Background: Treatment of ischemic mitral regurgitation (IMR) is in evolution, as percutaneous procedures and complex surgical repair have been recently investigated in randomized clinical trials and matched studies. This study aims to review and compare the current treatment options for IMR. Methods: A comprehensive literature search was conducted using electronic databases. The primary outcome was all-cause long-term mortality. The secondary outcomes were perioperative mortality, unplanned rehospitalization, reoperation, and composite end points as defined in the original articles. Results: A total of 12 articles met the inclusion criteria and were included in the final meta-analysis. The MitraClip procedure did not confer a significant benefit in mortality and repeated hospitalization compared with medical therapy alone. In patients with moderate IMR, the adjunct of mitral procedure over coronary artery bypass graft is not associated with clinical improvements. When evaluating mitral valve (MV) replacement versus repair, hospital mortality was greater among patients undergoing replacement (odds ratio [OR], 1.91; P = .009), but both reoperation and readmission rates were lower (OR, 0.60, P = .05; and OR, 0.45, P < .02, respectively). Comparing restrictive annuloplasty alone with adjunctive subvalvular repair, subvalvular procedures resulted in fewer readmissions (OR, 0.50; P = .06) and adverse composite end points (P = .009). Conclusions: MitraClip procedure is not associated with improved outcomes compared with medical therapy. MV replacement is associated with increased early mortality but reduced reoperation rate and readmission rate compared with MV repair using annuloplasty in moderate-to-severe IMR. Despite no significant benefit in isolated outcomes comparing annular and adjunct subvalvular procedures, the adjunct of subvalvular procedures reduces the risk of major postoperative adverse events.

With an ageing population and expected increases in the prevalence of heart failure, there will likely be more patients presenting with ischaemic mitral regurgitation (IMR). Multiple studies have shown that surgery can be performed safely in this patient population. Randomized trials have now addressed whether mitral valve repair should be performed concomitantly with coronary artery bypass grafting in the setting of moderate IMR, and whether mitral valve repair or replacement is superior in the setting of severe IMR. Novel percutaneous technologies to address the mitral valve are also in evolution. This chapter provides an overview of IMR including surgical indications, operative techniques, a review of randomized trial data, and percutaneous approaches for mitral valve disease.

Surgeons have always been on the frontline for the management of many emergency and severe medical issues. Recent events have resulted in unprecedented challenges in the delivery of surgical care. The demands of the coronavirus disease 2019 (COVID-19) pandemic highlight the extraordinary resilience and adaptability of American health care providers and trainees while testing the capacity of the health care system. The courage and willingness of surgeons to participate in crisis management was demonstrated during the recent surge of COVID-19 patients in New York City (NYC)—the epicenter of the pandemic in the United States.

Background. Sudden cardiac death (SCD) is common among patients awaiting heart transplantation. Medical management of SCD may fail due to lack of efficacy or adverse side effects. The implantable cardioverter-defibrillator (ICD) may extend patient survival until a donor heart is available. Methods and Results. We reviewed 16 patients listed for transplantation between November 1988 and October 1991 who underwent ICD implantation for ventricular arrhythmias refractory to medical management. Mean age was 51.4±+11.4 years (range, 19-66 years), mean ejection fraction was 15.4±3.0% (range, 10-21%), and underlying cardiomyopathy was ischemic (12 patients), valvular (one patient), or dilated (three patients). There was no mortality from ICD insertion. Fourteen patients were discharged before transplantation, and two patients remained in the hospital until transplantation. Twelve patients underwent transplantation after a mean of 155.7±+113.7 days (range, 3-319) on the transplant list. The ICD delivered shocks for tachyarrhythmia associated with near syncope in 15 of 16 patients. ICD shocks numbered >10 in five patients, 5-9 in three patients, and 1-4 in seven patients. There was no morbidity

Background. Sudden cardiac death (SCD) is common among patients awaiting heart transplantation. Medical management of SCD may fail due to lack of efficacy or adverse side effects. The implantable cardioverter-defibrillator (ICD) may extend patient survival until a donor heart is available. Methods and Results. We reviewed 16 patients listed for transplantation between November 1988 and October 1991 who underwent ICD implantation for ventricular arrhythmias refractory to medical management. Mean age was 51.4±+11.4 years (range, 19-66 years), mean ejection fraction was 15.4±3.0% (range, 10-21%), and underlying cardiomyopathy was ischemic (12 patients), valvular (one patient), or dilated (three patients). There was no mortality from ICD insertion. Fourteen patients were discharged before transplantation, and two patients remained in the hospital until transplantation. Twelve patients underwent transplantation after a mean of 155.7±+113.7 days (range, 3-319) on the transplant list. The ICD delivered shocks for tachyarrhythmia associated with near syncope in 15 of 16 patients. ICD shocks numbered >10 in five patients, 5-9 in three patients, and 1-4 in seven patients. There was no morbidity

Central MessageWhen determining whether to perform an MV repair procedure or MVR with CABG in ischemic MR, vital considerations include degree of IMR severity, LV dysfunction, LV abnormal geometry, scar, and poor coronary targets.See Commentary on page 17. When determining whether to perform an MV repair procedure or MVR with CABG in ischemic MR, vital considerations include degree of IMR severity, LV dysfunction, LV abnormal geometry, scar, and poor coronary targets. See Commentary on page 17. Ischemic mitral regurgitation (IMR) is a clinical condition that deserves our attention for a number of important reasons, including the prevalence of IMR has been steadily increasing; the clinical consequences of IMR are significant; and our improved understanding of the interaction between IMR severity, left ventricular (LV) geometry, and LV function have led to preferred treatment options and improved clinical results.1Baumgartner H. Falk V. Bax J.J. De Bonis M. Hamm C. Holm P.J. et al.2017 ESC/EACTS guidelines for the management of valvular heart disease.Eur Heart J. 2017; 38: 2739-2791Crossref PubMed Scopus (2) Google Scholar, 2de Marchena E. Badiye A. Robalino G. Junttila J. Atapattu S. Nakamura M. et al.Respective prevalence of the different Carpentier classes of mitral regurgitation: a stepping stone for future therapeutic research and development.J Card Surg. 2011; 26: 385-392Crossref PubMed Scopus (68) Google Scholar, 3Nappi F. Avatar Singh S.S. Santana O. Mihos C.G. Functional mitral regurgitation: an overview for surgical management framework.J Thorac Dis. 2018; 10: 4540-4555Crossref PubMed Scopus (21) Google Scholar, 4Michler R.E. Surgical management of moderate ischemic mitral regurgitation at the time of coronary artery bypass grafting remains controversial.J Thorac Cardiovasc Surg. 2018; 156: 1498-1500Abstract Full Text Full Text PDF Scopus (8) Google Scholar IMR is a consequence of regional wall motion abnormalities induced by myocardial ischemia and infarction. The interaction between postinfarction/ischemic regional wall motion abnormalities, papillary muscle displacement, leaflet tethering, reduced closing forces, and annular dilatation result in MR.5Grigioni F. Detaint D. Avierinos J.F. Scott C. Tajik J. Enriquez-Sarano M. Contribution of ischemic mitral regurgitation to congestive heart failure after myocardial infarction.J Am Coll Cardiol. 2005; 45: 260-267Crossref PubMed Scopus (175) Google Scholar The mitral valve (MV) leaflets appear normal. Adverse LV remodeling develops in approximately 50% of patients after a myocardial infarction.6Bursi F. Enriquez-Sarano M. Nkomo V.T. Jacobsen S.J. Weston S.A. Meverden R.A. et al.Heart failure and death after myocardial infarction in the community: the emerging role of mitral regurgitation.Circulation. 2005; 111: 295-301Crossref PubMed Scopus (382) Google Scholar,7Perez de Isla L. Zamorano J. Quezada M. Almería C. Rodrigo J.L. Serra V. et al.Functional mitral regurgitation after a first non-ST-segment elevation acute coronary syndrome: contribution to congestive heart failure.Eur Heart J. 2007; 28: 2866-2872Crossref PubMed Scopus (28) Google Scholar The presence of any degree of IMR identifies patients with LV dysfunction who have a higher mortality risk than those without IMR.6Bursi F. Enriquez-Sarano M. Nkomo V.T. Jacobsen S.J. Weston S.A. Meverden R.A. et al.Heart failure and death after myocardial infarction in the community: the emerging role of mitral regurgitation.Circulation. 2005; 111: 295-301Crossref PubMed Scopus (382) Google Scholar This fact alone remains the primary driver for considering a MV procedure in patients with IMR requiring coronary artery bypass grafting (CABG). To date, no IMR surgical trial has demonstrated improved survival following IMR resolution. The appropriate surgical management of IMR at the time of CABG begins with a thorough understanding and preferably, serial evaluation of IMR severity. My current decision algorithm for managing any degree of IMR focuses on 5 preoperative factors that help determine the surgical plan. In conjunction with echocardiography and cardiac catheterization, cardiac magnetic resonance imaging with gadolinium hyperenhancement can complete a comprehensive analysis and evaluate the degree of LV scar.•Severity of MR,•Severity of LV dysfunction,•Severity of LV remodeling,•Presence and extent of LV scar, and•Quality and distribution of the left circumflex and right coronary circulation. Mild IMR should be treated with CABG alone because of ample clinical evidence demonstrating the near certain resolution of the IMR. The surgical treatment options differ for moderate and severe IMR and therefore, distinguishing between moderate and severe IMR is critically important. For moderate ischemic disease, the surgical options range from CABG alone to CABG plus an MV repair procedure, and for severe ischemic disease, the surgical options range from CABG plus an MV repair procedure to CABG plus MV replacement. Let us review the evidence to support these options based on IMR severity. Historically, some experts have advocated for CABG alone in moderate IMR, expecting improvements in regional/global LV function and LV geometry following CABG to lead to a reduction in IMR.8Penicka M. Linkova H. Lang O. Fojt R. Kocka V. Vanderheyden M. et al.Predictors of improvement of unrepaired moderate ischemic mitral regurgitation in patients undergoing elective isolated coronary artery bypass graft surgery.Circulation. 2009; 120: 1474-1481Crossref PubMed Scopus (93) Google Scholar,9Roshanali F. Mandegar M.H. Yousefnia M.A. Alaeddini F. Wann S. Low-dose dobutamine stress echocardiography to predict reversibility of mitral regurgitation with CABG.Echocardiography. 2006; 23: 31-37Crossref PubMed Scopus (25) Google Scholar Other experts have supported a restrictive mitral annuloplasty (RMA) repair at the time of CABG to address more directly the IMR, expecting to prevent further adverse remodeling and decrease the risk of heart failure.10Fattouch K. Guccione F. Sampognaro R. Panzarella G. Corrado E. Navarra E. et al.Efficacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: a randomized trial.J Thorac Cardiovasc Surg. 2009; 138: 278-285Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar,11Chan K.M. Punjabi P.P. Flather M. Wage R. Symmonds K. Roussin I. et al.Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation: final results of the randomized ischemic mitral evaluation (RIME) trial.Circulation. 2012; 126: 2502-2510Crossref PubMed Scopus (208) Google Scholar The Cardiothoracic Surgical Trials Network (CTSN) Moderate IMR multicenter randomized trial12Smith P.K. Puskas J.D. Ascheim D.D. Voisine P. Gelijns A.C. Moskowitz A.J. et al.Surgical treatment of moderate ischemic mitral regurgitation.N Engl J Med. 2014; 371: 2178-2188Crossref PubMed Scopus (256) Google Scholar,13Michler R.E. Smith P.K. Parides M.K. Ailawadi G. Thourani V. Moskowitz A.J. et al.Two-year outcomes following surgical treatment of moderate ischemic mitral regurgitation.N Engl J Med. 2016; 374: 1932-1941Crossref PubMed Scopus (260) Google Scholar compared CABG alone with CABG plus RMA in 301 patients with moderate IMR. The primary end point measured was change in end systolic volume index (LVESVI). RMA resulted in a significant reduction over CABG alone in the prevalence of MR at 1 and 2 years and, importantly, no progression to severe MR was seen in the RMA group.13Michler R.E. Smith P.K. Parides M.K. Ailawadi G. Thourani V. Moskowitz A.J. et al.Two-year outcomes following surgical treatment of moderate ischemic mitral regurgitation.N Engl J Med. 2016; 374: 1932-1941Crossref PubMed Scopus (260) Google Scholar At 1 and 2 years, there was no difference between the 2 groups in change in LVESVI, survival, LV ejection fraction, New York Heart Association functional class, or major adverse cardiac and cerebrovascular events. RMA was associated with a longer hospital stay after surgery, a higher incidence of postoperative supraventricular arrhythmias, and more general neurologic events (eg, metabolic encephalopathy, seizures, transient ischemic attack, and stroke). In contrast, 2 distinct yet similarly designed randomized clinical trials produced very different results from the CTSN trial.10Fattouch K. Guccione F. Sampognaro R. Panzarella G. Corrado E. Navarra E. et al.Efficacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: a randomized trial.J Thorac Cardiovasc Surg. 2009; 138: 278-285Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar,11Chan K.M. Punjabi P.P. Flather M. Wage R. Symmonds K. Roussin I. et al.Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation: final results of the randomized ischemic mitral evaluation (RIME) trial.Circulation. 2012; 126: 2502-2510Crossref PubMed Scopus (208) Google Scholar The study by Fattouch and colleagues10Fattouch K. Guccione F. Sampognaro R. Panzarella G. Corrado E. Navarra E. et al.Efficacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: a randomized trial.J Thorac Cardiovasc Surg. 2009; 138: 278-285Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar and the Randomized Ischemic Mitral Evaluation (RIME) trial11Chan K.M. Punjabi P.P. Flather M. Wage R. Symmonds K. Roussin I. et al.Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation: final results of the randomized ischemic mitral evaluation (RIME) trial.Circulation. 2012; 126: 2502-2510Crossref PubMed Scopus (208) Google Scholar both demonstrated that the addition of a restrictive mitral annuloplasty to CABG resulted in significant improvements in LV reverse remodeling, LV ejection fraction, MR grade and New York Heart Association functional class. Specifically, Fattouch and colleagues10Fattouch K. Guccione F. Sampognaro R. Panzarella G. Corrado E. Navarra E. et al.Efficacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: a randomized trial.J Thorac Cardiovasc Surg. 2009; 138: 278-285Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar randomly assigned 102 patients and demonstrated that the addition of RMA significantly reduced LV end systolic dimension (LVESd) and LV end diastolic dimension (LVEDd) over CABG alone. The RIME trial11Chan K.M. Punjabi P.P. Flather M. Wage R. Symmonds K. Roussin I. et al.Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation: final results of the randomized ischemic mitral evaluation (RIME) trial.Circulation. 2012; 126: 2502-2510Crossref PubMed Scopus (208) Google Scholar randomly assigned 73 patients and demonstrated a dramatic 28% reduction in LVESVI over the baseline mean of 78 mL/m2. The importance of achieving LV size reduction lies in the knowledge that LV enlargement is an independent risk for mortality. In part, this is why the CTSN chose LV dimension as the primary end point for its trial. Why were the clinical outcomes of the CTSN trial unable to achieve the benefits seen in the Fattouch and colleagues10Fattouch K. Guccione F. Sampognaro R. Panzarella G. Corrado E. Navarra E. et al.Efficacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: a randomized trial.J Thorac Cardiovasc Surg. 2009; 138: 278-285Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar and RIME11Chan K.M. Punjabi P.P. Flather M. Wage R. Symmonds K. Roussin I. et al.Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation: final results of the randomized ischemic mitral evaluation (RIME) trial.Circulation. 2012; 126: 2502-2510Crossref PubMed Scopus (208) Google Scholar randomized clinical trials? There are several points to consider. First, in the CTSN trial, irrespective of treatment arm, patients with resolution of IMR had greater reverse remodeling and better wall motion scores than those who did not.13Michler R.E. Smith P.K. Parides M.K. Ailawadi G. Thourani V. Moskowitz A.J. et al.Two-year outcomes following surgical treatment of moderate ischemic mitral regurgitation.N Engl J Med. 2016; 374: 1932-1941Crossref PubMed Scopus (260) Google Scholar This point is noteworthy because it provides evidence that many patients in both arms of the CTSN trial had viable myocardium and minimal LV scar. Improvements in global and regional wall motion as well as reverse LV remodeling following CABG alone are indicative of viable myocardium.9Roshanali F. Mandegar M.H. Yousefnia M.A. Alaeddini F. Wann S. Low-dose dobutamine stress echocardiography to predict reversibility of mitral regurgitation with CABG.Echocardiography. 2006; 23: 31-37Crossref PubMed Scopus (25) Google Scholar,14Sundt T.M. Surgery for ischemic mitral regurgitation.N Engl J Med. 2014; 371: 2228-2229Crossref PubMed Scopus (15) Google Scholar In such patients, revascularization alone would undoubtedly result in a reduction in MR. As Penicka and colleagues8Penicka M. Linkova H. Lang O. Fojt R. Kocka V. Vanderheyden M. et al.Predictors of improvement of unrepaired moderate ischemic mitral regurgitation in patients undergoing elective isolated coronary artery bypass graft surgery.Circulation. 2009; 120: 1474-1481Crossref PubMed Scopus (93) Google Scholar demonstrated in a series of patients with moderate IMR who underwent CABG alone, resolution of IMR following surgery was associated at baseline with more viable segments and less LV dysynchrony. Second, patients in the CTSN trial experienced substantially lower rates of baseline prior myocardial infarction and therefore, less LV scar than in the Fattouch and colleagues10Fattouch K. Guccione F. Sampognaro R. Panzarella G. Corrado E. Navarra E. et al.Efficacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: a randomized trial.J Thorac Cardiovasc Surg. 2009; 138: 278-285Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar and RIME11Chan K.M. Punjabi P.P. Flather M. Wage R. Symmonds K. Roussin I. et al.Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation: final results of the randomized ischemic mitral evaluation (RIME) trial.Circulation. 2012; 126: 2502-2510Crossref PubMed Scopus (208) Google Scholar studies. Patients with LV scar are less likely to experience wall motion improvement from revascularization and consequently, such patients may be better suited to the addition of RMA as a treatment for IMR. Third, baseline LV size was significantly smaller in the CTSN trial compared with the Fattouch and colleagues10Fattouch K. Guccione F. Sampognaro R. Panzarella G. Corrado E. Navarra E. et al.Efficacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: a randomized trial.J Thorac Cardiovasc Surg. 2009; 138: 278-285Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar and RIME11Chan K.M. Punjabi P.P. Flather M. Wage R. Symmonds K. Roussin I. et al.Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation: final results of the randomized ischemic mitral evaluation (RIME) trial.Circulation. 2012; 126: 2502-2510Crossref PubMed Scopus (208) Google Scholar trials. This fact alone may have favored patients in the Fattouch and colleagues10Fattouch K. Guccione F. Sampognaro R. Panzarella G. Corrado E. Navarra E. et al.Efficacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: a randomized trial.J Thorac Cardiovasc Surg. 2009; 138: 278-285Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar and RIME11Chan K.M. Punjabi P.P. Flather M. Wage R. Symmonds K. Roussin I. et al.Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation: final results of the randomized ischemic mitral evaluation (RIME) trial.Circulation. 2012; 126: 2502-2510Crossref PubMed Scopus (208) Google Scholar trials who received a restrictive mitral annuloplasty, especially in the presence of scar, because CABG alone in these patients would be less likely to result in sufficient improvement in LV wall motion and LV size reduction, precisely those factors that influence IMR resolution. Fourth, significant reverse remodeling was achieved in the Fattouch and colleagues10Fattouch K. Guccione F. Sampognaro R. Panzarella G. Corrado E. Navarra E. et al.Efficacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: a randomized trial.J Thorac Cardiovasc Surg. 2009; 138: 278-285Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar and RIME11Chan K.M. Punjabi P.P. Flather M. Wage R. Symmonds K. Roussin I. et al.Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation: final results of the randomized ischemic mitral evaluation (RIME) trial.Circulation. 2012; 126: 2502-2510Crossref PubMed Scopus (208) Google Scholar trials with CABG plus RMA compared with CABG alone. In the RIME trial,11Chan K.M. Punjabi P.P. Flather M. Wage R. Symmonds K. Roussin I. et al.Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation: final results of the randomized ischemic mitral evaluation (RIME) trial.Circulation. 2012; 126: 2502-2510Crossref PubMed Scopus (208) Google Scholar a 28% reduction in LV size from baseline (baseline mean, 78 mL/m2) was achieved with CABG plus RMA, whereas in the CTSN trial patients who received the combined procedure saw only a 9% reduction in LV size from baseline (baseline mean, 57 mL/m2). To underscore this important point, patients enrolled in the CTSN trial had smaller ventricles at baseline and as the evidence implies, more viable myocardium—expressly the clinical substrate that is likely to benefit the most from CABG alone when seeking to achieve IMR reduction. Unfortunately, none among these 3 clinical trials required preoperative evaluation of myocardial viability, which may have helped in our understanding of the subsequent clinical outcome. It is known that viability assessment can help predict the effectiveness of revascularization in specific patient populations and must be considered in this setting.15Meluzín J. Cerný J. Frélich M. Stetka F. Spinarová L. Popelová J. et al.Prognostic value of the amount of dysfunctional but viable myocardium in revascularized patients with coronary artery disease and left ventricular dysfunction. Investigators of this Multicenter Study.J Am Coll Cardiol. 1998; 32: 912-920Crossref PubMed Scopus (206) Google Scholar The lessons learned from these randomized trials in moderate IMR emphasize the fact that individual treatment decisions require balancing the risks of adverse perioperative events against the benefits of a lower incidence of postoperative IMR. One surgical therapy does not fit all clinical scenarios of LV geometry and function. Effective revascularization, as reflected in improved regional and global LV function, plays an important role in reducing moderate IMR independent of restrictive annuloplasty repair. In other clinical settings, the anticipated low likelihood of generating significant functional improvement and reverse remodeling from CABG should lead to the performance of a restrictive mitral annuloplasty reparative procedure. Such circumstances include patients with documented scar or basal aneurysm/dyskinesia in the inferior-posterior-lateral LV, larger ventricles (LVESVI >50 mL/m2 and LVEDd >55 mm), and poor coronary targets in the circumflex/right coronary distributions because of the reduced likelihood that revascularization will provide significant enhancement of LV contractility and LV reverse remodeling. Whether a restrictive mitral annuloplasty repair together with CABG in moderate IMR will predictably benefit patients with LV enlargement, poor coronary targets, or baseline inferior-posterior-lateral wall motion abnormalities considered to be scar remains unknown. Until such evidence is available, restrictive mitral annuloplasty should be considered an essential part of the surgical armamentarium for these patients. The optimal surgical management of severe IMR is debatable and in evolution. Some experts advocate a chordal-sparing MV replacement, whereas other experts support a restrictive mitral annuloplasty repair alone or in combination with a papillary muscle approximation (PMA) procedure to reduce LV dimension.16Acker M.A. Parides M.K. Perrault L.P. Moskowitz A.J. Gelijns A.C. Voisine P. et al.Mitral-valve repair versus replacement for severe ischemic mitral regurgitation.N Engl J Med. 2014; 370: 23-32Crossref PubMed Scopus (533) Google Scholar, 17Goldstein D. Moskowitz A.J. Geijins A.C. Ailawadi G. Parides M.K. Perrault L.P. et al.Two-year outcomes of surgical treatment in severe ischemic mitral regurgitation.N Engl J Med. 2016; 374: 344-353Crossref PubMed Scopus (437) Google Scholar, 18Nappi F. Lusini M. Spadaccio C. Nenna A. Covino E. Acar C. et al.Papillary muscle approximation versus restrictive annuloplasty alone for severe ischemic mitral regurgitation: a randomized trial.J Am Coll Cardiol. 2016; 24: 2334-2346Crossref Scopus (97) Google Scholar, 19Gillinov A.M. Wierup P.N. Blackstone E.H. Bishay E.S. Cosgrove D.M. White J. et al.Is repair preferable to replacement for ischemic mitral regurgitation?.J Thorac Cardiovasc Surg. 2001; 122: 1125-1141Abstract Full Text Full Text PDF PubMed Scopus (453) Google Scholar, 20Reece T.B. Tribble C.G. Ellman P.I. Maxey T.S. Woodford R.L. Dimeling G.M. et al.Mitral repair is superior to replacement when associated with coronary artery disease.Ann Surg. 2004; 239: 671-675Crossref PubMed Scopus (70) Google Scholar, 21Al-Radi O.O. Austin P.C. Tu J.V. David T.E. Yau T.M. Mitral repair versus replacement for ischemic mitral regurgitation.Ann Thorac Surg. 2005; 79: 1260-1267Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar, 22Vassileva C.M. Boley T. Markwell S. Hazelrigg S. Meta-analysis of short-term and long-term survival following repair versus replacement for ischemic mitral regurgitation.Eur J Cardiothorac Surg. 2011; 39: 295-303Crossref PubMed Scopus (123) Google Scholar Although a MV repair procedure is associated with lower operative morbidity and mortality, as well as the presumed benefit of maintaining LV systolic function by preserving the subvalvular apparatus, the 1-year MR recurrence rate with RMA alone can be as high as 30% to 40%.16Acker M.A. Parides M.K. Perrault L.P. Moskowitz A.J. Gelijns A.C. Voisine P. et al.Mitral-valve repair versus replacement for severe ischemic mitral regurgitation.N Engl J Med. 2014; 370: 23-32Crossref PubMed Scopus (533) Google Scholar, 17Goldstein D. Moskowitz A.J. Geijins A.C. Ailawadi G. Parides M.K. Perrault L.P. et al.Two-year outcomes of surgical treatment in severe ischemic mitral regurgitation.N Engl J Med. 2016; 374: 344-353Crossref PubMed Scopus (437) Google Scholar, 18Nappi F. Lusini M. Spadaccio C. Nenna A. Covino E. Acar C. et al.Papillary muscle approximation versus restrictive annuloplasty alone for severe ischemic mitral regurgitation: a randomized trial.J Am Coll Cardiol. 2016; 24: 2334-2346Crossref Scopus (97) Google Scholar,23Capoulade R. Zeng X. Overbey J.R. Ailawadi G. Alexander J.H. Ascheim D. et al.Impact of left ventricular to mitral valve ring mismatch on recurrent ischemic mitral regurgitation after ring annuloplasty.Circulation. 2016; 134: 1247-1256Crossref PubMed Scopus (41) Google Scholar MV replacement, although more effective and durable in addressing IMR, is associated with greater operative risk, and greater long-term risks such as thromboembolism, valve deterioration, and endocarditis.19Gillinov A.M. Wierup P.N. Blackstone E.H. Bishay E.S. Cosgrove D.M. White J. et al.Is repair preferable to replacement for ischemic mitral regurgitation?.J Thorac Cardiovasc Surg. 2001; 122: 1125-1141Abstract Full Text Full Text PDF PubMed Scopus (453) Google Scholar, 20Reece T.B. Tribble C.G. Ellman P.I. Maxey T.S. Woodford R.L. Dimeling G.M. et al.Mitral repair is superior to replacement when associated with coronary artery disease.Ann Surg. 2004; 239: 671-675Crossref PubMed Scopus (70) Google Scholar, 21Al-Radi O.O. Austin P.C. Tu J.V. David T.E. Yau T.M. Mitral repair versus replacement for ischemic mitral regurgitation.Ann Thorac Surg. 2005; 79: 1260-1267Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar, 22Vassileva C.M. Boley T. Markwell S. Hazelrigg S. Meta-analysis of short-term and long-term survival following repair versus replacement for ischemic mitral regurgitation.Eur J Cardiothorac Surg. 2011; 39: 295-303Crossref PubMed Scopus (123) Google Scholar The CTSN sought to address this controversy by comparing chordal-sparing MV replacement to restrictive mitral annuloplasty in 251 patients with severe IMR.16Acker M.A. Parides M.K. Perrault L.P. Moskowitz A.J. Gelijns A.C. Voisine P. et al.Mitral-valve repair versus replacement for severe ischemic mitral regurgitation.N Engl J Med. 2014; 370: 23-32Crossref PubMed Scopus (533) Google Scholar,17Goldstein D. Moskowitz A.J. Geijins A.C. Ailawadi G. Parides M.K. Perrault L.P. et al.Two-year outcomes of surgical treatment in severe ischemic mitral regurgitation.N Engl J Med. 2016; 374: 344-353Crossref PubMed Scopus (437) Google Scholar Chordal-sparing MV replacement resulted in a significant reduction over RMA in the prevalence of recurrent/persistent MR at 1 year (2.3% vs 32.6%) and 2 years (3.8% vs 58.8%). At 1 and 2 years, there was no difference between the 2 groups in the degree of LV reverse remodeling, LV ejection fraction, survival, or major adverse cardiac and cerebrovascular events. Although the rate of serious adverse events and overall hospital readmissions were comparable, patients undergoing RMA had more frequent events related to heart failure and cardiovascular readmissions at 2 years. These data support the use of MV replacement in the setting of severe IMR for patients with similar clinical characteristics to those enrolled in the CTSN trial. As with all clinical studies, the implications and generalizability of the study require further examination. Critics of the CTSN trial contend that the high prevalence of persistent/recurrent MR with RMA alone was related to trial design and surgical technique deficiencies in the conduct of the CTSN trial.4Michler R.E. Surgical management of moderate ischemic mitral regurgitation at the time of coronary artery bypass grafting remains controversial.J Thorac Cardiovasc Surg. 2018; 156: 1498-1500Abstract Full Text Full Text PDF Scopus (8) Google Scholar,18Nappi F. Lusini M. Spadaccio C. Nenna A. Covino E. Acar C. et al.Papillary muscle approximation versus restrictive annuloplasty alone for severe ischemic mitral regurgitation: a randomized trial.J Am Coll Cardiol. 2016; 24: 2334-2346Crossref Scopus (97) Google Scholar For example, only 75% of patients received concomitant CABG surgery and hence, 25% of CTSN patients enrolled had a clinical substrate incapable of benefiting from the ability of a revascularization procedure to produce wall motion improvement and IMR reduction. Moreover, critics of the CTSN trial cite insufficient undersizing of the mitral annulus with RMA, which limited the ability of the leaflets to form an improved zone of coaptation to reduce tenting height and tenting area.18Nappi F. Lusini M. Spadaccio C. Nenna A. Covino E. Acar C. et al.Papillary muscle approximation versus restrictive annuloplasty alone for severe ischemic mitral regurgitation: a randomized trial.J Am Coll Cardiol. 2016; 24: 2334-2346Crossref Scopus (97) Google Scholar In contrast to the CTSN trial, Nappi and colleagues,18Nappi F. Lusini M. Spadaccio C. Nenna A. Covino E. Acar C. et al.Papillary muscle approximation versus restrictive annuloplasty alone for severe ischemic mitral regurgitation: a randomized trial.J Am Coll Cardiol. 2016; 24: 2334-2346Crossref Scopus (97) Google Scholar in the Papillary Muscle Approximation Randomized Trial, achieved a 2-year prevalence of recurrent/persistent MR with RMA alone of only 13.2%, which the authors claim was the result of more effective annular reduction as seen by a greater mean difference between annular size and ring size compared with the CTSN trial.18Nappi F. Lusini M. Spadaccio C. Nenna A. Covino E. Acar C. et al.Papillary muscle approximation versus restrictive annuloplasty alone for severe ischemic mitral regurgitation: a randomized trial.J Am Coll Cardiol. 2016; 24: 2334-2346Crossref Scopus (97) Google Scholar Indeed, the strategy of overcorrection in restrictive annuloplasty (ie, the tighter, the better) has been advocated for a number of years by many respected surgeons. But, can such an overcorrection strategy reliably produce consistent and durable IMR resolution? Or, is there something more at play that must be considered to achieve durable IMR resolution? An evolving sentiment among experts is that an overcorrection strategy with RMA alone will not reliably produce long-term IMR reduction, especially because RMA alone does not consider or therapeutically address LV enlargement and its influence on tethering forces. It is intellectually far reaching and probably wishful thinking to expect that a redesign of the prosthetic annuloplasty ring could alter LV anatomy sufficiently to reliably reverse adverse LV remodeling. Logic suggests that the best candidates for an RMA-alone procedure are those patients with a normal to mildly enlarged left ventricle and in particular, those ventricles that can achieve reverse remodeling as a result of simultaneous revascularization. Larger and scared ventricles represent clinical scenarios in which it is unlikely to expect a reliable and durable reduction in IMR from an annular reduction procedure alone. The evidence for this line of thinking in severe IMR arises from multiple observations, including restrictive mitral annuloplasty does not reliably prevent persistent or recurrent IMR, overcorrected restrictive mitral annuloplasty does lead to mitral stenosis, and overcorrection using severely undersized annuloplasty rings is associated with exacerbated leaflet tethering.16Acker M.A. Parides M.K. Perrault L.P. Moskowitz A.J. Gelijns A.C. Voisine P. et al.Mitral-valve repair versus replacement for severe ischemic mitral regurgitation.N Engl J Med. 2014; 370: 23-32Crossref PubMed Scopus (533) Google Scholar,17Goldstein D. Moskowitz A.J. Geijins A.C. Ailawadi G. Parides M.K. Perrault L.P. et al.Two-year outcomes of surgical treatment in severe ischemic mitral regurgitation.N Engl J Med. 2016; 374: 344-353Crossref PubMed Scopus (437) Google Scholar,23Capoulade R. Zeng X. Overbey J.R. Ailawadi G. Alexander J.H. Ascheim D. et al.Impact of left ventricular to mitral valve ring mismatch on recurrent ischemic mitral regurgitation after ring annuloplasty.Circulation. 2016; 134: 1247-1256Crossref PubMed Scopus (41) Google Scholar This latter point deserves further explanation. Recent post hoc analysis by the CTSN authors highlight the importance of understanding the influence of restrictive mitral annuloplasty on the spatial relationship between the left ventricle and the mitral annulus.23Capoulade R. Zeng X. Overbey J.R. Ailawadi G. Alexander J.H. Ascheim D. et al.Impact of left ventricular to mitral valve ring mismatch on recurrent ischemic mitral regurgitation after ring annuloplasty.Circulation. 2016; 134: 1247-1256Crossref PubMed Scopus (41) Google Scholar Because the anterior leaflet is attached to the fibrous trigones, it is the posterior leaflet that is primarily affected by restrictive mitral annuloplasty, and mitral annular area is reduced by reducing anterior–posterior dimension. If the posterior-inferior-lateral wall of the left ventricle remains displaced because of scar or deficient reverse remodeling, overcorrection RMA produces an increase in the geometric distance mismatch between the displaced ischemic papillary muscles and the mitral annulus, resulting in an exacerbation of posterior leaflet tethering. In other words, overcorrection of restrictive mitral annuloplasty exacerbates tethering of the posterior leaflet when the ischemic papillary muscles remain laterally and apically displaced relative to the mitral annulus. With this in mind, the CTSN authors evaluated the ratio of LVESd to prosthetic annuloplasty ring size and its ability to predict the risk of persistent or recurrent MR following restrictive mitral annuloplasty.23Capoulade R. Zeng X. Overbey J.R. Ailawadi G. Alexander J.H. Ascheim D. et al.Impact of left ventricular to mitral valve ring mismatch on recurrent ischemic mitral regurgitation after ring annuloplasty.Circulation. 2016; 134: 1247-1256Crossref PubMed Scopus (41) Google Scholar The authors identified an LVESd to ring size ratio ≥2 to be associated with an increased risk of persistent or recurrent IMR. Thus, increased tethering between the papillary muscle and leaflet edge can be produced by overcorrection of the annular dimension. Therefore, RMA is a necessary, but insufficient procedure in the treatment of severe IMR. Surgeons can readily assess this issue in their preoperative evaluation and plan appropriately in the operating room. But, will this strategy be sufficient to ensure the elimination of IMR in the operating room and provide a durable result with RMA alone? Unlikely, because it does not address LV enlargement and papillary muscle displacement. A logical therapeutic adjuvant to an appropriately sized annular correction with RMA would be to surgically reduce LVESd. Reducing LVESd would have the opposite effect of annular overcorrection because it would bring the papillary muscle closer to the mitral annulus and thus decrease leaflet tethering forces. Think of it this way: Reanimating ischemic muscle by coronary revascularization will improve regional wall motion and reduce LVESd and IMR. Because one cannot preoperatively reliably predict the degree of regional wall motion improvement and reverse remodeling achievable with revascularization alone (and hence, the likelihood of reducing LVESd and IMR), an additional ventricular surgical procedure such as PMA may be a necessary surgical complement to an appropriately sized restrictive mitral annuloplasty.4Michler R.E. Surgical management of moderate ischemic mitral regurgitation at the time of coronary artery bypass grafting remains controversial.J Thorac Cardiovasc Surg. 2018; 156: 1498-1500Abstract Full Text Full Text PDF Scopus (8) Google Scholar,18Nappi F. Lusini M. Spadaccio C. Nenna A. Covino E. Acar C. et al.Papillary muscle approximation versus restrictive annuloplasty alone for severe ischemic mitral regurgitation: a randomized trial.J Am Coll Cardiol. 2016; 24: 2334-2346Crossref Scopus (97) Google Scholar,23Capoulade R. Zeng X. Overbey J.R. Ailawadi G. Alexander J.H. Ascheim D. et al.Impact of left ventricular to mitral valve ring mismatch on recurrent ischemic mitral regurgitation after ring annuloplasty.Circulation. 2016; 134: 1247-1256Crossref PubMed Scopus (41) Google Scholar In support of this notion is recent work by Nappi and colleagues.24Nappi F. Lusini M. Avtaar Singh S.S. Santana O. Chello M. Mihos C.G. Risk of ischemic mitral regurgitation recurrence after combined valvular and subvalvular repair.Ann Thorac Surg. 2019; 108: 536-543Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar They evaluate preoperative echocardiograms in 96 patients who underwent CABG plus restrictive mitral annuloplasty versus CABG plus restrictive mitral annuloplasty and PMA in the Papillary Muscle Approximation Randomized Trial for severe IMR. They sought to determine whether any baseline echocardiographic parameter served as a marker for IMR recurrence. Of the 48 patients who underwent CABG plus RMA and PMA, 37 survived to 5 years and were available for matched clinical and echocardiographic evaluation. At baseline, 21 patients had moderate-severe IMR and 16 had severe IMR. Of the 37 patients, 31 left the operating room with none/trace IMR and 6 with mild IMR. By 5 years, 27 (73%) had none/trace IMR, 9 (24.3%) had moderate IMR, 1 (2.7%) had moderate-severe IMR, and 0 patients had severe IMR. Therefore, at 5 years, a very durable reduction in IMR severity was achieved with RMA plus PMA and no patients experienced severe IMR. A relatively small number of patients were enrolled, yet these results for RMA plus PMA surpass other published reports of late IMR recurrence rates for severe IMR treated by RMA alone. In addition, the results exceed the IMR recurrence rate of RMA alone in the other arm of the Papillary Muscle Approximation Randomized Trial. In the RMA alone arm at 5 years, the 34 surviving patients experienced a 55.9% prevalence of moderate or severe IMR, despite having experienced a recurrence rate of 13.2% at 2 years (38 patients). Although delayed in time, the data for RMA alone are consistent with the data from the CTSN trial and other published reports demonstrating a significant prevalence of late IMR with RMA alone. In the Papillary Muscle Approximation Randomized Trial, patients who underwent CABG plus RMA and PMA experienced a significant improvement over baseline in LV ejection fraction, reverse LV remodeling, MV tenting height, MV tenting area, and interpapillary muscle distance. These improvements were further magnified when the 27 patients with no/trace IMR were compared with the 10 patients with moderate or greater IMR. Statistical modeling by Nappi and colleagues18Nappi F. Lusini M. Spadaccio C. Nenna A. Covino E. Acar C. et al.Papillary muscle approximation versus restrictive annuloplasty alone for severe ischemic mitral regurgitation: a randomized trial.J Am Coll Cardiol. 2016; 24: 2334-2346Crossref Scopus (97) Google Scholar,24Nappi F. Lusini M. Avtaar Singh S.S. Santana O. Chello M. Mihos C.G. Risk of ischemic mitral regurgitation recurrence after combined valvular and subvalvular repair.Ann Thorac Surg. 2019; 108: 536-543Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar identified preoperative factors associated with persistent or recurrent IMR following CABG plus RMA and PMA. The predictive baseline markers included MV tenting area >3.1 cm2, LVEDd >64 mm, and LVESd >54 mm. These findings make intuitive sense because these markers represent larger ischemic remodeled ventricles, predictably those ventricles least likely to recover sufficient regional and global function to significantly reverse remodel following CABG. Decision making for patients with severe IMR is enhanced by preoperative identification of those patients most likely to have an improvement in regional wall motion and global LV function following CABG. Preoperative evaluation of myocardial viability, echocardiographic assessment of regional and global LV systolic function, and echocardiographic assessment of MV tethering parameters can help in the planning for which mitral valve procedure to perform in severe IMR. CMR imaging with gadolinium hyperenhancement is an appropriate tool when echocardiography or radionuclide imaging are equivocal or in patients suspected to have LV scar and hibernating myocardium. Therefore, this author believes there is a role for both an MV repair procedure and MV replacement in patients with severe IMR. The principle parameters that favor a replacement over an MV repair procedure include patients with poor coronary targets in the circumflex/right coronary distributions (ie, reduced likelihood that CABG will provide significant enhancement of LV contractility and reverse remodeling), scar or basal aneurysm/dyskinesia in the inferior-posterior-lateral LV, large ventricles (LVESVI >70 mL/m2 or LVESd >55 mm or LVEDd >65 mm), and an MV tenting area >3 cm2. Recognition that a durable repair is not only possible, but also likely following CABG plus RMA and PMA in patients presenting with a nonseverely dilated LV, low MV tenting area, and good coronary targets should influence surgeons to strongly consider MV repair therapy in patients with severe IMR. The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

Central MessageA reparative procedure is recommended for select cases of moderate ischemic MR: LV scar or aneurysm/dyskinesia, large ventricles, and poor coronary targets because of a low likelihood to improve LVEF.See Editorial Commentary page 1501. A reparative procedure is recommended for select cases of moderate ischemic MR: LV scar or aneurysm/dyskinesia, large ventricles, and poor coronary targets because of a low likelihood to improve LVEF. See Editorial Commentary page 1501. Ischemic mitral regurgitation (IMR) is a consequence of regional wall motion abnormalities induced by myocardial ischemia or infarction.1Grigioni F. Detaint D. Avierinos J.F. Scott C. Tajik J. Enriquez-Sarano M. Contribution of ischemic mitral regurgitation to congestive heart failure after myocardial infarction.J Am Coll Cardiol. 2005; 45: 260-267Crossref PubMed Scopus (201) Google Scholar Adverse left ventricular (LV) remodeling develops in approximately 50% of patients after a myocardial infarction, and moderate mitral regurgitation (MR) occurs in more than 10% of patients.2Bursi F. Enriquez-Sarano M. Nkomo V.T. Jacobsen S.J. Weston S.A. Meverden R.A. et al.Heart failure and death after myocardial infarction in the community: the emerging role of mitral regurgitation.Circulation. 2005; 111: 295-301Crossref PubMed Scopus (429) Google Scholar, 3Pérez de Isla L. Zamorano J. Quezada M. Almería C. Rodrigo J.L. Serra V. et al.Functional mitral regurgitation after a first non-ST-segment elevation acute coronary syndrome: contribution to congestive heart failure.Eur Heart J. 2007; 28: 2866-2872Crossref PubMed Scopus (31) Google Scholar The presence of any degree of IMR discriminates patients with LV dysfunction who have a higher mortality risk than those without IMR, regardless of the treatment.2Bursi F. Enriquez-Sarano M. Nkomo V.T. Jacobsen S.J. Weston S.A. Meverden R.A. et al.Heart failure and death after myocardial infarction in the community: the emerging role of mitral regurgitation.Circulation. 2005; 111: 295-301Crossref PubMed Scopus (429) Google Scholar MR results from a combination of regional wall motion abnormalities, papillary muscle displacement, leaflet tethering, reduced closing forces, and annular dilatation.1Grigioni F. Detaint D. Avierinos J.F. Scott C. Tajik J. Enriquez-Sarano M. Contribution of ischemic mitral regurgitation to congestive heart failure after myocardial infarction.J Am Coll Cardiol. 2005; 45: 260-267Crossref PubMed Scopus (201) Google Scholar The mitral valve leaflets appear normal to the surgeon. Most patients have multivessel coronary artery disease requiring revascularization, so surgeons must consider whether to add a mitral valve repair procedure to coronary artery bypass grafting (CABG) in patients with moderate IMR. The appropriate surgical management of moderate IMR at the time of CABG remains controversial. Some experts advocate revascularization alone for moderate IMR, expecting improvements in regional and global LV function and geometry after CABG to lead to a reduction in MR.4Penicka M. Linkova H. Lang O. Fojt R. Kocka V. Vanderheyden M. et al.Predictors of improvement of unrepaired moderate ischemic mitral regurgitation in patients undergoing elective isolated coronary artery bypass graft surgery.Circulation. 2009; 120: 1474-1481Crossref PubMed Scopus (111) Google Scholar, 5Roshanali F. Mandegar M.H. Yousefnia M.A. Alaeddini F. Wann S. Low-dose dobutamine stress echocardiography to predict reversibility of mitral regurgitation with CABG.Echocardiography. 2006; 23: 31-37Crossref PubMed Scopus (28) Google Scholar Others support restrictive mitral annuloplasty (RMA) repair at the time of CABG to address the IMR more directly, expecting to prevent further adverse remodeling and to decrease the risk of heart failure.6Fattouch K. Guccione F. Sampognaro R. Panzarella G. Corrado E. Navarra E. et al.Point: efficacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: a randomized trial.J Thorac Cardiovasc Surg. 2009; 138: 278-285Abstract Full Text Full Text PDF PubMed Scopus (252) Google Scholar, 7Chan K.M. Punjabi P.P. Flather M. Wage R. Symmonds K. Roussin I. et al.RIME InvestigatorsCoronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation: final results of the randomized ischemic mitral evaluation (RIME) trial.Circulation. 2012; 126: 2502-2510Crossref PubMed Scopus (247) Google Scholar Importantly, the addition of a mitral valve procedure to CABG surgery necessitates open heart exposure and is associated with longer durations of aortic crossclamping and cardiopulmonary bypass, which can increase perioperative risk.8Smith P.K. Puskas J.D. Ascheim D.D. Voisine P. Gelijns A.C. Moskowitz A.J. et al.Cardiothoracic Surgical Trials Network InvestigatorsSurgical treatment of moderate ischemic mitral regurgitation.N Engl J Med. 2014; 371: 2178-2188Crossref PubMed Scopus (295) Google Scholar Numerous observational, nonrandomized, single-center experiences are informative, but they suffer from the limitations of single-center experiences, study design, nonrigorous definition of the degree of MR, and the inclusion in the analysis of patients with both moderate and severe degrees of MR. Three recent randomized clinical trials of moderate IMR with well-defined criteria for the measurement of MR have compared CABG alone versus CABG plus RMA.6Fattouch K. Guccione F. Sampognaro R. Panzarella G. Corrado E. Navarra E. et al.Point: efficacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: a randomized trial.J Thorac Cardiovasc Surg. 2009; 138: 278-285Abstract Full Text Full Text PDF PubMed Scopus (252) Google Scholar, 7Chan K.M. Punjabi P.P. Flather M. Wage R. Symmonds K. Roussin I. et al.RIME InvestigatorsCoronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation: final results of the randomized ischemic mitral evaluation (RIME) trial.Circulation. 2012; 126: 2502-2510Crossref PubMed Scopus (247) Google Scholar, 8Smith P.K. Puskas J.D. Ascheim D.D. Voisine P. Gelijns A.C. Moskowitz A.J. et al.Cardiothoracic Surgical Trials Network InvestigatorsSurgical treatment of moderate ischemic mitral regurgitation.N Engl J Med. 2014; 371: 2178-2188Crossref PubMed Scopus (295) Google Scholar Both Fattouch and colleagues6Fattouch K. Guccione F. Sampognaro R. Panzarella G. Corrado E. Navarra E. et al.Point: efficacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: a randomized trial.J Thorac Cardiovasc Surg. 2009; 138: 278-285Abstract Full Text Full Text PDF PubMed Scopus (252) Google Scholar and the Randomized Ischemic Mitral Evaluation (RIME) investigators7Chan K.M. Punjabi P.P. Flather M. Wage R. Symmonds K. Roussin I. et al.RIME InvestigatorsCoronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation: final results of the randomized ischemic mitral evaluation (RIME) trial.Circulation. 2012; 126: 2502-2510Crossref PubMed Scopus (247) Google Scholar demonstrated that the addition of RMA resulted in improvements in LV reverse remodeling, LV ejection fraction, New York Heart Association functional class, and MR grade, but not in survival. Fattouch and colleagues6Fattouch K. Guccione F. Sampognaro R. Panzarella G. Corrado E. Navarra E. et al.Point: efficacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: a randomized trial.J Thorac Cardiovasc Surg. 2009; 138: 278-285Abstract Full Text Full Text PDF PubMed Scopus (252) Google Scholar randomly assigned 102 patients to undergo CABG alone or CABG plus RMA. They demonstrated that the addition of RMA significantly reduced LV end-systolic dimension (LVESd). The RIME trial7Chan K.M. Punjabi P.P. Flather M. Wage R. Symmonds K. Roussin I. et al.RIME InvestigatorsCoronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation: final results of the randomized ischemic mitral evaluation (RIME) trial.Circulation. 2012; 126: 2502-2510Crossref PubMed Scopus (247) Google Scholar randomly assigned 73 patients to undergo CABG alone or CABG plus RMA and demonstrated a 28% reduction in LV end-systolic volume index (LVESVI) relative to baseline (mean baseline, 78 mL/m2). The National Heart, Lung, and Blood Institute–sponsored Cardiothoracic Surgical Trials Network (CTSN) more recently conducted a multicenter randomized trial8Smith P.K. Puskas J.D. Ascheim D.D. Voisine P. Gelijns A.C. Moskowitz A.J. et al.Cardiothoracic Surgical Trials Network InvestigatorsSurgical treatment of moderate ischemic mitral regurgitation.N Engl J Med. 2014; 371: 2178-2188Crossref PubMed Scopus (295) Google Scholar, 9Michler R.E. Smith P.K. Parides M.K. Ailawadi G. Thourani V. Moskowitz A.J. et al.CTSNTwo-year outcomes of surgical treatment of moderate ischemic mitral regurgitation.N Engl J Med. 2016; 374: 1932-1941Crossref PubMed Scopus (346) Google Scholar comparing CABG alone with CABG plus RMA in 301 patients with moderate IMR. RMA resulted in a significant reduction relative to CABG alone in prevalences of MR at 1 and 2 years, with no progression to severe MR in the RMA group.9Michler R.E. Smith P.K. Parides M.K. Ailawadi G. Thourani V. Moskowitz A.J. et al.CTSNTwo-year outcomes of surgical treatment of moderate ischemic mitral regurgitation.N Engl J Med. 2016; 374: 1932-1941Crossref PubMed Scopus (346) Google Scholar There were no differences between the 2 groups in the degree of LV reverse remodeling (LVESVI), New York Heart Association functional class, LV ejection fraction, survival, or major adverse cardiac and cerebrovascular events at 1 and 2 years. RMA was associated with a longer hospital stay after surgery, a higher incidence of post-operative supraventricular arrhythmias and more postoperative neurologic events, (which included metabolic encephalopathy, seizures, transient ischemic attack, and stroke). It is well established that improvements in global and regional wall motion as well as reverse LV remodeling after CABG alone are indicative of viable myocardium.5Roshanali F. Mandegar M.H. Yousefnia M.A. Alaeddini F. Wann S. Low-dose dobutamine stress echocardiography to predict reversibility of mitral regurgitation with CABG.Echocardiography. 2006; 23: 31-37Crossref PubMed Scopus (28) Google Scholar, 10Sundt T.M. Surgery for ischemic mitral regurgitation.N Engl J Med. 2014; 371: 2228-2229Crossref PubMed Scopus (18) Google Scholar For example, Penicka and colleagues4Penicka M. Linkova H. Lang O. Fojt R. Kocka V. Vanderheyden M. et al.Predictors of improvement of unrepaired moderate ischemic mitral regurgitation in patients undergoing elective isolated coronary artery bypass graft surgery.Circulation. 2009; 120: 1474-1481Crossref PubMed Scopus (111) Google Scholar found that in a series of patients with moderate IMR who underwent CABG alone, resolution of MR after surgery was associated with more viable segments and less LV dyssynchrony at baseline. In the CTSN trial, irrespective of treatment arm, patients with resolution of IMR had greater reverse remodeling and better wall motion scores than those who did not.9Michler R.E. Smith P.K. Parides M.K. Ailawadi G. Thourani V. Moskowitz A.J. et al.CTSNTwo-year outcomes of surgical treatment of moderate ischemic mitral regurgitation.N Engl J Med. 2016; 374: 1932-1941Crossref PubMed Scopus (346) Google Scholar This latter point is noteworthy, because it provides evidence that many patients in both arms of the CTSN trial must have had viable myocardium and not LV scar tissue, which resulted in an improvement in wall motion, a reduction in LV size, and less MR with just the revascularization procedure. There are multiple comparative points to emphasize regarding these 3 clinical trials. First, the sample sizes differed greatly; the CTSN trial enrolled more than 3 times the number of patients in the other trials. Second, the 3 clinical trials used different primary end points. Third, the analytic approaches were different, with the CTSN trial counting patients who died as treatment failures in the primary end point analysis, whereas the other trials used a survivor analysis. Fourth, the CTSN trial had significantly lower rates of baseline previous MI and possibly less LV scar tissue. Fifth, and perhaps most importantly, baseline LV size was significantly larger in the trial of Fattouch and colleagues6Fattouch K. Guccione F. Sampognaro R. Panzarella G. Corrado E. Navarra E. et al.Point: efficacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: a randomized trial.J Thorac Cardiovasc Surg. 2009; 138: 278-285Abstract Full Text Full Text PDF PubMed Scopus (252) Google Scholar and the RIME trial7Chan K.M. Punjabi P.P. Flather M. Wage R. Symmonds K. Roussin I. et al.RIME InvestigatorsCoronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation: final results of the randomized ischemic mitral evaluation (RIME) trial.Circulation. 2012; 126: 2502-2510Crossref PubMed Scopus (247) Google Scholar than in the CTSN trial. This fact alone may have favored patients who received a restrictive annuloplasty, especially if more scar tissue was present, because CABG alone in these patients would be less likely to result in an improvement in LV wall motion and reduced LV size, precisely those factors that lead to less MR. Not surprisingly, it is in patients with LV scar tissue for whom CABG alone is less likely to provide benefit and precisely those patients who may need the addition of RMA to reduce IMR. In the RIME trial,7Chan K.M. Punjabi P.P. Flather M. Wage R. Symmonds K. Roussin I. et al.RIME InvestigatorsCoronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation: final results of the randomized ischemic mitral evaluation (RIME) trial.Circulation. 2012; 126: 2502-2510Crossref PubMed Scopus (247) Google Scholar a 28% reduction in LV size from baseline (mean baseline, 78 mL/m2) was achieved with CABG plus RMA, whereas in the CTSN trial, those patients who received the combined procedure saw only a 9% reduction in LV size from baseline (mean, baseline 57 ml/m2). To underscore this important point, patients in the CTSN trial had smaller ventricles at baseline and, as the evidence suggests, more viable myocardium—precisely the clinical substrate that is likely to benefit most from CABG alone. Surgical decision making for patients with moderate IMR therefore could be enhanced by preoperative identification of those patients most likely to have an improvement in regional wall motion and global LV function from CABG alone. Not one of these 3 clinical trials required preoperative evaluation of myocardial viability. It is known that viability assessment can predict the effectiveness of revascularization in specific patient populations, and one should therefore consider it in this setting.11Meluzín J. Cerný J. Frélich M. Stetka F. Spinarová L. Popelová J. et al.Investigators of this multicenter study… Prognostic value of the amount of dysfunctional but viable myocardium in revascularized patients with coronary artery disease and left ventricular dysfunction.J Am Coll Cardiol. 1998; 32: 912-920Crossref PubMed Scopus (212) Google Scholar Cardiac magnetic resonance imaging with gadolinium hyperenhancement is an appropriate tool when viability imaging results are equivocal or LV scar tissue is suspected. Individual treatment decisions require balancing the risks of adverse perioperative events against the benefits of a lower incidence of postoperative MR. Effective revascularization, as reflected in improved regional and global LV function, plays an important role in reducing MR, independent of restrictive annuloplasty repair. In other clinical settings, the anticipated low likelihood of generating significant functional improvement and reverse remodeling from CABG should lead to the performance of a mitral valve reparative procedure. Such circumstances include patients with documented scar tissue or basal aneurysm or dyskinesia in the inferoposterior lateral LV, large ventricles (LVESVI >60 mL/m2 and left ventricular end diastolic diameter >50 mm) and poor coronary targets in the circumflex and right coronary distributions because of the reduced likelihood that revascularization will provide significant enhancement of LV contractility and LV reverse remodeling. Recent post hoc analysis by the CTSN authors12Capoulade R. Zeng X. Overbey J.R. Ailawadi G. Alexander J.H. Ascheim D. et al.Cardiothoracic Surgical Trials Network (CTSN) InvestigatorsImpact of left ventricular to mitral valve ring mismatch on recurrent ischemic mitral regurgitation after ring annuloplasty.Circulation. 2016; 134: 1247-1256Crossref PubMed Scopus (48) Google Scholar has highlighted the importance of evaluating the ratio of LVESd to prosthetic annuloplasty ring size in predicting the risk of persistent or recurrent MR after surgery in patients with moderate and severe IMR. The CTSN authors12Capoulade R. Zeng X. Overbey J.R. Ailawadi G. Alexander J.H. Ascheim D. et al.Cardiothoracic Surgical Trials Network (CTSN) InvestigatorsImpact of left ventricular to mitral valve ring mismatch on recurrent ischemic mitral regurgitation after ring annuloplasty.Circulation. 2016; 134: 1247-1256Crossref PubMed Scopus (48) Google Scholar noted that a LVESd/ring size ratio of at least 2 was associated (multivariate analysis) with increased risk of persistent or recurrent MR. Therefore, insertion of too small of a prosthetic ring could increase this ratio and lead to persistent MR or even mitral stenosis. In my judgment, patients with an enlarged ventricle (especially those with scar tissue, dyskinesia, or a basal aneurysm) in whom mitral repair is feasible should therefore receive a ventricular procedure to surgically reduce LVESd together with a restrictive annuloplasty procedure. A papillary muscle approximation has been used in clinical trials of severe IMR to produce excellent long-term freedom from recurrent or persistent IMR.13Nappi F. Lusini M. Spadaccio C. Nenna A. Covino E. Acar C. et al.Papillary muscle approximation versus restrictive annuloplasty alone for severe ischemic mitral regurgitation: a randomized trial.J Am Coll Cardiol. 2016; 24: 2334-2346Crossref Scopus (131) Google Scholar A papillary muscle approximation procedure mechanically reduces the LVESd and has the potential to reduce leaflet tethering, thus producing a lower ratio of LVESd to ring size and a realistic expectation of reducing MR. My current decision algorithm for managing moderate IMR focuses on 5 preoperative factors that help determine the surgical plan. In conjunction with echocardiography and cardiac catheterization, cardiac magnetic resonance imaging can complete a comprehensive analysis of these factors.1.Severity of MR2.Severity of LV dysfunction3.Severity of LV remodeling (LVESVI)4.Presence and extent of LV scar tissue5.Quality and distribution of the left circumflex and right coronary circulations Whether RMA repair together with CABG will predictably benefit patients with an enlarged LV or with baseline inferoposterior lateral wall motion abnormalities considered to represent scar tissue remains unknown. Until such evidence is available, RMA and papillary muscle approximation should be considered an essential part of the surgical armamentarium for patients with moderate IMR. Author has nothing to disclose with regard to commercial support. More decision-making criteria for moderate chronic ischemic mitral regurgitationThe Journal of Thoracic and Cardiovascular SurgeryVol. 157Issue 2PreviewWe read with great interest the expert opinion by Michler and colleagues,1 which provides insight into better repair of ischemic mitral regurgitation (IMR). The importance of add-on subvalvular approaches is further emphasized in this article, and a decision algorithm for managing moderate IMR on the basis of specific criteria is provided. We would like to propose some additional criteria that might be of help in planning the operation. Full-Text PDF Open ArchiveCautious optimism and tempered enthusiasm for a more thorough, tailored intervention in ischemic moderate mitral regurgitationThe Journal of Thoracic and Cardiovascular SurgeryVol. 156Issue 4PreviewModerate mitral regurgitation (MR) in the setting of ischemic heart disease is not uncommon, particularly after a myocardial infarction (MI).1 It is more common after inferior MI when compared with anterior MI.2 When confronted with moderate MR, the decision to add a mitral valve intervention to a coronary artery bypass grafting (CABG) operation can be difficult. Many factors influence the choice of surgical strategy preferred by the patient and eventually pursued by the surgeon. Adding a mitral intervention prolongs surgical time and cardiac ischemic time3-5 and, on occasion, requires a skill set that may not be mastered by the surgeon. Full-Text PDF Open Archive

Background. Ischemic mitral regurgitation is a condition characterized by mitral insufficiency secondary to an ischemic left ventricle. Primarily, the pathology is the result of perturbation of normal regional left ventricular geometry combined with adverse remodeling. We present a comprehensive review of contemporary surgical, medical, and percutaneous treatment options for ischemic mitral regurgitation, rigorously examined by current guidelines and literature. Methods. We conducted a literature search of the PubMed database, Embase, and the Cochrane Library (through November 2018) for studies reporting perioperative or late mortality and echocardiographic outcomes after surgical and nonsurgical intervention for ischemic mitral regurgitation. Results. Treatment of this condition is challenging and often requires a multimodality approach. These patients usually have multiple comorbidities that may preclude surgery as a viable option. A multidisciplinary team discussion is crucial in optimizing outcomes. There are several options for treatment and management of ischemic mitral regurgitation with differing benefits and risks. Guideline-directed medical therapy for heart failure is the treatment choice for moderate and severe ischemic mitral regurgitation, with consideration of coronary revascularization, mitral valve surgery, cardiac resynchronization therapy, or a combination of these, in appropriate candidates. The use of transcatheter mitral valve therapy is considered appropriate in high-risk patients with severe ischemic mitral regurgitation, heart failure, and reduced left ventricular ejection fraction, especially in those with hemodynamic instability. Conclusions. The role of mitral valve surgery and transcatheter mitral valve therapy continues to evolve. (C) 2019 by The Society of Thoracic Surgeons.

BackgroundThis study examined the impact of mitral valve repair (MVRe) on survival of patients with moderate or severe (≥2+) MR and ischemic cardiomyopathy randomized to coronary artery bypass grafting (CABG) versus CABG+surgical ventricular reconstruction (SVR) in the STICH trial.MethodsAmong patients with moderate or severe MR and ischemic cardiomyopathy undergoing CABG or CABG+SVR, the impact of MVRe on mortality between the two treatment arms was compared.ResultsAmong 867 patients with assessment of baseline MR severity, 211 had moderate or severe MR. After excluding 7 patients who underwent mitral valve replacement, 50, 44, 62, and 48 patients underwent CABG, CABG+MVRe, CABG+SVR, and CABG+SVR+MVRe, respectively. Four-year mortality rates were lower following CABG+MVRe than CABG alone (16% vs. 55%; adjusted hazard ratio [HR] 0.30; 95% CI 0.13–0.71). In contrast, the CABG+SVR+MVRe and CABG+SVR groups had similar 4-year mortality of 39% vs. 39% (adjusted HR 0.88; 95% CI 0.46–1.70). MVRe had a more favorable effect on survival in patients undergoing CABG alone compared to CABG+SVR (p = 0.013). Baseline MR severity was similar between patients that received CABG+MVRe and those that underwent CABG+SVR+MVRe. A larger proportion of patients demonstrated a reduction in MR between 4 and 24 months after CABG+MVRe compared to CABG+SVR+MVRe (50.0% versus 25.0%, p = 0.023).ConclusionIn patients with moderate or severe MR and ischemic cardiomyopathy undergoing CABG, MVRe appears to have a favorable effect on survival. The addition of SVR to CABG may attenuate the anticipated benefits of MVRe by limiting the long-term reduction of MR with MVRe.

Front Cover Caption: The cover image is based on the Case Report Aortic Recoarctation and Pseudoaneurysm Five Decades atier Repair by Stephen J. Forest et al., https://doi.org/10.1111/jocs.14201.

BACKGROUND:Coarctation of the aorta is a congenital cardiac defect characterized by a narrowing of the proximal thoracic aorta. Despite excellent long-term results, surgical repair is rarely complicated by recoarctation.METHODS/RESULTS:We describe a case with the longest time to reintervention to date, featuring surgical repair of delayed aortic recoarctation and pseudoaneurysm 53 years after the initial operation.DISCUSSION:This case emphasizes the need for lifelong surveillance in this patient population and exemplifies a multidisciplinary approach in evaluating treatment options of complex aortic pathology, including open and endovascular considerations.

Background: The STICH trial showed superiority of coronary artery bypass plus medical treatment (CABG) over medical treatment alone (MED) in patients with left ventricular ejection fraction (LVEF) <= 35%. In previous publications, percutaneous coronary intervention (PCI) prior to CABG was associated with worse prognosis. Objectives: The main purpose of this study was to analyse if prior PCI influenced outcomes in STICH. Methods and results: Patients in the STICH trial (n=1212), followed for a median time of 9.8 years, were included in the present analyses. In the total population, 156 had a prior PCI (74 and 82, respectively, in the MED and CABG groups). In those with vs. without prior PCI, the adjusted hazard-ratios (aHRs) were 0.92 (95% CI=0.74-1.15) for all-cause mortality, 0.85 (95% CI=0.64-1.11) for CV mortality, and 1.43 (95% CI=1.15-1.77) for CV hospitalization. In the group randomized to CABG without prior PCI, the aHRs were 0.82 (95% CI=0.70-0.95) for all-cause mortality, 0.75 (95% CI=0.62-0.90) for CV mortality and 0.67 (95% CI=0.56-0.80) for CV hospitalization. In the group randomized to CABG with prior PCI, the aHRs were 0.76 (95% CI=0.50-1.15) for all-cause mortality, 0.81 (95% CI=0.49-1.36) for CV mortality and 0.61 (95% CI=0.41-0.90) for CV hospitalization. There was no evidence of interaction between randomized treatment and prior PCI for any endpoint (all adjusted p > 0.05). Conclusion: In the STICH trial, prior PCI did not affect the outcomes of patients whether they were treated medically or surgically, and the superiority of CABG over MED remained unchanged regardless of prior PCI. (C) 2019 Elsevier B.V. All rights reserved.

Ischemic mitral regurgitation (IMR) is a consequence of regional wall motion abnormalities induced by myocardial ischemia or infarction.1Grigioni F. Detaint D. Avierinos J.F. Scott C. Tajik J. Enriquez-Sarano M. Contribution of ischemic mitral regurgitation to congestive heart failure after myocardial infarction.J Am Coll Cardiol. 2005; 45: 260-267Crossref PubMed Scopus (177) Google Scholar Adverse left ventricular (LV) remodeling develops in approximately 50% of patients after a myocardial infarction.2Bursi F. Enriquez-Sarano M. Nkomo V.T. et al.Heart failure and death after myocardial infarction in the community: the emerging role of mitral regurgitation.Circulation. 2005; 111: 295-301Crossref PubMed Scopus (386) Google Scholar, 3Perez de Isla L. Zamorano J. Quezada M. et al.Functional mitral regurgitation after a first non-ST-segment elevation acute coronary syndrome: contribution to congestive heart failure.Eur Heart J. 2007; 28: 2866-2872Crossref PubMed Scopus (28) Google Scholar The presence of any degree of IMR identifies patients with LV dysfunction who have a higher mortality risk than those without IMR.2Bursi F. Enriquez-Sarano M. Nkomo V.T. et al.Heart failure and death after myocardial infarction in the community: the emerging role of mitral regurgitation.Circulation. 2005; 111: 295-301Crossref PubMed Scopus (386) Google Scholar This fact alone remains the primary driver for recommending a mitral valve (MV) procedure in patients with severe IMR. For related article, see page 536 For related article, see page 536 The appropriate surgical management of severe IMR at the time of coronary artery bypass grafting (CABG) is in evolution. Some experts advocate chordal-sparing MV replacement, whereas others support restrictive mitral annuloplasty (RA) repair.4Acker M.A. Parides M.K. Perrault L.P. et al.Mitral-valve repair versus replacement for severe ischemic mitral regurgitation.N Engl J Med. 2014; 370: 23-32Crossref PubMed Scopus (544) Google Scholar, 5Goldstein D. Moskowitz A.J. Geijins A.C. et al.Two year outcomes of surgical treatment in severe ischemic mitral regurgitation.N Engl J Med. 2016; 374: 344-353Crossref PubMed Scopus (446) Google Scholar, 6Nappi F. Lusini M. Spadaccio C. et al.Papillary muscle approximation versus restrictive annuloplasty alone for severe ischemic mitral regurgitation: a randomized trial.J Am Coll Cardiol. 2016; 24: 2334-2346Crossref Scopus (98) Google Scholar, 7Gillinov A.M. Wierup P.N. Blackstone E.H. et al.Is repair preferable to replacement for ischemic mitral regurgitation?.J Thorac Cardiovasc Surg. 2001; 122: 1125-1141Abstract Full Text Full Text PDF PubMed Scopus (454) Google Scholar, 8Reece T.B. Tribble C.G. Ellman P.I. et al.Mitral repair is superior to replacement when associated with coronary artery disease.Ann Surg. 2004; 239: 671-675Crossref PubMed Scopus (70) Google Scholar, 9Al-Radi O.O. Austin P.C. Tu J.V. David T.E. Yau T.M. Mitral repair versus replacement for ischemic mitral regurgitation.Ann Thorac Surg. 2005; 79: 1260-1267Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar, 10Vassileva C.M. Boley T. Markwell S. Hazelrigg S. Meta-analysis of short-term and long-term survival following repair versus replacement for ischemic mitral regurgitation.Eur J Cardiothorac Surg. 2011; 39: 295-303Crossref PubMed Scopus (124) Google Scholar RA is generally associated with lower operative morbidity and mortality, as well as with the presumed benefits of preserving the subvalvular apparatus to maintain LV systolic function. However, 1-year mitral regurgitation (MR) recurrence rates as high as 30% to 40% with RA in IMR have been reported. MV replacement, although more effective and durable in addressing IMR, is associated with greater operative risk and greater long-term risks of thromboembolism, valve deterioration, and endocarditis.7Gillinov A.M. Wierup P.N. Blackstone E.H. et al.Is repair preferable to replacement for ischemic mitral regurgitation?.J Thorac Cardiovasc Surg. 2001; 122: 1125-1141Abstract Full Text Full Text PDF PubMed Scopus (454) Google Scholar, 8Reece T.B. Tribble C.G. Ellman P.I. et al.Mitral repair is superior to replacement when associated with coronary artery disease.Ann Surg. 2004; 239: 671-675Crossref PubMed Scopus (70) Google Scholar, 9Al-Radi O.O. Austin P.C. Tu J.V. David T.E. Yau T.M. Mitral repair versus replacement for ischemic mitral regurgitation.Ann Thorac Surg. 2005; 79: 1260-1267Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar, 10Vassileva C.M. Boley T. Markwell S. Hazelrigg S. Meta-analysis of short-term and long-term survival following repair versus replacement for ischemic mitral regurgitation.Eur J Cardiothorac Surg. 2011; 39: 295-303Crossref PubMed Scopus (124) Google Scholar The National Heart, Lung and Blood Institute–sponsored Cardiothoracic Surgical Trials Network (CTSN) sought to address this controversy by comparing chordal-sparing MV replacement with RA in 251 patients with severe IMR.4Acker M.A. Parides M.K. Perrault L.P. et al.Mitral-valve repair versus replacement for severe ischemic mitral regurgitation.N Engl J Med. 2014; 370: 23-32Crossref PubMed Scopus (544) Google Scholar, 5Goldstein D. Moskowitz A.J. Geijins A.C. et al.Two year outcomes of surgical treatment in severe ischemic mitral regurgitation.N Engl J Med. 2016; 374: 344-353Crossref PubMed Scopus (446) Google Scholar Chordal-sparing MV replacement resulted in a significant reduction over RA in the prevalence of MR at 1 year (2.3% vs 32.6%) and 2 years (3.8% vs 58.8%). There was no difference between the 2 groups in the degree of LV reverse remodeling, New York Heart Association functional class, LV ejection fraction, survival, or major adverse cardiac and cerebrovascular events at 1 and 2 years. Although the rates of serious adverse events and overall hospital readmissions were comparable, patients undergoing repair had more frequent serious adverse events related to heart failure and cardiovascular readmissions at 2 years. Collectively, these data support the use of MV replacement in the setting of severe IMR. Critics of the CTSN trial believe that the high prevalence of MR with RA was related to surgical deficiencies in the conduct of the CTSN trial, including the finding that only 75% of patients received concomitant CABG surgery (eliminating the possibility of improved regional wall motion in 25% of patients) and undersizing of the mitral annulus with RA was insufficient (limiting the ability of the leaflets to form an improved zone of coaptation to reduce tenting height and tenting area).6Nappi F. Lusini M. Spadaccio C. et al.Papillary muscle approximation versus restrictive annuloplasty alone for severe ischemic mitral regurgitation: a randomized trial.J Am Coll Cardiol. 2016; 24: 2334-2346Crossref Scopus (98) Google Scholar In the Papillary Muscle Approximation Randomized Trial, Nappi and colleagues6Nappi F. Lusini M. Spadaccio C. et al.Papillary muscle approximation versus restrictive annuloplasty alone for severe ischemic mitral regurgitation: a randomized trial.J Am Coll Cardiol. 2016; 24: 2334-2346Crossref Scopus (98) Google Scholar achieved a 2-year prevalence of MR with RA of 13.2%, which they claimed was the result of more effective annular reduction as seen by a greater mean difference between annular size and ring size compared with the CTSN trial. Herein lies the controversy because in recent years, respected surgeons have strongly advocated for overcorrection RA (“the tighter, the better”). However, an overcorrection strategy is beginning to show signs of unraveling as we grow in our understanding that (1) RA does not reliably prevent persistence or recurrence of moderate to severe IMR; (2) overcorrected RA does lead to mitral stenosis, and (3) excessive restriction using severely undersized annuloplasty rings is associated with exacerbating leaflet tethering.4Acker M.A. Parides M.K. Perrault L.P. et al.Mitral-valve repair versus replacement for severe ischemic mitral regurgitation.N Engl J Med. 2014; 370: 23-32Crossref PubMed Scopus (544) Google Scholar, 5Goldstein D. Moskowitz A.J. Geijins A.C. et al.Two year outcomes of surgical treatment in severe ischemic mitral regurgitation.N Engl J Med. 2016; 374: 344-353Crossref PubMed Scopus (446) Google Scholar, 11Capoulade R. Zeng X. Overbey J.R. et al.Impact of left ventricular to mitral valve ring mismatch on recurrent ischemic mitral regurgitation after ring annuloplasty.Circulation. 2016; 134: 1247-1256Crossref PubMed Scopus (41) Google Scholar This last point deserves further explanation. A post hoc analysis by the CTSN investigators highlights the importance of understanding the impact of RA on the spatial relationship between the left ventricle and the mitral annulus.11Capoulade R. Zeng X. Overbey J.R. et al.Impact of left ventricular to mitral valve ring mismatch on recurrent ischemic mitral regurgitation after ring annuloplasty.Circulation. 2016; 134: 1247-1256Crossref PubMed Scopus (41) Google Scholar RA has the potential to disrupt this ischemia-induced abnormal geometric spatial relationship further by exacerbating tethering of the posterior leaflet, especially if the ischemic papillary muscles remain laterally and apically displaced relative to the mitral annulus. Because the anterior leaflet is attached to the fibrous trigones, it is the posterior leaflet that is primarily affected by RA, and the mitral annular area is decreased by reducing the anterior-posterior dimension. If the posterior-inferior-lateral wall of the left ventricle remains displaced, there will be an increase in the geometric mismatch between the left ventricle and the mitral annulus and an exacerbation of posterior leaflet tethering with overcorrection RA. With this in mind, the CTSN investigators evaluated the ratio of LV end-systolic dimension (LVESD) to prosthetic annuloplasty ring size and its ability to predict the risk of persistent or recurrent MR after RA.11Capoulade R. Zeng X. Overbey J.R. et al.Impact of left ventricular to mitral valve ring mismatch on recurrent ischemic mitral regurgitation after ring annuloplasty.Circulation. 2016; 134: 1247-1256Crossref PubMed Scopus (41) Google Scholar The CTSN investigators identified that a ratio of LVESD to ring size of 2 or greater was associated with an increased risk of persistent or recurrent MR. Increased tethering between the papillary muscle and the leaflet edge may be produced by overcorrection of the annular dimension. Thus, RA is a necessary, but insufficient procedure in the treatment of severe IMR. Surgeons can readily assess this issue in the preoperative evaluation and plan accordingly in the operating room. However, will this be enough to ensure the elimination of MR in the operating room and provide a durable result with RA alone? A logical adjuvant to appropriate-sized annular correction with RA is to reduce the LVESD. Theoretically, this would have a result opposite to that of annular overcorrection by bringing the papillary muscle closer to the mitral leaflet edge, thereby reducing tethering forces. It is well recognized that reanimating ischemic muscle through coronary revascularization and improved regional wall motion will reduce LVESD. Given that one cannot reliably predict preoperatively the degree of regional wall motion improvement achievable with revascularization alone (and the likelihood of reducing LVESD and IMR), one may wish to consider additional ventricular surgical procedures that have been advocated as a complement to an appropriately sized RA. Papillary muscle approximation (PMA) has been advocated and studied by Nappi and colleagues in patients with severe IMR as an adjuvant ventricular procedure to reduce LVESD and thus posterior leaflet tethering.6Nappi F. Lusini M. Spadaccio C. et al.Papillary muscle approximation versus restrictive annuloplasty alone for severe ischemic mitral regurgitation: a randomized trial.J Am Coll Cardiol. 2016; 24: 2334-2346Crossref Scopus (98) Google Scholar In this issue of The Annals of Thoracic Surgery, Nappi and colleagues12Nappi F. Lusini M. Singh S.S.A. Santana O. Chello M. Mihos C.G. Risk of ischemic mitral regurgitation recurrence after combined valvular and subvalvular repair.Ann Thorac Surg. 2019; 108: 536-543Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar evaluated preoperative echocardiograms in the population of patients who underwent CABG and in combination with RA and PMA in the Papillary Muscle Approximation Randomized Trial. Nappi and colleagues12Nappi F. Lusini M. Singh S.S.A. Santana O. Chello M. Mihos C.G. Risk of ischemic mitral regurgitation recurrence after combined valvular and subvalvular repair.Ann Thorac Surg. 2019; 108: 536-543Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar sought to determine whether any baseline echocardiographic parameter served as a marker for MR recurrence. Of the 48 patients who underwent CABG with RA and PMA, 37 survived to 5 years and constituted the study population available for matched clinical and echocardiographic evaluation. At baseline, 21 patients had moderate to severe MR, and 16 had severe MR. Of the 37 patients, 31 left the operating room with no MR or trace MR, and 6 had mild MR. By 5 years, 27 (73%) had no MR or trace MR, 9 (24.3%) had moderate MR, 1 (2.7%) had moderate to severe MR, and no patients had severe MR. Therefore, at 5 years, a very durable reduction in MR severity was achieved with RA plus PMA, and no patients had severe MR. Nappi and colleagues12Nappi F. Lusini M. Singh S.S.A. Santana O. Chello M. Mihos C.G. Risk of ischemic mitral regurgitation recurrence after combined valvular and subvalvular repair.Ann Thorac Surg. 2019; 108: 536-543Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar do not comment on the clinical condition of these 10 patients with moderate MR and whether they had more frequent heart failure events or hospitalizations. However, moderate MR is generally well tolerated with guideline medical therapy. These excellent results surpass those of other published reports of late MR prevalence in severe IMR treated by RA alone. In addition, the results surpass the other arm of the Papillary Muscle Approximation Randomized Trial. In that arm, at 5 years, 34 of 48 surviving patients who underwent CABG and RA alone experienced a 55.9% prevalence of moderate or greater MR, despite having a prevalence of 15% at 2 years (38 patients). Despite time delayed in achieving a significant level of MR severity, the data are consistent with the data from the CTSN trial and other published reports demonstrating a significant prevalence of late MR with RA alone. Consistent with the reduction in MR prevalence, patients who underwent CABG in combination with RA and PMA experienced a significant improvement over baseline in LV ejection fraction, reverse LV remodeling, MV tenting height, MV tenting area, and interpapillary muscle distance. These improvements were further magnified when the 27 patients with no MR or trace MR were compared with the 10 patients with moderate or greater MR. Predictive statistical modeling identified preoperative factors associated with persistent or recurrent MR after revascularization in combination with RA and PMA: (1) MV tenting area larger than 3.1 cm2, (2) LV end-diastolic dimension (LVEDD) greater than 64 mm, and (3) LVESD greater than 54 mm. These findings make intuitive sense because these markers are all consistent with very large ischemic remodeled ventricles, which are less likely to recover sufficient regional and global function and thus to undergo reverse remodeling after CABG. Our current understanding of the surgical techniques for performing an RA and a PMA procedure provides little insight into how we could adjust these procedures in the operating room to deal with the severely dilated and remodeled left ventricle. Although the surgeon may be driven to overcorrect the RA in such a circumstance (to achieve an adequate intraoperative result), it is precisely in these situations that MV replacement should be the recommended option. Considering the dilated remodeled ventricle and those factors associated with late recurrence outlined by Nappi and coauthors12Nappi F. Lusini M. Singh S.S.A. Santana O. Chello M. Mihos C.G. Risk of ischemic mitral regurgitation recurrence after combined valvular and subvalvular repair.Ann Thorac Surg. 2019; 108: 536-543Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar prompt one to ask why these investigators limited the correction by PMA to only a 25% reduction in the end-diastolic interpapillary muscle distance. Is it possible that a more aggressive reduction to 50% or even the elimination of any distance between the papillary muscles would result in a more effective reduction in LVESD and less recurrent MR? This is certainly a question worth addressing in an animal model of IMR. Finally, there is ample evidence to pursue an appropriate reparative strategy for patients with severe IMR that includes both an annular and a ventricular procedure. The CTSN trial provided an intriguing example. Those 74 patients in the CTSN trial with severe IMR who did not experience persistent or recurrent MR after RA had a dramatically smaller left ventricle at 2-year follow-up compared with those patients with recurrent MR after RA alone (43 ± 26 mL/m2 vs 63 ± 27 mL/m2) and, surprisingly, when compared with those patients who underwent MV replacement (61 ± 39 mL/m2). We must pursue a better understanding of how to achieve this clinical goal of LV reverse remodeling through continued rigorous evaluation of mitral annular and LV geometric relationships in ischemic heart disease. In summary, the choice MV procedure to perform in severe ischemic MR has been an evolving discussion with advocates for both an MV replacement and an MV reparative procedure. The data provided by Nappi and colleagues12Nappi F. Lusini M. Singh S.S.A. Santana O. Chello M. Mihos C.G. Risk of ischemic mitral regurgitation recurrence after combined valvular and subvalvular repair.Ann Thorac Surg. 2019; 108: 536-543Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar add significantly to our understanding and have practical therapeutic relevance. Surgical decision making in patients with severe IMR is enhanced by preoperative identification of those patients most likely to have an improvement in regional wall motion and global LV function after CABG. Preoperative evaluation of myocardial viability, echocardiographic assessment of regional and global LV systolic function, and echocardiographic assessment of MV tethering parameters can help in the planning of which MV procedure to perform. Cardiac magnetic resonance imaging with gadolinium hyperenhancement is an appropriate tool when findings on echocardiographic or radionuclide imaging are equivocal or in patients suspected to have LV scar. Individual treatment decisions require balancing the risks of adverse perioperative events for each therapy against the predicted benefits of a lower incidence of postoperative MR, better reverse remodeling, and improved clinical outcomes. Geometric parameters that favor an MV replacement over an MV reparative procedure have been further clarified by Nappi and colleagues,12Nappi F. Lusini M. Singh S.S.A. Santana O. Chello M. Mihos C.G. Risk of ischemic mitral regurgitation recurrence after combined valvular and subvalvular repair.Ann Thorac Surg. 2019; 108: 536-543Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar and they include patients with large ventricles (LVESD >55 mm and LVEDD >65 mm), MV tenting area larger than 3 cm2, and factors previously known such as documented scar or basal aneurysm or dyskinesia in the inferior-posterior-lateral left ventricle and poor coronary targets in the circumflex or right coronary distributions because of the reduced likelihood that revascularization will provide significant enhancement of LV contractility and LV reverse remodeling. Recognition of the likelihood of a durable repair after CABG plus RA and PMA in patients presenting with a nondilated LV, low MV tenting area, and good coronary targets should influence surgeons to favor MV reparative therapy over MV replacement. Restrictive annuloplasty and papillary muscle approximation combined with CABG is an appropriate option in patients with severe IMR. Risk of Ischemic Mitral Regurgitation Recurrence After Combined Valvular and Subvalvular RepairThe Annals of Thoracic SurgeryVol. 108Issue 2PreviewMitral valve repair (MVr) combined with papillary muscle approximation (PMA) may improve repair durability in severe ischemic mitral regurgitation (MR), when compared with MVr alone. We sought to identify preoperative transthoracic echocardiographic markers associated with MR recurrence after MVr with PMA. Full-Text PDF Pathophysiologic Mechanisms of Subvalvular Repair and Its Clinical ImplicationsThe Annals of Thoracic SurgeryVol. 110Issue 1PreviewThe observations by Dr Michler,1 as well as by our group, should provide food for thought and potentially lead to revisiting the randomized clinical trials published on the subject that require another type of surgical comparison: a “complete mitral repair” (ie, involving both the valvular apparatus and subvalvular)2 vs chordal-sparing mitral replacement3 and the Mitraclip (Abbott Vascular, Santa Clara, CA) procedure.4,5 Full-Text PDF

Background: The CTSN (Cardiothoracic Surgical Trials Network) recently reported no difference in left ventricular end-systolic volume index or in survival at 2 years between patients with severe ischemic mitral regurgitation (MR) randomized to mitral valve repair or replacement. However, replacement provided more durable correction of MR and fewer cardiovascular readmissions. Yet, cost-effectiveness outcomes have not been addressed. Methods and Results: We conducted a cost-effectiveness analysis of the surgical treatment of ischemic MR based on the CTSN trial (n=126 for repair; n=125 for replacement). Patient-level data on readmissions, survival, quality-of-life, and US hospital costs were used to estimate costs and quality-adjusted life years per patient over the trial duration and a 10-year time horizon. We performed microsimulation for extrapolation of outcomes beyond the 2 years of trial data. Bootstrap and deterministic sensitivity analyses were done to address parameter uncertainty. In-hospital cost estimates were $78 216 for replacement versus $72 761 for repair (difference: $5455; 95% uncertainty interval [UI]: −7784–21 193) while 2-year costs were $97 427 versus $96 261 (difference: $1166; 95% UI: −16 253–17 172), respectively. Quality-adjusted life years at 2 years were 1.18 for replacement versus 1.23 for repair (difference: −0.05; 95% UI: −0.17 to 0.07). Over 5 and 10 years, the benefits of reduction in cardiovascular readmission rates with replacement increased, and survival minimally improved compared with repair. At 5 years, cumulative costs and quality-adjusted life years showed no difference on average, but by 10 years, there was a small, uncertain benefit for replacement: $118 023 versus $119 837 (difference: −$1814; 95% UI: −27 144 to 22 602) and quality-adjusted life years: 4.06 versus 3.97 (difference: 0.09; 95% UI: −0.87 to 1.08). After 10 years, the incremental cost-effectiveness of replacement continued to improve. Conclusions: Our cost-effectiveness analysis predicts potential savings in cost and gains in quality-adjusted survival at 10 years when mitral valve replacement is compared with repair for severe ischemic MR. These projected benefits, however, were small and subject to variability. Efforts to further delineate predictors of long-term outcomes in patients with severe ischemic MR are needed to optimize surgical decisions for individual patients, which should yield more cost-effective care. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT00807040.

Objectives: We performed a prospective, single-arm clinical trial approved under a Food and Drug Administration Investigational Device Exemption to assess safety and efficacy of Perceval, a sutureless bovine pericardial aortic valve representing the initial US experience. Methods: From June 2013 to January 2015, 300 patients (mean age 76.7 +/- 7.7 years, 54.3% men, 37.3% >= 80 years, median Society of Thoracic Surgeons Predicted Risk of Mortality 2.8%), underwent Perceval valve implantation at 18 centers across the United States. Twenty patients (6.7%) had a bicuspid aortic valve and 5 (1.7%) patients had previous aortic valve replacement. A minimally invasive approach was used in 80 (26.7%) and concomitant procedures were performed in 113 (37.8%) patients. Results: Two hundred eighty-nine patients (96.3%) were successfully implanted. Operative mortality (<= 30 days) was 1.3% (n=4) (observed to expected ratio of 0.40). One-year results included all-cause mortality in 5.2% (n=15), stroke in 1% (n=3), and endocarditis in 1.7% (n=5). New permanent periprocedural pacemaker rate was 10.7% (n=30/281); 2.5% (n=7/281) resulted from third-degree atrioventricular block. One-year valve-related reoperation was 2.1%(n=6). At 1-year follow-up, 98% of patients were in New York Heart Association class I/II, left ventricular mass index decreased from 103.5 +/- 30.1 g/m(2) at discharge to 95.8 +/- 27.1 g/m(2) (P=.001), and 3 (1.3%) moderate paravalvular leaks were identified. Health-related quality of life score increased from 62.7 +/- 21.8 before surgery to 85.5 +/- 17.8 at 1 year (P<.001). Conclusions: These results confirm the safety and effectiveness of the Perceval sutureless aortic valve replacement in study patients with lower mortality than expected from a risk prediction model. Persistent hemodynamic benefit and improvement in quality of life at 1 year support the importance of this device in the management of aortic valve disease.

Total anomalous pulmonary venous return (TAPVR) is a rare congenital cardiac defect, accounting for 1.5-3% of cases of congenital heart disease. With prenatal ultrasonography, the majority of these patients are diagnosed in utero with definitive surgery performed during the neonatal period. However, as prenatal screening may not be available in developing countries, patients may present in later infancy. We present successful surgical repair of a 6-month-old infant with TAPVR who presented for medical care at 5 months of age in Lima, Peru. The late presentation of such infants and the limited resources available for the treatment of elevated pulmonary vascular resistance may impact successful surgical correction of such defects. The perioperative care of such infants in developing countries is discussed and strategies for managing postoperative pulmonary hypertension is reviewed.