Predicting recurrent mitral regurgitation after mitral valve repair for severe ischemic mitral regurgitation

• Published in: The Journal of thoracic and cardiovascular surgery Vol. 149; no. 3; pp. 752 - 761.e1
• Main Authors: Kron, Irving L., MD, Hung, Judy, MD, Overbey, Jessica R., MS, Bouchard, Denis, MD, Gelijns, Annetine C., PhD, Moskowitz, Alan J., MD, Voisine, Pierre, MD, O'Gara, Patrick T., MD, Argenziano, Michael, MD, Michler, Robert E., MD, Gillinov, Marc, MD, Puskas, John D., MD, Gammie, James S., MD, Mack, Michael J., MD, Smith, Peter K., MD, Sai-Sudhakar, Chittoor, MD, Gardner, Timothy J., MD, Ailawadi, Gorav, MD, Zeng, Xin, MD, O'Sullivan, Karen, MPH, Parides, Michael K., PhD, Swayze, Roger, RN, BSN, Thourani, Vinod, MD, Rose, Eric A., MD, Perrault, Louis P., MD, Acker, Michael A., MD
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-03-2015
• Subjects: Aged; Area Under Curve; Canada; Cardiothoracic Surgery; Chi-Square Distribution; Decision Support Techniques; Echocardiography, Doppler, Color; Female; Heart Valve Prosthesis Implantation - adverse effects; Heart Valve Prosthesis Implantation - mortality; Humans; Logistic Models; Male; Middle Aged; Mitral Valve Annuloplasty - adverse effects; Mitral Valve Annuloplasty - mortality; Mitral Valve Insufficiency - diagnosis; Mitral Valve Insufficiency - etiology; Mitral Valve Insufficiency - mortality; Mitral Valve Insufficiency - surgery; Myocardial Ischemia - complications; Myocardial Ischemia - diagnosis; Myocardial Ischemia - mortality; Patient Selection; Predictive Value of Tests; Recurrence; Risk Assessment; Risk Factors; ROC Curve; Severity of Illness Index; Time Factors; Treatment Outcome; United States; Canada; United States; left ventricle; left ventricular end-systolic volume index; LV; AUC; New York Heart Association; CTSN; EDV; effective regurgitant orifice area; mitral valve; end-diastolic volume; receiver operating characteristic; coronary artery bypass grafting; EROA; operating room; NYHA; 35; PISA; OR; MR; mitral regurgitation; LVESVI; ROC; MV; proximal isovelocity surface area; area under the curve; 35.4.1; Cardiothoracic Surgical Trials Network; IMR; ischemic mitral regurgitation; CABG; 35.4
• ISSN: 0022-5223; 1097-685X
• DOI: 10.1016/j.jtcvs.2014.10.120

Abstract Objectives The Cardiothoracic Surgical Trials Network recently reported no difference in the primary end point of left ventricular end-systolic volume index at 1 year postsurgery in patients randomized to repair (n = 126) or replacement (n = 125) for severe ischemic mitral regurgitation. However, patients undergoing repair experienced significantly more recurrent mitral regurgitation than patients undergoing replacement (32.6% vs 2.3%). We examined whether baseline echocardiographic and clinical characteristics could identify those who will develop moderate/severe recurrent mitral regurgitation or die. Methods Our analysis includes 116 patients who were randomized to and received mitral valve repair. Logistic regression was used to estimate a model-based probability of recurrence or death from baseline factors. Receiver operating characteristic curves were constructed from these estimated probabilities to determine classification cut-points maximizing accuracy of prediction based on sensitivity and specificity. Results Of the 116 patients, 6 received a replacement before leaving the operating room; all other patients had mild or less mitral regurgitation on intraoperative echocardiogram after repair. During the 2-year follow-up period, 76 patients developed moderate/severe mitral regurgitation or died (53 mitral regurgitation recurrences, 13 mitral regurgitation recurrences and death, and 10 deaths). The mechanism for recurrent mitral regurgitation was largely mitral valve leaflet tethering. Our model (including age, body mass index, sex, race, effective regurgitant orifice area, basal aneurysm/dyskinesis, New York Heart Association class, history of coronary artery bypass grafting, percutaneous coronary intervention, or ventricular arrhythmias) yielded an area under the receiver operating characteristic curve of 0.82. Conclusions The model demonstrated good discrimination in identifying patients who will survive 2 years without recurrent mitral regurgitation after mitral valve repair. Although our results require validation, they offer a clinically relevant risk score for selection of surgical candidates for this procedure.