Surgical treatment of moderate ischemic mitral regurgitation

Peter K. Smith, John D. Puskas, Deborah D. Ascheim, Pierre Voisine, Annetine C. Gelijns, Alan J. Moskowitz, Judy W. Hung, Michael K. Parides, Gorav Ailawadi, Louis P. Perrault, Michael A. Acker, Michael Argenziano, Vinod Thourani, James S. Gammie, Marissa A. Miller, Pierre Pagé, Jessica R. Overbey, Emilia Bagiella, François Dagenais, Eugene H. Blackstone & 9 others Irving L. Kron, Daniel J. Goldstein, Eric A. Rose, Ellen G. Moquete, Neal Jeffries, Timothy J. Gardner, Patrick T. O'Gara, John H. Alexander, Robert E. Michler

Research output: Contribution to journalArticle

196 Citations (Scopus)

Abstract

Background Ischemic mitral regurgitation is associated with increased mortality and morbidity. For surgical patients with moderate regurgitation, the benefits of adding mitralvalve 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.).

Original languageEnglish (US)
Pages (from-to)2178-2188
Number of pages11
JournalNew England Journal of Medicine
Volume371
Issue number23
DOIs
StatePublished - Dec 4 2014

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Mitral Valve Insufficiency
Coronary Artery Bypass
Mitral Valve
Stroke Volume
Ventricular Remodeling
Therapeutics
Nonparametric Statistics
Mortality
Body Surface Area
National Institutes of Health (U.S.)
Nervous System
Length of Stay
Quality of Life
Confidence Intervals
Morbidity
Health

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Smith, P. K., Puskas, J. D., Ascheim, D. D., Voisine, P., Gelijns, A. C., Moskowitz, A. J., ... Michler, R. E. (2014). Surgical treatment of moderate ischemic mitral regurgitation. New England Journal of Medicine, 371(23), 2178-2188. https://doi.org/10.1056/NEJMoa1410490

Surgical treatment of moderate ischemic mitral regurgitation. / Smith, Peter K.; Puskas, John D.; Ascheim, Deborah D.; Voisine, Pierre; Gelijns, Annetine C.; Moskowitz, Alan J.; Hung, Judy W.; Parides, Michael K.; Ailawadi, Gorav; Perrault, Louis P.; Acker, Michael A.; Argenziano, Michael; Thourani, Vinod; Gammie, James S.; Miller, Marissa A.; Pagé, Pierre; Overbey, Jessica R.; Bagiella, Emilia; Dagenais, François; Blackstone, Eugene H.; Kron, Irving L.; Goldstein, Daniel J.; Rose, Eric A.; Moquete, Ellen G.; Jeffries, Neal; Gardner, Timothy J.; O'Gara, Patrick T.; Alexander, John H.; Michler, Robert E.

In: New England Journal of Medicine, Vol. 371, No. 23, 04.12.2014, p. 2178-2188.

Research output: Contribution to journalArticle

Smith, PK, Puskas, JD, Ascheim, DD, Voisine, P, Gelijns, AC, Moskowitz, AJ, Hung, JW, Parides, MK, Ailawadi, G, Perrault, LP, Acker, MA, Argenziano, M, Thourani, V, Gammie, JS, Miller, MA, Pagé, P, Overbey, JR, Bagiella, E, Dagenais, F, Blackstone, EH, Kron, IL, Goldstein, DJ, Rose, EA, Moquete, EG, Jeffries, N, Gardner, TJ, O'Gara, PT, Alexander, JH & Michler, RE 2014, 'Surgical treatment of moderate ischemic mitral regurgitation', New England Journal of Medicine, vol. 371, no. 23, pp. 2178-2188. https://doi.org/10.1056/NEJMoa1410490
Smith PK, Puskas JD, Ascheim DD, Voisine P, Gelijns AC, Moskowitz AJ et al. Surgical treatment of moderate ischemic mitral regurgitation. New England Journal of Medicine. 2014 Dec 4;371(23):2178-2188. https://doi.org/10.1056/NEJMoa1410490
Smith, Peter K. ; Puskas, John D. ; Ascheim, Deborah D. ; Voisine, Pierre ; Gelijns, Annetine C. ; Moskowitz, Alan J. ; Hung, Judy W. ; Parides, Michael K. ; Ailawadi, Gorav ; Perrault, Louis P. ; Acker, Michael A. ; Argenziano, Michael ; Thourani, Vinod ; Gammie, James S. ; Miller, Marissa A. ; Pagé, Pierre ; Overbey, Jessica R. ; Bagiella, Emilia ; Dagenais, François ; Blackstone, Eugene H. ; Kron, Irving L. ; Goldstein, Daniel J. ; Rose, Eric A. ; Moquete, Ellen G. ; Jeffries, Neal ; Gardner, Timothy J. ; O'Gara, Patrick T. ; Alexander, John H. ; Michler, Robert E. / Surgical treatment of moderate ischemic mitral regurgitation. In: New England Journal of Medicine. 2014 ; Vol. 371, No. 23. pp. 2178-2188.
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abstract = "Background Ischemic mitral regurgitation is associated with increased mortality and morbidity. For surgical patients with moderate regurgitation, the benefits of adding mitralvalve 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.).",
author = "Smith, {Peter K.} and Puskas, {John D.} and Ascheim, {Deborah D.} and Pierre Voisine and Gelijns, {Annetine C.} and Moskowitz, {Alan J.} and Hung, {Judy W.} and Parides, {Michael K.} and Gorav Ailawadi and Perrault, {Louis P.} and Acker, {Michael A.} and Michael Argenziano and Vinod Thourani and Gammie, {James S.} and Miller, {Marissa A.} and Pierre Pag{\'e} and Overbey, {Jessica R.} and Emilia Bagiella and Fran{\cc}ois Dagenais and Blackstone, {Eugene H.} and Kron, {Irving L.} and Goldstein, {Daniel J.} and Rose, {Eric A.} and Moquete, {Ellen G.} and Neal Jeffries and Gardner, {Timothy J.} and O'Gara, {Patrick T.} and Alexander, {John H.} and Michler, {Robert E.}",
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doi = "10.1056/NEJMoa1410490",
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TY - JOUR

T1 - Surgical treatment of moderate ischemic mitral regurgitation

AU - Smith, Peter K.

AU - Puskas, John D.

AU - Ascheim, Deborah D.

AU - Voisine, Pierre

AU - Gelijns, Annetine C.

AU - Moskowitz, Alan J.

AU - Hung, Judy W.

AU - Parides, Michael K.

AU - Ailawadi, Gorav

AU - Perrault, Louis P.

AU - Acker, Michael A.

AU - Argenziano, Michael

AU - Thourani, Vinod

AU - Gammie, James S.

AU - Miller, Marissa A.

AU - Pagé, Pierre

AU - Overbey, Jessica R.

AU - Bagiella, Emilia

AU - Dagenais, François

AU - Blackstone, Eugene H.

AU - Kron, Irving L.

AU - Goldstein, Daniel J.

AU - Rose, Eric A.

AU - Moquete, Ellen G.

AU - Jeffries, Neal

AU - Gardner, Timothy J.

AU - O'Gara, Patrick T.

AU - Alexander, John H.

AU - Michler, Robert E.

PY - 2014/12/4

Y1 - 2014/12/4

N2 - Background Ischemic mitral regurgitation is associated with increased mortality and morbidity. For surgical patients with moderate regurgitation, the benefits of adding mitralvalve 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.).

AB - Background Ischemic mitral regurgitation is associated with increased mortality and morbidity. For surgical patients with moderate regurgitation, the benefits of adding mitralvalve 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.).

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