2004;78:794-799 Ann Thorac SurgRalph J. Damiano, Jr

Moazami, Jennifer S. Lawton, Marci S. Bailey, Tracey J. Guthrie, Bryan F. Meyers and Michael D. Diodato, Marc R. Moon, Michael K. Pasque, Hendrick B. Barner, Nader

propensity analysislong-term survival in patients undergoing coronary artery revascularization: A Repair of ischemic mitral regurgitation does not increase mortality or improve

http://ats.ctsnetjournals.org/cgi/content/full/78/3/794located on the World Wide Web at:

The online version of this article, along with updated information and services, is

Print ISSN: 0003-4975; eISSN: 1552-6259. Southern Thoracic Surgical Association. Copyright © 2004 by The Society of Thoracic Surgeons.

is the official journal of The Society of Thoracic Surgeons and theThe Annals of Thoracic Surgery

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epair of Ischemic Mitral Regurgitation Does Notncrease Mortality or Improve Long-Term Survivaln Patients Undergoing Coronary Arteryevascularization: A Propensity Analysisichael D. Diodato, MD, Marc R. Moon, MD, Michael K. Pasque, MD,endrick B. Barner, MD, Nader Moazami, MD, Jennifer S. Lawton, MD,arci S. Bailey, RN, Tracey J. Guthrie, RN, Bryan F. Meyers, MD, and

alph J. Damiano, Jr, MD

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Background. The purpose of this study was to compareperative mortality and midterm outcome of patientsith ischemic mitral regurgitation (MR) undergoing ei-

her coronary artery bypass grafting (CABG) alone orABG with mitral valve (MV) repair.Methods. From 1996 to 2001, 51 consecutive patients

nderwent CABG with MV repair for ischemic MR. Allatients in this group were matched to similar patientsith ischemic MR undergoing CABG alone during the

ame 6-year period using propensity analysis (consider-ng 24 covariates, including severity of MR and Nework Heart Association [NYHA] class).Results. Propensity score matching yielded 51 closelyatched control patients. Preoperative MR severity was

� or 4� in 94% of CABG with MV repair and 96% ofABG-alone patients, and 86% of patients in each group

ere NYHA class III or IV. Operative mortality was 3.9%

he impact of adding mitral valve (MV) repair to M

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2.8% in both groups. Survival was also similar be-ween CABG with MV repair and CABG alone at 1 year84% � 5% versus 82% � 5%) and 3 years (70% � 7%ersus 71% � 7% (p � 0.43). Among survivors, NYHAlass improved at follow-up (50 � 20 months) from 3.4 �.7 to 1.7 � 1.0 for CABG with MV repair (p < 0.001) androm 3.4 � 0.7 to 1.8 � 1.0 for CABG alone (p < 0.001).

Conclusions. Operative mortality, midterm survival,nd late functional class were similar between two well-atched groups of patients undergoing CABG for ischemicR, differing only in the addition of MV repair. WhereasV repair can be added safely to CABG in this group of

igh-risk patients without increasing mortality, its impactn late survival and functional class may be limited.

(Ann Thorac Surg 2004;78:794–9)

© 2004 by The Society of Thoracic Surgeons

aterial and Methods

coronary artery bypass grafting (CABG) alone for

atients with ischemic mitral regurgitation (MR) remainsnclear. Several interesting reports have addressed this

ssue, but study groups have typically been heteroge-eous, making interpretation of the resulting statisticalnalyses difficult [1–6].The purpose of the current investigation was to com-

are operative mortality and midterm outcome inatched groups of patients with ischemic MR undergo-

ng either CABG alone or CABG with MV repair. Toccomplish this goal, propensity score analysis was per-ormed to best match the two distinct groups and mini-

ize the effect of confounding variables on patientutcome.

ccepted for publication March 8, 2004.

resented at the Fiftieth Annual Meeting of the Southern Thoracicurgical Association, Bonita Springs, FL, Nov 13–15, 2003.

ddress reprint requests to Dr Moon, Division of Cardiothoracic Surgery,ueeny Tower, Suite 3108, One Barnes-Jewish Hospital Plaza, St. Louis,

rom January 1996 to December 2001, 1180 patientsnderwent CABG at Washington University Medicalenter (Barnes-Jewish Hospital), including 71 patientsho underwent simultaneous CABG with MV repair. Of

hese patients, 51 underwent combined CABG with MVepair for “functional” ischemic MR with anatomicallyormal leaflets and intact papillary muscle (Carpentier I,IIb). Based on echocardiography, MR severity wasraded as absent (0�), trace (1�), mild (2�), moderate3�), or severe (4�). Left ventricular (LV) function wasategorized based on ejection fraction (EF) as normal (0�,VEF greater than 0.50), mildly impaired (1�, LVEF 0.40

o 0.50), moderately impaired (2�, LVEF 0.25 to 0.40), oreverely impaired (3�, LVEF less than 0.25). To select aatched control group of patients who underwent CABG

lone despite the presence of an equivalent degree ofR, propensity score analysis was performed [7].

ropensity Score Analysishe decision to repair the valve was made by the oper-

ting surgeon, often in consultation with the referring

0003-4975/04/$30.00doi:10.1016/j.athoracsur.2004.03.022

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ardiologist, based on the patient’s preoperative echocar-iogram, cardiac catheterization, and clinical status. Theesulting selection bias to CABG with MV repair versusABG alone was addressed by propensity matching.ogistic regression analysis was used to identify covari-tes, among 24 baseline patient variables, that werembalanced in the two groups of interest (SPSS 11.0 for

indows, SPSS Inc, Chicago, IL). Fifteen variables wereot significant in the logistic regression analysis, includ-

ng sex, diabetes mellitus, hypercholesterolemia, chronicenal insufficiency, current dialysis requirement, familyistory of coronary artery disease, pulmonary hyperten-ion, previous cerebrovascular accident, chronic obstruc-ive pulmonary disease, peripheral vascular disease, his-ory of myocardial infarction, congestive heart failure,table versus unstable angina, LVEF, and cardiogenichock. In contrast, the logistic regression analysis identi-ed nine variables as significant predictors for the per-

ormance of MV repair during CABG, including youngerge, smoking history, systemic hypertension, lack oferebrovascular disease, preoperative intraaortic balloonounterpulsation, New York Heart Association (NYHA)lass III or IV, nonurgent/emergent operative status, lesshan three-vessel disease, and an increased degree of MVnsufficiency. Using the significant regression coeffi-ients, a propensity score was calculated for all 1180atients who underwent CABG at our institution from996 to 2001, and patients were closely matched on theasis of this score. This process matched the 51 patientsho underwent CABG with MV repair with 51 patientsho underwent CABG alone. The resulting 102 matchedatients form the focus of the outcomes analysis for thistudy.

atient Characteristicselected preoperative clinical patient characteristics for

he CABG alone and CABG with MV repair groups areisted in Table 1. In the CABG with MV repair group, the

ean age was slightly lower (p � 0.05), but LVEF tendedo be higher (p � 0.07). The CABG with MV repair groupncluded fewer patients with three-vessel disease (p �.009) and more smokers (p � 0.07). The groups wereimilar as far as sex (p � 0.84), emergency procedures (p

0.152), unstable angina (p � 0.81), history of myocardialnfection (p � 0.27), NYHA class (p � 0.77), hypertensionp � 0.17), cerebrovascular disease (p � 0.14), preopera-ive intraaortic balloon pump use (p � 0.35), and severityf MR (p � 0.99).

urgical Techniquell procedures were performed using cardiopulmonaryypass with cardioplegic arrest. In the CABG-aloneroup, the most common reasons noted for not perform-

ng a simultaneous MV repair were urgent or emergentevascularization in patients who were deemed “too highisk” or because of intraoperative “downgrading” of MRy transesophageal echocardiography. During the periodf this study, all other patients had satisfactory MV repairith 0� to 1� mitral regurgitation as judged by intraop-

rative transesophageal echocardiogram. C

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The average number of bypass grafts was similaretween groups (p � 0.15), but a tendency was noted forreater internal mammary artery use in the CABG-aloneroup (p � 0.06) (Table 2). As expected, when MV repairas added to CABG the mean cross-clamp time was 25inutes longer (p � 0.001) and cardiopulmonary bypass

ime was increased (p � 0.001). In the CABG with MVepair group, all patients underwent annuloplasty aloneithout an intervention on the leaflets or chords. Aartial posterior band was used in 37 patients and a fullircumferential ring was used in 14 patients. Ring sizesuring the 6-year period were diverse and included 26m in 12 patients, 28 mm in 16, 30 mm in 12, and 32 mm

n 11, but a significant shift was noted toward smallernnuloplasty sizes during recent years (Fig 1). In 1996 and997, 21% of rings were 28 mm or smaller compared with5% in the years 2000 and 2001 (p � 0.001). Operative yearid not influence use of partial versus full annuloplasty (p

0.95).

able 1. Preoperative Clinical Characteristics

haracteristicCABGAlone

CABG WithMV Repair

umber of patients 51 51ge, mean � SD (years) 69 � 11 65 � 10a

ale 26 (51%) 24 (47%)eft ventricular ejection fraction,mean � SD

0.31 � 0.11 0.35 � 0.12

mergency procedure 14 (27%) 8 (16%)nstable angina 11 (22%) 11 (22%)revious myocardial infarction 34 (67%) 40 (78%)ypertension 35 (69%) 42 (82%)erebrovascular disease 14 (27%) 7 (14%)reoperative IABP 4 (8%) 8 (16%)moking 26 (51%) 36 (71%)YHA class III or IV 44 (86%) 44 (86%)riple-vessel disease 36 (71%) 22 (43%)� or 4� mitral regurgitation 49 (96%) 48 (94%)

p � 0.05 CABG alone versus CABG with repair (Student’s t test, �2 test).

alues are number (percentage) unless otherwise indicated.

ABG � coronary artery bypass graft; IABP � intraaortic balloonump; MV � mitral valve; NYHA � New York Heart Association.

able 2. Intraoperative Clinical Characteristics

haracteristicCABGAlone

CABG WithMV Repair

umber of bypass grafts,mean � SD

3.0 � 0.9 2.7 � 1.1

nternal mammary artery use,n (%)

43 (84%) 35 (69%)

ross-clamp time, mean �SD (min)

87 � 39 112 � 33a

ardiopulmonary bypasstime, mean � SD (min)

140 � 50 176 � 48a

p � 0.05 CABG alone versus CABG with MV repair (Student’s t test, �2

est).

ABG � coronary artery bypass graft; MV � mitral valve.

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tatistical Analysisontinuous data are reported as mean � 1 standardeviation and were compared between groups usingtudent’s t test. Repeated-measures analysis of varianceas used to compare the change in LV function and MR

everity after surgery for patients who underwent bothreoperative and postoperative echocardiography. Clin-

cally important ratios are reported with 70% confidencentervals. Actuarial survival estimates were calculatedsing the Kaplan–Meier method and compared using the

og rank test. Variability of the actuarial estimates isxpressed as � 1 standard error of the mean.

esults

perative mortality (30 days or before hospital dis-harge) occurred in 2 patients in each group, yieldingqual mortality rates of 4% � 3%. At the time of midtermollow-up, an additional 36 patients were no longer alive,eaving 33 patients in the CABG-alone group and 29atients in the CABG with MV repair group available foridterm functional assessment. Surviving patients were

ontacted by telephone during a 2-week closing intervalnding November 2003. Mean follow-up was 39 � 25onths in the CABG-alone group and 37 � 25 months in

he CABG with MV repair group (p � 0.70). In theABG-alone group, survival was 82% � 5% at 1 year,1% � 7% at 3 years, and 65% � 7% at 5 years (Fig 2). Inhe CABG with MV repair group, survival was 84% � 5%t 1 year, 70% � 7% at 3 years, and 49% � 9% at 5 years,nd was not statistically different than CABG alone (p �.43).

ostoperative Echocardiography and Functional Statusor patients who underwent multiple echocardiograms,nly the latest examination was used for comparativenalysis between groups. This included 20 CABG withV repair patients and 19 CABG-alone patients who

nderwent echocardiograms at 21 � 21 months and 30 �6 months, respectively (p � 0.22). In the CABG with MV

ig 1. Influence of operative year on annuloplasty size ( � 26–28m; ■ � 30–32 mm; p � 0.001, �2 test).

epair group, postoperative severity of MR was similar C

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ith small rings (26 to 28 mm, 1.2 � 1.2) and large rings30 to 32 mm, 1.5 � 0.7) (p � 0.31). A tendency was notedor higher gradients with small rings (3.7 � 3.2 versus 2.2

3.0), but the difference did not reach statistical signif-cance (p � 0.13). In addition, no significant differenceas noted between partial bands or complete rings with

egards to mean gradient (3.8 � 3.5 mm Hg versus 3.0 �.5 mm Hg, p � 0.58) or MR severity (1.1 � 1.2 versus 1.3

1.2, p � 0.61).As expected, severity of MR improved significantly

fter CABG with MV repair from 3.9 � 0.2 to 1.2 � 1.2 (p0.001), and the number of patients with 3� to 4� MR

ell from 94% to 10%. However, a significant increase wasoted in MR severity when comparing studies performedefore hospital discharge (0.7 � 0.8 in 12 patients) with

ater studies (1.6 � 1.0 in 14 patients at 30 � 19 months)p � 0.03). This finding may be due, in part, to the facthat the surgeon, as a baseline assessment of the repair,ften obtained echocardiograms before hospital dis-harge, whereas later studies were obtained by the pa-ient’s cardiologist to evaluate a change in symptomatol-gy. In the CABG-alone group, improvement in MReverity after surgery was not as dramatic. Severity of MRell from 3.9 � 0.3 to 2.3 � 1.1 with CABG alone (p �.001), and the incidence of 3� to 4� MR fell from 96% to2%. Too few patients in the CABG-alone group under-ent echocardiograms before hospital discharge to allowmeaningful analysis of early versus midterm results.Postoperative echocardiography was performed in 29

f 62 patients who were alive at late follow-up and 10 of0 patients at some point before their death. Interest-ngly, whereas the difference in LV function betweenonsurvivors and survivors was not significant (1.6 � 1.2ersus 1.7 � 1.2, p � 0.66), the severity of MR was 30%igher in patients who were no longer alive (2.2 � 1.0ersus 1.7 � 1.2, p � 0.05). Among survivors, mean NYHAlass improved from 3.4 � 0.7 to 1.8 � 1.0 in the CABG-lone group (p � 0.001) and from 3.4 � 0.7 to 1.7 � 1.0 inhe CABG with MV repair group (p � 0.001). Midterm

YHA class was not significantly different betweenroups, with 80% of CABG-alone patients and 86% of

ig 2. Postoperative survival estimates (Kaplan–Meier) for patientsith ischemic mitral regurgitation undergoing coronary artery by-ass grafting (CABG) alone (dark line) or CABG with mitral valveMV) repair (light line) (n � 51 for each). The numbers of patientst risk are indicated. p � 0.437.

ABG with MV repair patients in NYHA I or II (p � 0.87).

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legant experimental work has helped delineate theathogenesis of ischemic MR [8–10]. Functional MR, asas present in all patients in the current report, appears

o be the consequence of a combination of two distinctnatomic abnormalities. Globally, annular dilatation oc-urs secondary to LV enlargement, which causes incom-lete coaptation of the mitral valve despite normal leafletotion. Locally, remodeling in the inferior wall causes

apillary muscle displacement with restricted motion ofhe mitral leaflets. Novel surgical techniques have beenroposed to correct ischemic valvular dysfunction, in-luding infarct restraint, ventricular reconstruction, Pan-th suture annuloplasty, and chordal transection [11–14].owever, these methods remain experimental. Since

996, our approach for patients with ischemic MR haseen to leave the mitral leaflets alone and perform aeduction annuloplasty with either a partial posteriorand or a full circumferential ring. In recent years, theing has been “undersized,” generally to 26 mm inomen and 28 mm in men. This approach effectively

elieved MR during the early postoperative period forost patients. The incidence of 3� to 4� MR fell from

4% preoperatively to 10% at 21 months postoperativelyfter CABG with MV repair with a residual nonrestrictiveean gradient of 3.5 mm Hg across the ring.Several important studies have demonstrated that MRhich persists long-term in patients with significant

oronary artery disease negatively impacts patient sur-ival [3, 15, 16]. In a multicenter, prospective study,amas and coinvestigators [15] followed patients long-

erm after myocardial infarction and found that 3-yearurvival decreased significantly from 90% without resid-al MR to 70% with residual MR. Similarly, at theleveland Clinic, Ellis and associates [16] noted a dimi-ution in 3-year survival from 92% to 69% after percuta-eous coronary interventions in patients with 2� orreater MR at the time of catheterization. Thus, if correc-ion of MR can be performed safely at the time of CABG,t would be likely to have long-term benefit.

The goal of the current investigation was to determinehether addition of MV repair for patients with ischemicR increased mortality compared with CABG alone, and

o determine whether repair of significant MR at the timef CABG improved midterm survival and functionaltatus in this high-risk patient population. Using propen-ity score analysis in an attempt to control selection bias,e found that when MV repair was added to CABG foratients with ischemic MR. Operative mortality wascceptable and identical to case-matched controls under-oing CABG alone. Unfortunately, midterm survival re-ults did not parallel the low initial operative mortalityate, with 3-year survival of 70% in both groups. Theseata, while generated using propensity analysis to helpinimize selection bias, are consistent with previous

etrospective studies [2, 4–6]. Some investigators suggesthat disappointing midterm survival in these patientseflects the “end-stage” nature of the disease process by

he time surgeons are asked to intervene [17, 18]. Indeed, a

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he best hope to improve outcomes in these high-riskatients may be to focus efforts on early intervention torevent the detrimental myopathic changes consequent

o ischemic remodeling.Historically, MV replacement, when combined with

ABG for ischemic MR, has been associated with oper-tive mortality rates of 20% to 50% and poor long-termurvival [4, 19, 20], likely due to selection bias. During the-year period of the current investigation, 16 additionalatients with ischemic MR underwent simultaneousABG with MV replacement rather than MV repair, all ofhom had acute papillary muscle rupture or obvious

nfarction that was suspicious for impending rupture. Wehought that this group represented a different subset ofatients and did not think including these patients in theurrent analysis would be helpful. The overall mortalityate was 50% (8 of 16 patients) for this very high-riskroup, including 63% for emergent and 38% for non-mergent cases.Recent reports have successfully compared late resultsith repair versus replacement for ischemic MR in a

tatistically controlled fashion [21, 22]. Both studies sug-ested that MV repair may be better in low-risk patients,ut as expected the patient populations were diverse.ne study concluded that 70% of patients with ischemicR benefit from repair over replacement, but in the

igh-risk setting, or with complex regurgitant jets, survivalas similar with both techniques [22]. In the current report,

he only patient in the CABG with MV repair group whonderwent an emergent procedure died, as did 5 of 8atients who underwent emergent CABG with MV replace-ent. In contrast, for nonemergent cases, the 50:8 ratio of

epair to replacement for ischemic MR at our institutionas similar to the data presented by other studies [21, 22]

nd is a consequence of our improved understanding ofhis complex disease and our belief that repair is preferredn lower-risk patients with functional ischemic MR.

The current study was subject to the limitations inher-nt to a nonrandomized, nonblinded study, includingelection bias as to which patients underwent MV repairuring CABG for ischemic MR. Propensity score analysisas used in an attempt to account for selection bias, but

uch biases are impossible to eliminate completely whenhe patient analysis is retrospective.

Early postoperative echocardiography was not per-ormed routinely in all patients, especially during therst 3 years of the study. Therefore, follow-up data mayave overestimated the severity of residual MR postop-ratively, because these data were preferentially col-ected in patients with signs or symptoms of clinicalongestive heart failure. In contrast, midterm NYHAlass was likely skewed toward lower scores, because aubstantial portion of patients with diminished functionnd elevated NYHA class postoperatively were amonghose who died during the follow-up period.

By design, this study encompassed only the mostecent 6 years of our clinical experience, with an addi-ional 2 years to increase minimum follow-up. This timeeriod was selected because it was thought to represent

relatively consistent, modern approach to the manage-

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ent of patients with ischemic MR at our institution,ost specifically, with a paradigm shift from replacement

o repair for patients with functional MR. Thus, whereasaximum follow-up was limited to only 7 years, the

revailing opinion was that this time frame offered us thecleanest” study groups in which to address the complexssue of ischemic MR.

In summary, the current report demonstrated that theddition of MV repair to CABG for patients with func-ional ischemic MR did not increase operative mortality.

owever, midterm survival was disappointing after ei-her CABG alone or CABG with MV repair, and thempact of MV repair on midterm functional status wasot evident from our results.

he authors gratefully acknowledge the clinical contributions ofilliam A. Gay, Jr, MD, and Thoralf M. Sundt III, MD.

eferences

1. Duarte IG, Shen Y, MacDonald MJ, Jones EL, Craver JM,Guyton RA. Treatment of moderate mitral regurgitation andcoronary disease by coronary bypass alone: late results. AnnThorac Surg 1999;68:426–30.

2. Gangemi JJ, Tribble CG, Ross SD, McPherson JA, Kern JA,Kron IL. Does the additive risk of mitral valve repair inpatients with ischemic cardiomyopathy prohibit surgicalintervention? Ann Surg 2000;231:710–4.

3. Aklog L, Filsoufi F, Flores KQ, et al. Does coronary arterybypass grafting alone correct moderate ischemic mitral re-gurgitation? Circulation 2001;104(Suppl 1):I-68–75.

4. Harris KM, Sundt TM, Aeppli D, Sharma R, Barzilai B. Canlate survival of patients with moderate ischemic mitralregurgitation be impacted by intervention on the valve? AnnThorac Surg 2002;74:1468–75.

5. Tolis GA, Korkolis DP, Kopf GS, Elefteriades JA. Revascu-larization alone (without mitral valve repair) suffices inpatients with advanced ischemic cardiomyopathy, and mild-to-moderate mitral regurgitation. Ann Thorac Surg 2002;74:1476–81.

6. Trichon BH, Glower DD, Shaw LK, et al. Survival aftercoronary revascularization, with and without mitral valvesurgery, in patients with ischemic mitral regurgitation. Cir-culation 2003;108(Suppl 2):II-103–10.

7. Blackstone EH. Comparing apples and oranges. J Thorac

Cardiovasc Surg 2002;123:8–15.

ypass grafting?

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Dg

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8. Gorman JH, Gorman RC, Jackson BM, et al. Distortions ofthe mitral valve in acute ischemic mitral regurgitation. AnnThorac Surg 1997;64:1026–31.

9. Timek TA, Lai DT, Tibayan F, et al. Ischemia in three leftventricular regions: insights into the pathogenesis of acuteischemic mitral regurgitation. J Thorac Cardiovasc Surg2003;125:559–69.

0. Tibayan FA, Rodriguez F, Zasio MK, et al. Geometric distor-tions of the mitral valvular-ventricular complex in chronicischemic mitral regurgitation. Circulation 2003;108(Suppl2):II-116–21.

1. Moainie SL, Guy TS, Gorman JH, et al. Infarct restraintattenuates remodeling and reduces chronic ischemic mitralregurgitation after postero-lateral infarction. Ann ThoracSurg 2002;74:444–9.

2. Menicanti L, Di Donato M, Frigola A, et al. Ischemic mitralregurgitation: intraventricular papillary muscle imbricationwithout mitral ring during left ventricular restoration. J Tho-rac Cardiovasc Surg 2002;123:1041–50.

3. Tibayan FA, Rodriguez F, Liang D, Daughters GT, Ingels NB,Miller DC. Paneth suture annuloplasty abolishes acute isch-emic mitral regurgitation but preserves annular and leafletdynamics. Circulation 2003;108(Suppl 2):II-128–33.

4. Messas E, Pouzet B, Touchot B, et al. Efficacy of chordalcutting to relieve chronic persistent ischemic mitral regur-gitation. Circulation 2003;108(Suppl 2):II-111–5.

5. Lamas GA, Mitchell GF, Flaker GC, et al. Clinical signifi-cance of mitral regurgitation after myocardial infarction.Circulation 1997;96:827–33.

6. Ellis SG, Whitlow PL, Raymond RE, Schneider JP. Impact ofmitral regurgitation on long-term survival after percutane-ous coronary intervention. Am J Cardiol 2002;89:315–8.

7. Miller DC. Ischemic mitral regurgitation redux—to repair orto replace? J Thorac Cardiovasc Surg 2001;122:1059–62.

8. Gorman RC, Gorman JH. Invited commentary on Tolis. AnnThorac Surg 2002;74:1481.

9. Galloway AC, Grossi EA, Spencer FC, et al. Operativetherapy for mitral insufficiency from coronary artery disease.Semin Thorac Cardiovasc Surg 1995;7:227–32.

0. Cohn LH, Rizzo RJ, Adams DH, et al. The effect of patho-physiology on the surgical treatment of ischemic mitralregurgitation: operative and late risks of repair versus re-placement. Eur J Cardiothorac Surg 1995;9:568–74.

1. Grossi EA, Goldberg JD, LaPietra A, et al. Ischemic mitralvalve reconstruction and replacement: comparison of long-term survival and complications. J Thorac Cardiovasc Surg2001;122:1107–24.

2. Gillinov AM, Wierup PN, Blackstone EH, et al. Is repairpreferable to replacement for ischemic mitral regurgitation?

J Thorac Cardiovasc Surg 2001;122:1125–41.

ISCUSSION

R ALAA Y. AFIFI (Albany, NY): I congratulate you on anxcellent series, with a low mortality and very good midtermesults. The concern of increased morbidity and mortality in theschemic MR patient has been a profound problem for many of usor years.

The question and the problem that keeps plaguing many of usnd that was noted in earlier debates during the postgraduateession was the issue of how to evaluate patients with moderate-o-severe MR. Do you identify them through transthoracic orransesophageal echocardiogram preoperatively or do you iden-ify them through transesophageal echocardiogram after theyre intubated in the operating room? In other words, when is theecision made to operate on these patients, that is, to do aoncomitant mitral valve procedure in addition to coronary

R DIODATO: I can only comment on this series of patients. Iannot comment on the institutional policy at Washingtonniversity. All 102 patients of this study were identified to havead MR preoperatively with echocardiography. In the 51 pa-

ients not undergoing valve repair in this series, in cases inhich the operating surgeon specifically noted the reason forot performing an operation, 66% of the time it was because ofn intraoperative downgrading of MR on transesophageal echo-ardiogram. For the other 33% a cardiologist was consulteduring the operation to review the transesophageal echocardio-ram, and they concluded that the MR would be repaired withevascularization alone.

R MOON: As Thor knows, at Washington University, our

roup is diverse and each surgeon has his own preference as to

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ow he would treat these patients. However, our trend duringhe last 2 to 3 years has been to base our intraoperative decisionn the preoperative evaluation. Preoperatively, most patientsith diminished left ventricular function or mitral regurgitationn cardiac catheterization undergo a transthoracic echocardio-ram. Patients with moderate-to-severe regurgitation on theransthoracic echocardiogram will then often undergo a trans-sophageal echocardiogram, with possible stressing, to betterelineate the etiology of the regurgitation and determine theeed for repair at the time of revascularization. It is rare, at least

n my practice these days, that I find a patient with obviouseversible ischemia to the distal circumflex distribution whoseegurgitation will be resolved by revascularization alone, at leastn my opinion. I think we need to try now not to base the

he CTSNet Discussion Forum and Web site.

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2004 by The Society of Thoracic Surgeonsublished by Elsevier Inc

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ecision to repair the valve on the intraoperative evaluation. Well have learned by Aklog’s paper and others [References 3–5 inhe manuscript], that the downgrading that occurs during anes-hesia may mislead us into making the wrong decision at theime of surgery.

R ROBERT S. POSTON (Baltimore, MD): There are some datahat high-risk patients demonstrate reduced mortality using anff-pump compared with on-pump approach. Yet all of theatients in your CABG-alone group were done on-pump. Haveou analyzed the mortality of ischemic MR patients after off-ump CABG alone at Washington University?

R DIODATO: We did not do that analysis for this study.

nternet Discussion Forum

ach month, we select an article from The Annals ofhoracic Surgery for discussion within the Surgeon’s Fo-um of the CTSNet Discussion Forum Section. The arti-les chosen rotate among the six dilemma topics coverednder the Surgeon’s Forum, which include: Generalhoracic Surgery, Adult Cardiac Surgery, Pediatric Car-iac Surgery, Cardiac Transplantation, Lung Transplan-

ation, and Aortic and Vascular Surgery.Once the article selected for discussion is published

n the online version of The Annals, we will post aotice on the CTSNet home page (http://www.ctsnet.org)ith a FREE LINK to the full-text article. Readers wishing

o comment can post their own commentary in theiscussion forum for that article, which will be informallyoderated by The Annals Internet Editor. We encourage

ll surgeons to participate in this interesting exchangend to avail themselves of the other valuable features of

For September, the article chosen for discussion underhe Adult Cardiac Surgery Dilemma Section of the Dis-ussion Forum is:

eduction Aortoplasty and External Wrapping for Mod-rately Sized Tubular Ascending Aortic Aneurysm Withoncomitant Operationsinan Arsan, MD, Serdar Akgun, MD, Nuri Kurtoglu, MD,ekin Yildirim, MD, and Bulent Tekinsoy, MD

om R. Karl, MDhe Annals Internet EditorCSF Children’s Hospitalediatric Cardiac Surgical Unit05 Parnassus Ave, Room S-549an Francisco, CA 94143-0118hone: (415) 476-3501ax: (212) 202-3622

-mail: karlt@surgery.ucsf.edu

Ann Thorac Surg 2004;78:799 • 0003-4975/04/$30.00

by on June 12, 2013 als.org

2004;78:794-799 Ann Thorac SurgRalph J. Damiano, Jr

Moazami, Jennifer S. Lawton, Marci S. Bailey, Tracey J. Guthrie, Bryan F. Meyers and Michael D. Diodato, Marc R. Moon, Michael K. Pasque, Hendrick B. Barner, Nader

propensity analysislong-term survival in patients undergoing coronary artery revascularization: A Repair of ischemic mitral regurgitation does not increase mortality or improve

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