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Edwin C. McGee, Jr
Eugene H. Blackstone
Gideon Cohen
Farzad Najam
Joseph F. Sabik
Bruce W. Lytle
Patrick M. McCarthy
Delos M. Cosgrove
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J Thorac Cardiovasc Surg 2004;128:916-924
© 2004 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Recurrent mitral regurgitation after annuloplasty for functional ischemic mitral regurgitation

Edwin C. McGee, Jr, MDa, A. Marc Gillinov, MDa,*, Eugene H. Blackstone, MDa,,b, Jeevanantham Rajeswaran, MScb, Gideon Cohen, MDa, Farzad Najam, MDa, Takahiro Shiota, MDc, Joseph F. Sabik, MDa, Bruce W. Lytle, MDa, Patrick M. McCarthy, MDa, Delos M. Cosgrove, MDa

a Department of Thoracic and Cardiovascular Surgery, Biostatistics and Epidemiology
b Department of Cardiovascular Medicine
c The Cleveland Clinic Foundation, Cleveland, Ohio

Received for publication April 23, 2004; revisions received July 22, 2004; accepted for publication July 26, 2004.

* Address for reprints: A. Marc Gillinov, MD, The Cleveland Clinic Foundation, 9500 Euclid Ave/Desk F24, Cleveland, OH 44195 (E-mail: gillinom{at}ccf.org).

OBJECTIVES: We sought to characterize the temporal return of mitral regurgitation after annuloplasty for functional ischemic mitral regurgitation; to identify its predictors, particularly with respect to annuloplasty type; and to determine whether annuloplasty type influences survival.

METHODS: From April 1985 through November 2002, 585 patients underwent annuloplasty alone for repair of functional ischemic mitral regurgitation, generally with concomitant coronary revascularization (95%). A flexible band (Cosgrove) was used in 68%, a rigid ring (Carpentier) in 21%, and bovine pericardial annuloplasty (Peri-Guard) in 11%. Six hundred seventy-eight postoperative echocardiograms were available in 422 patients to assess the time course of postoperative mitral regurgitation and its correlates. Most echocardiograms were performed early after the operation (median, 8 days); 17% were performed at 1 year or beyond.

RESULTS: During the first 6 months after repair, the proportion of patients with 0 or 1+ mitral regurgitation decreased from 71% to 41%, whereas the proportion with 3+ or 4+ regurgitation increased from 13% to 28% (P < .0001); the regurgitation grade was stable thereafter. The temporal pattern of development of 3+ or 4+ regurgitation was similar for Cosgrove bands and Carpentier rings (25%) but substantially worse for Peri-Guard annuloplasties (66%). Small annuloplasty size did not influence postoperative regurgitation grade (P = .2), although Cosgrove bands were used in most patients receiving 26- and 28-mm annuloplasties. Freedom from reoperation was 97% at 5 years. Annuloplasty type was not associated with survival.

CONCLUSIONS: Although initial mitral valve replacement would eliminate the risk of postoperative mitral regurgitation, this strategy has been associated with reduced survival. Therefore the development of additional techniques is necessary to achieve more secure repair of functional ischemic mitral regurgitation.




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M. A. Borger, P. M. Murphy, A. Alam, S. Fazel, M. Maganti, S. Armstrong, V. Rao, and T. E. David
Initial results of the chordal-cutting operation for ischemic mitral regurgitation
J. Thorac. Cardiovasc. Surg., June 1, 2007; 133(6): 1483 - 1492.
[Abstract] [Full Text] [PDF]

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 Eur. J. Cardiothorac. Surg.Home page
L. Ryan, B. Jackson, L. Parish, H. Sakamoto, T. Plappert, M. St. J. Sutton, J. Gorman III, and R. Gorman
Quantification and localization of mitral valve tenting in ischemic mitral regurgitation using real-time three-dimensional echocardiography
Eur. J. Cardiothorac. Surg., May 1, 2007; 31(5): 839 - 844.
[Abstract] [Full Text] [PDF]

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 CirculationHome page
J. Magne, P. Pibarot, F. Dagenais, Z. Hachicha, J. G. Dumesnil, and M. Senechal
Preoperative Posterior Leaflet Angle Accurately Predicts Outcome After Restrictive Mitral Valve Annuloplasty for Ischemic Mitral Regurgitation
Circulation, February 13, 2007; 115(6): 782 - 791.
[Abstract] [Full Text] [PDF]

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 J. Thorac. Cardiovasc. Surg.Home page
F. Langer and H.-J. Schafers
RING plus STRING: Papillary muscle repositioning as an adjunctive repair technique for ischemic mitral regurgitation
J. Thorac. Cardiovasc. Surg., January 1, 2007; 133(1): 247 - 249.
[Full Text] [PDF]

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 Eur. J. Cardiothorac. Surg.Home page
G. Buckberg
Editorial comment: Left ventricular reconstruction for dilated ischemic cardiomyopathy: biology, registry, randomization, and credibility
Eur. J. Cardiothorac. Surg., November 1, 2006; 30(5): 759 - 761.
[Full Text] [PDF]

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 J. Thorac. Cardiovasc. Surg.Home page
E. A. Grossi and G. A. Crooke
Mitral valve surgery in heart failure: Insights from the Acorn clinical trial.
J. Thorac. Cardiovasc. Surg., September 1, 2006; 132(3): 455 - 456.
[Full Text] [PDF]

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 CirculationHome page
M. J. Mack
Coronary Sinus in the Management of Functional Mitral Regurgitation: The Mother Lode or Fool's Gold?
Circulation, August 1, 2006; 114(5): 363 - 364.
[Full Text] [PDF]

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E. Messas, C. Yosefy, M. Chaput, J. L. Guerrero, S. Sullivan, P. Menasche, A. Carpentier, M. Desnos, A. A. Hagege, G. J. Vlahakes, et al.
Chordal Cutting Does Not Adversely Affect Left Ventricle Contractile Function
Circulation, July 4, 2006; 114(1_suppl): I-524 - I-528.
[Abstract] [Full Text] [PDF]

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E. Kuwahara, Y. Otsuji, Y. Iguro, T. Ueno, F. Zhu, N. Mizukami, K. Kubota, K. Nakashiki, T. Yuasa, B. Yu, et al.
Mechanism of Recurrent/Persistent Ischemic/Functional Mitral Regurgitation in the Chronic Phase After Surgical Annuloplasty: Importance of Augmented Posterior Leaflet Tethering
Circulation, July 4, 2006; 114(1_suppl): I-529 - I-534.
[Abstract] [Full Text] [PDF]

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M. Daimon, S. Fukuda, D. H. Adams, P. M. McCarthy, A. M. Gillinov, A. Carpentier, F. Filsoufi, V. M. Abascal, V. H. Rigolin, S. Salzberg, et al.
Mitral Valve Repair With Carpentier-McCarthy-Adams IMR ETlogix Annuloplasty Ring for Ischemic Mitral Regurgitation: Early Echocardiographic Results From a Multi-Center Study
Circulation, July 4, 2006; 114(1_suppl): I-588 - I-593.
[Abstract] [Full Text] [PDF]

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A. Cheng, T. C. Nguyen, M. Malinowski, D. Liang, G. T. Daughters, N. B. Ingels Jr, and D. C. Miller
Effects of Undersized Mitral Annuloplasty on Regional Transmural Left Ventricular Wall Strains and Wall Thickening Mechanisms
Circulation, July 4, 2006; 114(1_suppl): I-600 - I-609.
[Abstract] [Full Text] [PDF]

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 Ann. Thorac. Surg.Home page
T. Ueno, R. Sakata, Y. Iguro, T. Nagata, Y. Otsuji, and C. Tei
New Surgical Approach to Reduce Tethering in Ischemic Mitral Regurgitation by Relocation of Separate Heads of the Posterior Papillary Muscle
Ann. Thorac. Surg., June 1, 2006; 81(6): 2324 - 2325.
[Abstract] [Full Text] [PDF]

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 J. Thorac. Cardiovasc. Surg.Home page
E.A. Grossi, Y.J. Woo, C.F. Schwartz, D.M. Gangahar, V.A. Subramanian, N. Patel, J. Wudel, P.L. DiGiorgi, A. Singh, and R.D. Davis
Comparison of Coapsys annuloplasty and internal reduction mitral annuloplasty in the randomized treatment of functional ischemic mitral regurgitation: Impact on the left ventricle
J. Thorac. Cardiovasc. Surg., May 1, 2006; 131(5): 1095 - 1098.
[Abstract] [Full Text] [PDF]

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 J. Thorac. Cardiovasc. Surg.Home page
F. Langer, F. Rodriguez, A. Cheng, S. Ortiz, T. C. Nguyen, M. K. Zasio, D. Liang, G. T. Daughters, N. B. Ingels, and D. C. Miller
Posterior mitral leaflet extension: An adjunctive repair option for ischemic mitral regurgitation?
J. Thorac. Cardiovasc. Surg., April 1, 2006; 131(4): 868 - 877.
[Abstract] [Full Text] [PDF]

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 SEMIN CARDIOTHORAC VASC ANESTHHome page
H. (Cindy) Le and D. M. Thys
Ischemic Mitral Regurgitation
Seminars in Cardiothoracic and Vascular Anesthesia, March 1, 2006; 10(1): 73 - 77.
[Abstract] [PDF]

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 J. Thorac. Cardiovasc. Surg.Home page
Pitfalls and limitations in measuring and interpreting the outcomes of mitral valve repair.
J. Thorac. Cardiovasc. Surg., March 1, 2006; 131(3): 523 - 529.


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 J. Thorac. Cardiovasc. Surg.Home page
Is a good perioperative echocardiographic result predictive of durability in ischemic mitral valve repair?
J. Thorac. Cardiovasc. Surg., March 1, 2006; 131(3): 565 - 573.e2.


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 Ann. Thorac. Surg.Home page
M. A. Borger, A. Alam, P. M. Murphy, T. Doenst, and T. E. David
Chronic Ischemic Mitral Regurgitation: Repair, Replace or Rethink?
Ann. Thorac. Surg., March 1, 2006; 81(3): 1153 - 1161.
[Abstract] [Full Text] [PDF]

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 CirculationHome page
J. G. Webb, J. Harnek, B. I. Munt, P. O. Kimblad, M. Chandavimol, C. R. Thompson, J. R. Mayo, and J. O. Solem
Percutaneous Transvenous Mitral Annuloplasty: Initial Human Experience With Device Implantation in the Coronary Sinus
Circulation, February 14, 2006; 113(6): 851 - 855.
[Abstract] [Full Text] [PDF]

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 HeartHome page
J M Ferrao de Oliveira and M. J Antunes
Mitral valve repair: better than replacement
Heart, February 1, 2006; 92(2): 275 - 281.
[Full Text] [PDF]

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 Ann. Thorac. Surg.Home page
Y. K. Mishra, S. Mittal, P. Jaguri, and N. Trehan
Coapsys Mitral Annuloplasty for Chronic Functional Ischemic Mitral Regurgitation: 1-Year Results
Ann. Thorac. Surg., January 1, 2006; 81(1): 42 - 46.
[Abstract] [Full Text] [PDF]

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 Ann. Thorac. Surg.Home page
A. M. Gillinov, E. H. Blackstone, J. Rajeswaran, M. Mawad, P. M. McCarthy, J. F. Sabik III, T. Shiota, B. W. Lytle, and D. M. Cosgrove
Ischemic Versus Degenerative Mitral Regurgitation: Does Etiology Affect Survival?
Ann. Thorac. Surg., September 1, 2005; 80(3): 811 - 819.
[Abstract] [Full Text] [PDF]

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 J. Thorac. Cardiovasc. Surg.Home page
K. J. Grande-Allen, J. E. Barber, K. M. Klatka, P. L. Houghtaling, I. Vesely, C. S. Moravec, and P. M. McCarthy
Mitral valve stiffening in end-stage heart failure: Evidence of an organic contribution to functional mitral regurgitation
J. Thorac. Cardiovasc. Surg., September 1, 2005; 130(3): 783 - 790.
[Abstract] [Full Text] [PDF]

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 Am. J. Physiol. Heart Circ. Physiol.Home page
H.-Y. Yu, M.-Y. Su, Y.-S. Chen, F.-Y. Lin, and W.-Y. I. Tseng
Mitral tetrahedron as a geometrical surrogate for chronic ischemic mitral regurgitation
Am J Physiol Heart Circ Physiol, September 1, 2005; 289(3): H1218 - H1225.
[Abstract] [Full Text] [PDF]

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 CirculationHome page
F. Langer, F. Rodriguez, S. Ortiz, A. Cheng, T. C. Nguyen, M. K. Zasio, D. Liang, G. T. Daughters, N. B. Ingels, and D. C. Miller
Subvalvular Repair: The Key to Repairing Ischemic Mitral Regurgitation?
Circulation, August 30, 2005; 112(9_suppl): I-383 - I-389.
[Abstract] [Full Text] [PDF]

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F. Zhu, Y. Otsuji, G. Yotsumoto, T. Yuasa, T. Ueno, B. Yu, C. Koriyama, S. Hamasaki, S. Biro, A. Kisanuki, et al.
Mechanism of Persistent Ischemic Mitral Regurgitation After Annuloplasty: Importance of Augmented Posterior Mitral Leaflet Tethering
Circulation, August 30, 2005; 112(9_suppl): I-396 - I-401.
[Abstract] [Full Text] [PDF]

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 CirculationHome page
A. Matsunaga and C. M. G. Duran
Progression of Tricuspid Regurgitation After Repaired Functional Ischemic Mitral Regurgitation
Circulation, August 30, 2005; 112(9_suppl): I-453 - I-457.
[Abstract] [Full Text] [PDF]

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 CirculationHome page
R. A. Levine and E. Schwammenthal
Ischemic Mitral Regurgitation on the Threshold of a Solution: From Paradoxes to Unifying Concepts
Circulation, August 2, 2005; 112(5): 745 - 758.
[Full Text] [PDF]

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 Eur Heart JHome page
E. Schwammenthal and R. A. Levine
The non-ischaemic dynamics of ischaemic mitral regurgitation: solving the paradox
Eur. Heart J., August 1, 2005; 26(15): 1454 - 1455.
[Full Text] [PDF]

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 Eur. J. Cardiothorac. Surg.Home page
S. Geidel, M. Lass, C. Schneider, G. Groth, S. Boczor, K.-H. Kuck, and J. Ostermeyer
Downsizing of the mitral valve and coronary revascularization in severe ischemic mitral regurgitation results in reverse left ventricular and left atrial remodeling
Eur. J. Cardiothorac. Surg., June 1, 2005; 27(6): 1011 - 1016.
[Abstract] [Full Text] [PDF]


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