order to evaluate efficacy and safety. The primary end point was the left ventricular end-systolic volume index (LVESVI) at 12 months, as assessed with the use of a Wilcoxon rank-sum test in which deaths were categorized below the lowest LVESVI rank. RESULTS: At 12 months, the mean LVESVI among surviving patients was 54.6±25.0 ml per square meter of body-surface area in the repair group and 60.7±31.5 ml per square meter in the replacement group (mean change from baseline, -6.6 and -6.8 ml per square meter, respectively). The rate of death was 14.3% in the repair group and 17.6% in the replacement group (hazard ratio with repair, 0.79; 95% confidence interval, 0.42 to 1.47; P = 0.45 by the log-rank test). There was no significant between-group difference in LVESVI after adjustment for death (z score, 1.33; P = 0.18). The rate of moderate or severe recurrence of mitral regurgitation at 12 months was higher in the repair group than in the replacement group (32.6% vs. 2.3%, P<0.001). There were no significant between-group differences in the rate of a composite of major adverse cardiac or cerebrovascular events, in functional status, or in quality of life at 12 months. CONCLUSIONS: We observed no significant difference in left ventricular reverse remodeling or survival at 12 months between patients who underwent mitral-valve repair and those who underwent mitral-valve replacement. Replacement provided a more durable correction of mitral regurgitation, but there was no significant between-group difference in clinical outcomes.

AB - BACKGROUND: Ischemic mitral regurgitation is associated with a substantial risk of death. Practice guidelines recommend surgery for patients with a severe form of this condition but acknowledge that the supporting evidence for repair or replacement is limited. METHODS: We randomly assigned 251 patients with severe ischemic mitral regurgitation to undergo either mitral-valve repair or chordal-sparing replacement in order to evaluate efficacy and safety. The primary end point was the left ventricular end-systolic volume index (LVESVI) at 12 months, as assessed with the use of a Wilcoxon rank-sum test in which deaths were categorized below the lowest LVESVI rank. RESULTS: At 12 months, the mean LVESVI among surviving patients was 54.6±25.0 ml per square meter of body-surface area in the repair group and 60.7±31.5 ml per square meter in the replacement group (mean change from baseline, -6.6 and -6.8 ml per square meter, respectively). The rate of death was 14.3% in the repair group and 17.6% in the replacement group (hazard ratio with repair, 0.79; 95% confidence interval, 0.42 to 1.47; P = 0.45 by the log-rank test). There was no significant between-group difference in LVESVI after adjustment for death (z score, 1.33; P = 0.18). The rate of moderate or severe recurrence of mitral regurgitation at 12 months was higher in the repair group than in the replacement group (32.6% vs. 2.3%, P<0.001). There were no significant between-group differences in the rate of a composite of major adverse cardiac or cerebrovascular events, in functional status, or in quality of life at 12 months. CONCLUSIONS: We observed no significant difference in left ventricular reverse remodeling or survival at 12 months between patients who underwent mitral-valve repair and those who underwent mitral-valve replacement. Replacement provided a more durable correction of mitral regurgitation, but there was no significant between-group difference in clinical outcomes.

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