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J Thorac Cardiovasc Surg 2001;122:1125-1141
© 2001 The American Association for Thoracic Surgery
Surgery for Acquired Cardiovascular Disease (ACD) |
From the Department of Thoracic and Cardiovascular Surgerya and the Department of Biostatistics and Epidemiology,b The Cleveland Clinic Foundation, Cleveland, Ohio.
Received for publication May 3, 2000. Revisions requested Sept 5, 2000; revisions received March 14, 2001. Accepted for publication April 11, 2001. Address for reprints: A. Marc Gillinov, MD, The Cleveland Clinic Foundation, 9500 Euclid Ave, Desk F25, Cleveland, OH 44195 (E-mail: gillinom{at}ccf.org).
Abstract
Objective: This study was undertaken to compare mitral valve repair and replacement as treatments for ischemic mitral regurgitation.
Methods: From 1985 through 1997, a total of 482 patients with ischemic mitral regurgitation underwent either valve repair (n = 397) or valve replacement (n = 85). Patients more likely (P 
.01) to undergo repair had functional mitral regurgitation or coronary revascularization with an internal thoracic artery graft; those more likely to receive valve replacement were in higher New York Heart Association functional classes or underwent emergency operations. These factors were used for multivariable propensity matching. Risk factors for early and late death were identified by multivariable, multiphase hazard function analysis.
Results: Within the propensity-matched better-risk group, survivals after valve replacement were 81%, 56%, and 36% at 30 days, 1 year, and 5 years, but survivals after repair were 94%, 82%, and 58% at these intervals (P = .08). In contrast, within the poor-risk group, survivals after repair and replacement were similar (P = .4). Risk factors (P .01) included older age, higher functional class, greater wall motion abnormality, and renal dysfunction. Approximately 70% of patients were predicted to benefit from repair; the benefit lessened or was negated if an internal thoracic artery graft was not used, if a lateral wall motion abnormality was present, or if the mitral regurgitation jet pattern was complex. Freedom from repair failure at 5 years was 91%.
Conclusion: Late survival is poor after surgery for ischemic mitral regurgitation. Most patients with ischemic mitral regurgitation benefit from mitral valve repair. In the most complex, high-risk settings, survivals after repair and replacement are similar.
See related editorial on page 1059.
Surgical treatment of ischemic mitral regurgitation is associated with a high operative mortality rate and poor long-term survival. Choosing the most appropriate surgical treatment to maximize survival for these patients is made difficult by inconsistent classification schemes for the entity, a paucity of long-term data to compare alternatives, and an absence of randomized trials of valve repair versus valve replacement. In fact, such trials are unlikely ever to be undertaken. The purposes of this study were therefore to develop a simple and clinically useful echocardiographic classification scheme, to determine which patients were more likely to receive valve repair rather than replacement at this center, to determine whether survival was better after mitral valve repair or replacement, to discover which patients benefit from valve repair and which from replacement, and to quantify the durability of valve repair.
Methods
Patients
Study group
From 1985 through 1997, records of 482 consecutive patients undergoing either mitral valve repair (n = 397) or replacement (n = 85) for ischemic mitral regurgitation were found. The Cardiovascular Information Registry was used to discriminate nearly 2000 potential patients with this condition. Their clinical records were reviewed to determine whether their mitral regurgitation was indeed caused by ischemic heart disease and did not just coexist with it (see Definitions section). All patients had at least 2+ (moderate) mitral regurgitation. The decision to perform mitral valve surgery was made by the operating surgeon and the cardiologist on the basis of clinical presentation and findings at cardiac catheterization and echocardiography. In general it has been our policy to perform mitral valve surgery for mitral regurgitation that is 3+ or greater. Patients with any degree of mitral regurgitation who did not undergo a surgical procedure on the mitral valve were not included in this study. Patients who underwent concomitant aortic valve procedures were also excluded and are discussed in a separate report. Patients who underwent left ventricular restoration procedures (Batista procedure, Dor procedure) were also excluded and similarly are discussed in separate reports.
The mean age of patients undergoing mitral valve repair was 67 ± 9.2 years, similar to that among those receiving mitral valve replacement (67 ± 8.7 years, P = .4). Patient characteristics overall and according to whether the patient underwent repair or mitral valve replacement are tabulated in Table 1.
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Ischemic mitral regurgitation was further subdivided into three mechanisms of regurgitation: (1) ruptured papillary muscle, (2) infarcted papillary muscle without rupture, and (3) functional regurgitation. Patients with elongated and infarcted but unruptured papillary muscles were classified as having infarcted papillary muscles. Patients with isolated functional mitral regurgitation had normal papillary muscles, chordae, and leaflets; however, the leaflets failed to coapt, and echocardiograms frequently demonstrated restricted leaflet motion. Thus patients with functional mitral regurgitation included those with Carpentier type I and IIIb leaflet motion. Mitral regurgitation was functional in 76% of the cases, papillary muscle infarction without rupture was present in 24%, and papillary muscle rupture was present in 9% (Table 2). Components of both papillary muscle pathologic changes and functional regurgitation were present in 9% of the cases.
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). A complex jet was specified when there were multiple jets or the jet was eccentric (eg, posterolateral or anterolateral).
Regional wall motion abnormalities were documented with echocardiograms or ventriculograms from cardiac catheterization (Figure 1). Abnormalities were categorized as being anterior, septal, inferior, posterior, and lateral in location (Appendix I, Table 1; Figure 1
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Data analysis
Overview
The data analysis first addressed the question, "Were patients undergoing mitral valve repair similar to those undergoing replacement?" The answer to that question was no. Therefore a matched group of patients was assembled to answer a second question: "Is survival better after mitral valve repair than after replacement?" However, these patients represented only one end of the spectrum of ischemic mitral regurgitation (the most complex with the sickest patients). Multivariable analyses of mortality were therefore performed separately for repair and replacement groups. These analyses were then combined, including an analysis of interactions, to yield an overall equation for comparison of repair and replacement propensity-adjusted for selection factors in choice of procedure. We then asked, "Which patients benefit from which procedure?" Multivariable simulation was used to answer that question. Finally, we asked, "Is mitral valve repair durable?" We answered this question by analyzing repair failure. Details of the methodology are supplemented by material in Appendix II.
Were patients undergoing mitral valve repair similar to those undergoing replacement?
To answer this question, multivariable logistic regression was used to identify factors associated with valve repair rather than replacement. In this analysis demographic characteristics, symptoms and clinical status, left ventricular function, pathyphysiology of valve disease, cardiac comorbidity, noncardiac comorbidity, and concomitant coronary artery procedure variables were considered (Appendix III). Details of risk factor identification are given in Appendix II. After examining these patient factors we explored surgeon differences.
The latter parsimonious analysis was amplified into a propensity model by adding nonsignificant variables representing gender, body size (body mass index), preoperative use of an intra-aortic balloon pump, coronary system disease greater than 50%, hypertension, treated diabetes, peripheral vascular disease, chronic obstructive pulmonary disease, history of smoking, concomitant coronary artery bypass grafting, and all indicator variables for missing values. 1-3 The concordance obtained with this model was represented by a C statistic of 0.92.
The patients were then sorted according to their individual propensity score and for some analyses were divided into five quintiles of equal numbers of patients for comparison of repair versus replacement among closed propensity-matched patients.
Is survival better after mitral valve repair than after replacement?
To answer this question, initial nonparametric estimates of survival were obtained by the Kaplan-Meier method. A parametric method was used to resolve the number of phases of instantaneous risk of death (hazard function) and to estimate its shaping parameters. 4 Exploratory analyses of the variables in Appendix III included correlation analysis, stratified life table analyses, and decile risk analysis of ordinal and continuous variables to determine possible transformations of scale needed to calibrate properly the variables to survival. Thereafter multivariable analysis was performed in the hazard function domain. In all analyses we forced the variable mitral valve repair versus mitral valve replacement and the propensity score. Details of the methods for managing missing values for variables and for the strategies of variable selection are given in Appendix II.
Which patients benefit from which procedure?
The overall multivariable survival equation was solved twice for each patient, once as though the patient's mitral valve had been replaced and once again as though a repair had been performed (simulation). The difference between predicted 7-year survivals for these two strategies was compared. A positive difference was interpreted as a repair benefit, and a negative difference was interpreted as a replacement benefit. The comparison included multiple linear regression of the 7-year survival differences. Details of this analysis are given in Appendix II.
Analysis of echocardiographic features
Lateral wall motion abnormality and complex regurgitant jet direction were both risk factors. Their correlates were explored with multivariable logistic regression by the techniques described previously.
Is mitral valve repair durable?
Durability of mitral valve repair was assessed by the time-related event mitral valve replacement for recurrent mitral regurgitation. We considered a repair failure to have occurred when the repair was completed and then assessed, generally by removal of cardiopulmonary bypass, with the finding of important residual mitral valve regurgitation. If this failure resulted in mitral valve replacement, it was called a repair failure; these few cases were carried in the mitral valve repair group throughout the analyses according to the strategy of intent to treat.
Presentation
Mortality and survival estimates are accompanied by an asymmetric 68% confidence interval, comparable to ±1 SE.
Results
Were patients undergoing mitral valve repair similar to those undergoing replacement?
The characteristics of patients undergoing valve repair and valve replacement differed (Tables 1 and 2). Factors associated with a greater likelihood of mitral valve repair versus replacement included nonemergency surgery, isolated functional mitral regurgitation, and use of ITA grafting. Factors associated with replacement were higher New York Heart Association (NYHA) functional class and more severe regurgitation (Table 4). When identifiers for surgeons were entered, two surgeons were found, after adjustment for patient factors, to be more likely to repair than to replace the valve (P .01, C statistic = 0.88), but no factors became statistically significant.
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Overall survival
Fifty-four patients (11%, confidence interval 9%-13%) died in the hospital. Operative mortality rate (including those dying within 30 days) was 13% (confidence interval 11%-14%). Time-related survivals were 77% at 1 year and 55% at 5 years (Figure 2).
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, B) and particularly in quintiles III through V (Figure 3, C), however, which contained progressively fewer complex conditions and sicker patients (Table 5), repair afforded a survival advantage.
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Which patients benefit from which procedure?
When we simulated both valve repair and valve replacement by solving the multivariable equation twice for each patient, the predicted difference in 7-year survival showed a repair benefit for 66% of patients (Figure 6, A This repair benefit was true for both the actual repair and actual replacement groups (Figure 6, B). The patients with the most complex and severe conditions did not appear to benefit from mitral valve repair; indeed, their 7-year survival was better with replacement. However, this apparent advantage to mitral valve replacement was partially neutralized if patients undergoing repair received an ITA graft and an annuloplasty by a technique other than a bovine pericardial strip (see Appendix V).
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Classification of ischemic mitral regurgitation
All patients in this report had mitral regurgitation caused by a previous myocardial infarction. From analysis of echocardiograms and operative reports, we were able to classify patients into three groups according to the mechanism of regurgitation: ruptured papillary muscle, infarcted papillary muscle without rupture, and functional ischemic mitral regurgitation. Others have proposed similar classification schemes. 5-11 Differences among these schemes create confusion. We propose a simple system of classification that encompasses all patients with ischemic mitral regurgitation caused by previous myocardial infarction. This system should permit uniform reporting of surgical results and meaningful comparisons between different series. Furthermore, in this system, the mechanism of mitral regurgitation dictates the repair techniques used when mitral reconstruction is attempted.
It is of particular importance, however, to verify that the mitral regurgitation is, in fact, caused by a myocardial infarction. Most patients with concomitant mitral regurgitation and coronary artery disease do not have ischemic mitral regurgitation. Rather, they have a primary mitral valve pathologic condition (degenerative or rheumatic) and coexisting coronary artery disease.
The minority of patients with ischemic mitral regurgitation have pathologic changes of the papillary muscle. Papillary muscle rupture, which is usually an acute and catastrophic event, has a different presentation from papillary muscle infarction with an elongated but intact papillary muscle. Repair techniques for these two conditions differ. 9,10,12 Although these conditions represent end points of the same pathologic process, it is thus useful to consider them as distinct entities.
Most patients with ischemic mitral regurgitation have functional ischemic mitral regurgitation. In such cases, the mitral leaflets and subvalvular apparatus appear structurally normal on echocardiography and direct inspection. The leaflets fail to coapt during ventricular systole and may appear restricted, producing a regurgitant jet that is usually central but occasionally eccentric (complex). 5,6,13 We agree with others that this entity should be termed functional ischemic mitral regurgitation. The term papillary muscle dysfunction 7 should be used with caution; although papillary muscle dysfunction may contribute to transient mitral regurgitation in patients with intermittent ischemia, it does not explain the mechanism of functional mitral regurgitation.
The mechanism of functional ischemic mitral regurgitation has been debated. It is probably a complex entity produced by changes in annular, ventricular, and papillary muscle geometry and function. 11,14,15 The mechanism may differ from patient to patient, depending on the site and extent of myocardial infarction. Pathologic examinations by Bulkley and Roberts 16 suggest that isolated annular dilatation is a rare cause of mitral regurgitation; however, others believe that annular dilatation is an important component of functional ischemic mitral regurgitation. 6,11,17,18 The primary pathologic condition may involve alterations in ventricular and papillary muscle geometry, producing a tethering effect on the mitral leaflets. 5,8,11 Although the mechanism of functional ischemic mitral regurgitation is unclear, the most important point is that these patients have normal mitral leaflets and subvalvular apparatus, which allows treatment by annuloplasty alone. 5,6,8,13
The mechanism of ischemic mitral regurgitation has been investigated in several animal models. In an acute sheep model, Gorman found that large posterior infarction caused asymmetric annular dilatation and changes in papillary muscle geometry. 19 Both posterior papillary muscle infarction and left ventricular dilatation were necessary to produce ischemic mitral regurgitation; left ventricular dilatation alone did not produce mitral regurgitation. 20 An elegant study from Stanford University of acute ischemic mitral regurgitation suggested that early systolic annular dilatation, shape change, and altered posterior papillary muscle motion are the primary mechanisms of acute ischemic mitral regurgitation. 21 Experimental studies in other models suggest roles for alterations in left ventricular shape 22 and changes in distance from the papillary muscles to the anulus. 23 These studies of acute ischemic mitral regurgitation in animal models are limited in their ability to explain the mechanism of human ischemic mitral regurgitation. Nevertheless, they demonstrate that functional ischemic mitral regurgitation is probably more complicated in its pathogenesis than simple annular dilatation.
Implications of differences among patients undergoing mitral valve repair versus replacement
Patients who underwent a mitral valve repair differed in important respects from many of the patients who underwent replacement. We therefore approached this potential confounding of the comparison by using the propensity score. 1-3 This is one of a suite of balancing scores whereby patients can be matched multivariably (balanced) at the expense of imbalanced numbers of patients from each group in each comparison(Table 5). The imbalance in numbers renders the comparison in quintiles III through V tenuous. This extreme imbalance revealed that we were dealing with a wide spectrum of disease in this group of patients and that less ill patients with fewer sequelae of this myocardial damage whose surgery was elective preferentially underwent repair. We believe that our use of the propensity score as a covariable in our modeling and our extensive subgroup and interaction analyses adjusted well for these imbalances (see Appendix III and Appendix IV for details).
Mitral valve repair versus replacement
Patients with ischemic mitral regurgitation have an unfavorable prognosis, with poor survival relative to patients with other causes of mitral dysfunction. 6,7,24 It is therefore important to determine which factors influence early and late survival for risk stratification and alteration of surgical approach that might improve survival.
We documented several risk factors for early and late death after surgical treatment of ischemic mitral regurgitation. These included such general factors as older age, advanced NYHA functional class, severe left ventricular dysfunction, preoperative atrial fibrillation, and renal dysfunction. In addition, patients with inferior wall motion abnormalities, corresponding to right coronary artery infarcts, had better survival than did patients with other wall motion abnormalities. Others have reported similar findings. 6,7
Which patients benefit from repair?
The previously discussed information can be used for risk stratification, but does not afford the surgeon the opportunity to influence outcome by surgical technique. We therefore asked the specific question, "For whom is repair better than replacement as treatment for ischemic mitral regurgitation?"
The answer is that repair confers a survival advantage for most patients with ischemic mitral regurgitation. The impact of mitral valve repair was investigated with a variety of methods. Propensity matching was invaluable in the analysis, because there was a great deal of interaction between it and outcome. Across all propensity-matched quintiles, mitral valve replacement resulted in a fairly uniform outcome, with poor long-term survival independent of patient status. In contrast, mitral valve repair produced a modulated result across the quintiles. Thus patients who underwent elective surgery and had a more stable condition derived a survival benefit from mitral valve repair (see Appendix IV).
A more detailed examination of patients in the repair group revealed that they had reduced survival if they had a lateral infarct or a complex regurgitant jet. The reason for these findings is not entirely clear but may relate to the extent of the wall motion abnormality and difficulty in achieving a perfect repair in cases of complex regurgitant jets. Patients who underwent mitral valve repair had improved survival if they had an ITA graft and a formal annuloplasty band or ring (rather than a bovine pericardial strip).
Several investigators have suggested that repair is better than replacement for patients with ischemic mitral regurgitation. 7,17 Others, however, have documented equivalent late survivals after repair and replacement. 5,24 Chordal preservation at mitral valve replacement may be an important means of improving survival. 5 Cohn and colleagues 6 and Dion and associates 14 concluded that the pathophysiologic mechanism of mitral regurgitation and the mode of presentation of the patient were more important determinants of outcome than was the surgical technique. In an earlier analysis of a smaller number of patients, we found better survival after repair among patients with leaflet prolapse than among those with functional ischemic mitral regurgitation. 10 This study suggests a far more complicated interaction, however, with important impacts on results of patient presentation, specific regurgitant and wall motion abnormalities, and surgical technique.
Surgical techniques for mitral valve repair in patients with ischemic mitral regurgitation have been described by others. 5,6,8,10,12 Papillary muscle rupture was repaired by papillary muscle reimplantation or occasionally by resection of a prolapsing portion of the posterior leaflet. Papillary muscle infarction was repaired by papillary muscle shortening. Functional ischemic mitral regurgitation was repaired by annuloplasty alone. We prefer to use an undersized annuloplasty, and 79% of patients who underwent mitral valve repair had an annuloplasty that was 30 mm or smaller. Others have also reported excellent results with an undersized annuloplasty for functional ischemic mitral regurgitation. 9,13,15 Frater 13 believes that the undersized annuloplasty compensates for posterior left ventricular dilatation. Bolling and colleagues 15 suggest that an undersized annuloplasty may in time result in reversal of ventricular remodeling. The technique of annuloplasty is important. Bovine pericardial annuloplasty jeopardized late survival, and others have demonstrated that ring annuloplasty is superior to suture annuloplasty for patients with ischemic mitral regurgitation. 9 Experimental data suggest that posterior annuloplasty may be sufficient to correct functional ischemic mitral regurgitation. 21 Our own data confirm this, because survivals were similar with the Cosgrove-Edwards annuloplasty band and the Carpentier-Edwards annuloplasty ring.
Although some favor cardiac transplantation for certain subsets of patients with ischemic mitral regurgitation, 24 we have not used this strategy. Contemporary 5- and 10-year survivals after cardiac transplantation are 68% and 46%, rendering this an imperfect option. 25 In addition, most patients in this series were elderly, making them unlikely candidates for transplantation.
Limitations
This was a nonrandomized clinical study. By using the propensity score, we attempted to adjust the multivariable analyses of outcomes for nonrandom selection bias related to choice of valvular procedure.
The need for surgical intervention for patients with moderate (2+) mitral regurgitation remains a matter of debate and should be the subject of a prospective study. The question cannot be addressed by this clinical study.
Serial echocardiographic follow-up assessment of mitral valve function was unavailable for most patients who underwent mitral valve repair. Therefore the data do not allow discrimination of patients who had recurrent mitral valve dysfunction but did not undergo reoperation.
The end points investigated in this study were death and mitral valve reoperation. We did not analyze other valve-related complications, all of which have been thoroughly documented in the literature for mitral valve repair and replacement.
We were unable to determine from review of all operative reports which patients with mitral valve replacement had preservation of all or part of the subvalvular apparatus. The impact of this surgical technique therefore could not be analyzed. Only a single patient in this study had an Alfieri stitch. The impact of the Alfieri stitch in ischemic mitral regurgitation is the subject of an ongoing study.
Finally, patients with intermittent ischemic mitral regurgitation treated by coronary revascularization alone were not included in this analysis.
Clinical inferences and decision-making
Patients who require mitral valve surgery for ischemic mitral regurgitation can be classified by echocardiography and direct inspection as having a ruptured papillary muscle, infarcted but unruptured papillary muscle, or functional ischemic mitral regurgitation. Late survival is poor for all groups, with most patients dying within 7 years of surgery. However, choice of surgical procedure has an important impact on late survival. Most patients derive a survival advantage from mitral valve repair rather than replacement. Among the most severely ill patients, the survival benefit of mitral valve repair is diminished. When mitral valve repair is performed, a formal annuloplasty should be used, and left anterior descending disease should be treated by ITA grafting.
Appendix: Discussion
Dr D. Craig Miller (Stanford, Calif). I commend Wierup and colleagues for a fine presentation of a complex data set and compliment them on this massive undertaking, which took 2 years to complete. This report is the best we can hope for in encompassing this challenging topic and finally gets rid, for the most part, of the problem of comparing apples and oranges, which we have faced for many years.
This is the largest report to date on surgically treated patients with ischemic mitral regurgitation, and it should be emphasized that this is a "clean" series in that all of these patients had causal ischemic mitral regurgitation as a consequence of coronary disease and not just incidental coronary artery disease, something which has confounded previous reports. Now that we have large numbers of patients analyzed by the unbelievable statistical prowess of Dr Blackstone, who has truly done statistical backflips in gleaning meaningful messages, what have we learned?
First, patients with ischemic mitral regurgitation treated either way have a soberingly poor 5- to 7-year prognosis. This sad fact, which concurs with previous honest reports, begs the question of whether transplantation might be a better option for suitable individuals.
Second, we now know that mitral annuloplasty, even if performed at the heralded Cleveland Clinic Foundation, does not confer immortality. Indeed, in the sickest quintile of patients there really was no difference in survival between repair and replacement. Why? Well, as always, it is probably patient selection first, patient selection second, and patient selection third, which brings up the possible presence of subtle patient referral or patient selection biases in this report. There probably is a difference in patient substrate between the patient with ischemic mitral regurgitation who has been on surgeon X's waiting list for 2 or 3 months and has an operation done during daylight hours and the patient who is airlifted in so that an emergency operation can be undertaken in the middle of the night. Dr Wierup, did you look for the influence of such possible bias by adjusting results by surgeon, or perhaps maybe even by the time of day or night that the operation commenced?
Is the take-home message really that the low-risk patients with "functional" ischemic mitral regurgitation, a central jet with Carpentier type I (or normal) leaflet motion, really do better after repair than they would have if they had received a valve replacement? This may well be the case, Dr Wierup, but because you do not know who had what type of replacement or what type of chorda-sparing replacement, how can we be sure the survival would not have been equivalent if the patients undergoing valve replacement had had complete or partial chordal preservation? For example, you stated that survivals were similar after valve replacement and repair in the sickest, highest-risk quintile of patients. Later, you mentioned that the survival advantage of repair was partially neutralized if the repair did not involve an ITA graft, or a Carpentier-Edwards ring or a Cosgrove annuloplasty band instead of vein grafting alone or nonring pericardial strip annuloplasty. Conversely, could the putative survival advantage of repair for the least sick, lowest-risk patients have been potentially neutralized if all or some of the chordae had been preserved in all the replacements?
Something predictable and reproducible is what we all want here, especially in the middle of the night in less than ideal circumstances, and maybe mitral valve replacement with total chordal preservation is the way to go in many cases. Given the dismal long-term survival of these patients, this patient substrate is an ideal indication for a tissue bioprosthesis, no matter the patient's age.
Third, if repair really is that much better than replacement, why wasn't this evident for the sickest patients? Indeed, I was even struck by the modest magnitude of survival advantage in the least sick quintiles. None of us can make a silk purse out of a sow's ear here, and I think that is the crux of the matter; but this sad news could be due to the challenging subset of cases with a "complex" mitral regurgitation jet. I think that this subgroup probably had the restricted systolic leaflet motion, or so-called Carpentier type III leaflet motion, and apical tethering of the leaflets. It is a much more complicated setting than simple annular dilatation and a central mitral regurgitation jet, where a small ring probably is adequate. Are you and your colleagues at the Clinic in such circumstances now adding other adjuncts to your repair techniques, such as a commissuroplasty or an Alfieri stitch? If so, where? In the posteromedial scallop or in the middle of the valve? What about actual leaflet elongation or extension procedures such as those performed by Kohl in Lund, Sweden, and in Toronto by Tirone David?
To sum up, none of us has all the answers yet, but this article sure helps.
Dr Wierup. Thank you, Dr Miller. Certainly these patients face a poor survival, and transplantation, as previously suggested by Houseman from Berlin, is an alternative.
We have not looked for the influence of different surgeons on the outcome, nor have we taken into account the time of day.
We are aware of the beneficial results shown by Dr David and colleagues for preservation of the subvalvular apparatus in mitral valve replacement, and our current practice is to preserve as much as possible of the subvalvular apparatus when we replace the valve. This information was not stated in some of the charts, however, and we elected not to analyze this aspect.
Regarding mitral valve replacement in the sickest patients, analyses showed slightly different survival patterns for replacement versus repair, with more early deaths and fewer later ones, resulting in no overall survival advantage.
Let me comment on the "complex jet." In our material 15% of the patients had a complex jet, which was frequently seen at the posteromedial commissure. Our current techniques are undersizing of the annuloplasty and commissuroplasty at the posteromedial commissure. We have not yet started with leaflet extension, but it could certainly be an alternative.
Dr Robert A. Dion (Leiden, The Netherlands). What is your rationale for adding a mitral valve procedure for patients with only moderate or fluctuating or intermittent mitral regurgitation?
Dr Wierup. We make sure that the patient has adequate preload and afterload, and if the regurgitation does increase to more than 2+, we do not operate on the valve.
Dr Alain Carpentier (Paris, France). First of all, I congratulate you on this excellent presentation and pointing out the superiority of valve repair. Let me talk about just the patients with not as good a result in the group of very sick patients.
It was mentioned that a solution to that problem could be leaflet extension. I do not recommend leaflet extension for this particular group because it is just time-consuming, and for this particular subgroup of patients it will not be the solution. I would rather recommend downsizing the ring. Have you tried to downsize the annuloplasty in this particular group, which I think is a simple solution?
Dr Wierup. Yes, our current practice is to undersize in this entity.
Appendix I
Wall motion abnormalities
The sources of left ventricular wall motion data were, in order of preference, the intraoperative echocardiogram, preoperative transthoracic echocardiogram, and preoperative left ventriculogram. Five general ventricular segments were recorded
(Figure 1). The anterior segment included anterior, anteroseptal, anterolateral, and anteroapical locations. The septal segment included septal, anteroseptal, and inferoseptal locations. The inferior segment included inferior, inferior-posterior, and inferior-septal locations. The lateral segment included lateral, posterolateral, and anterolateral locations. The posterior segment included posterior, posterolateral, and inferior-posterior locations. Thus when composite locations were encountered (eg, anteroseptal), abnormalities were recorded in both anterior and septal segments.
Each location was assessed as normal or abnormal. An abnormal assessment was recorded for findings of hypokinesis, akinesis, dyskinesis, or aneurysm.
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Details of data analysis
Propensity analysis
The propensity analysis (see Methods) resulted in a logistic equation from which the probability of receiving mitral valve repair rather than replacement could be calculated for each patient. The propensity score was constructed with regard to patient outcome, and the calculation was made regardless of whether the patient actually underwent repair or replacement.
Each patient's propensity score was calculated from the sum of the values for all variables in the model multiplied by their respective logistic coefficients. The patients were then sorted according to the propensity score. Patients with similar propensity scores were well matched for all these factors. Only in the first quintile, however, was there a large, well-matched comparison group of patients. Characteristics of this quintile differed in many important ways from those of the others, particularly with respect to the complexity and consequences of the disease and the prevalence of replacement versus mitral valve repair
(Table 5).
Risk factor identification
In the analysis of risk factors, it became clear that the propensity score itself represented a gradient of mortality risk, and within quintiles an increasingly different outcome for repair and replacement. We therefore developed models for the repair and replacement groups separately (Appendix II, Table 1; Appendix II, Table 2).
We then combined these analyses, examining every interaction with repair versus replacement. This yielded a model that better fit the data than did the two separate analyses.
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26 and bootstrap resampling variable selection (so-called "bagging"). 27,28 For the latter, the data set was randomly sampled with replacement to generate a data set of the same size. This was repeated 500 times. Each data set was analyzed by automated forward stepwise variable selection. The variables entered into the final model by the directed approach relied on the frequency with which variables appeared in these 500 models. Generally, factors that appeared in 50% or more of the models were retained. The P value criterion for retention of variables in the final models with this combined variable selection approach was .1, except for the variables repair versus replacement and propensity score, which were forced into the models.
Management of missing data
The data exhibited typical sporadic missing value difficulties. Nearly every patient had missing values for at least one variable. In this setting it is better to retain all patients than to delete individuals with missing values. Therefore all variables were scrutinized with respect to the pattern of missing values. If more than 20% to 25% of values were missing, the variable was not considered in any analyses. In the remaining cases, the missing informative imputation was not possible. We therefore assumed that the values were missing at random and substituted the mean value for the remainder of the group for the missing values. In addition, we generated indicator variables for each variable with missing values; the value was 0 if the value was present and 1 if it was missing. We incorporated these indicator variables in the propensity score to distribute them appropriately, and we tested for their significance in multivariable modeling. In all cases, patients with missing values behaved with respect to outcome the same (P > .1) as those with values.
Analysis of benefit
In addition to comparing 7-year survivals, we not only simulated the 7-year survival difference between repair and replacement but also constructed complete survival curves for the patients who were predicted to fare better at 7 years with the surgical procedure other than that which they had undergone. For this, the other characteristics of each were entered into the multivariable equation
(Table 6) to generate a patient-specific survival curve and to calculate the cumulative hazard at the actual time of follow-up. The curves were averaged and compared with Kaplan-Meier estimates of actual outcome. 29 With the sum of the cumulative hazard values, the predicted number of deaths was compared with the actual number.
Appendix III
Variables considered in risk analyses
Demographic characteristics
Symptoms and clinical status
Left ventricular function
Pathophysiology of valve disease
Cardiac comorbidity
Noncardiac comorbidity
Operation
Concomitant procedures
Appendix IV
Repair versus replacement: Lines of evidence
The answer to the question, "Is repair better than replacement?" is not a simple yes or no but "depends." The lines of evidence are as follows.
). Appendix V
Who benefits?
The multiple linear regression for the difference in 7-year survival is presented in Appendix V, Table 1.
When the equation is solved for a given patient's characteristics, a positive value predicts a benefit for replacement and a negative value predicts a benefit for repair strictly on the basis of point estimates.
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Acknowledgments
We thank Karen Mrazeck for assembling and verifying the clinical data and performing the follow-up; John Hendricks, Linda DiPaola, and Maura Schnauffer for constructing the data set; and Lucinda Mitchin for expert secretarial assistance.
Footnotes
Read at the Eightieth Annual Meeting of The American Association for Thoracic Surgery, Toronto, Ontario, Canada, April 30-May 3, 2000. 
*Currently at Department of Cardiothoracic Surgery, Aarhus University Hospital, Aarhus, Denmark.
References
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P. Tozzi, D. Locca, F. Gronchi, D. Hayoz, E. Ferrari, L. K. von Segesser, and R. Hullin Active mitral ring for post-surgical remote correction of residual mitral regurgitation on the beating heart Eur J Cardiothorac Surg, February 5, 2013; (2013) ezs710v1. [Abstract] [Full Text] [PDF]
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 |
|
 R. Lorusso, S. Gelsomino, E. Vizzardi, A. D'Aloia, G. De Cicco, F. Luca, O. Parise, G. F. Gensini, P. Stefano, U. Livi, et al. Mitral valve repair or replacement for ischemic mitral regurgitation? The Italian Study on the Treatment of Ischemic Mitral Regurgitation (ISTIMIR) J. Thorac. Cardiovasc. Surg., January 1, 2013; 145(1): 128 - 139. [Abstract] [Full Text] [PDF]
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 |
|
 K. M. J. Chan, P. P. Punjabi, M. Flather, R. Wage, K. Symmonds, I. Roussin, S. Rahman-Haley, D. J. Pennell, P. J. Kilner, G. D. Dreyfus, 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, November 20, 2012; 126(21): 2502 - 2510. [Abstract] [Full Text] [PDF]
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 |
|
 L. S. Lee, M. H. Kwon, M. Cevasco, J. D. Schmitto, S. A. Mokashi, S. McGurk, L. H. Cohn, R. M. Bolman III, and F. Y. Chen Postoperative Recurrence of Mitral Regurgitation After Annuloplasty for Functional Mitral Regurgitation Ann. Thorac. Surg., October 1, 2012; 94(4): 1211 - 1217. [Abstract] [Full Text] [PDF]
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 |
|
 E. Caradonna, N. Testa, C. M. De Filippo, E. Calvo, G. Di Giannuario, P. Spatuzza, M. Rossi, and F. Alessandrini Implantation of a new mitral ring, adjustable during follow-up: a simplified technique Interact CardioVasc Thorac Surg, October 1, 2012; 15(4): 578 - 579. [Abstract] [Full Text] [PDF]
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M. Vergnat, M. M. Levack, A. S. Jassar, B. M. Jackson, M. A. Acker, Y. J. Woo, R. C. Gorman, and J. H. Gorman III The influence of saddle-shaped annuloplasty on leaflet curvature in patients with ischaemic mitral regurgitation Eur J Cardiothorac Surg, September 1, 2012; 42(3): 493 - 499. [Abstract] [Full Text] [PDF]
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M. De Bonis, D. Ferrara, M. Taramasso, M. C. Calabrese, A. Verzini, N. Buzzatti, and O. Alfieri Mitral Replacement or Repair for Functional Mitral Regurgitation in Dilated and Ischemic Cardiomyopathy: Is it Really the Same? Ann. Thorac. Surg., July 1, 2012; 94(1): 44 - 51. [Abstract] [Full Text] [PDF]
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K. Fattouch, P. Lancellotti, S. Castrovinci, G. Murana, R. Sampognaro, E. Corrado, M. Caruso, G. Speziale, S. Novo, and G. Ruvolo Papillary muscle relocation in conjunction with valve annuloplasty improve repair results in severe ischemic mitral regurgitation J. Thorac. Cardiovasc. Surg., June 1, 2012; 143(6): 1352 - 1355. [Abstract] [Full Text] [PDF]
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L. P. Perrault, A. J. Moskowitz, I. L. Kron, M. A. Acker, M. A. Miller, K. A. Horvath, V. H. Thourani, M. Argenziano, D. A. D'Alessandro, E. H. Blackstone, et al. Optimal surgical management of severe ischemic mitral regurgitation: To repair or to replace? J. Thorac. Cardiovasc. Surg., June 1, 2012; 143(6): 1396 - 1403. [Abstract] [Full Text] [PDF]
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|
|
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D. J. LaPar, D. P. Mulloy, I. K. Crosby, D. S. Lim, J. A. Kern, I. L. Kron, and G. Ailawadi Contemporary outcomes for surgical mitral valve repair: A benchmark for evaluating emerging mitral valve technology J. Thorac. Cardiovasc. Surg., April 1, 2012; 143(4_suppl): S12 - S16. [Abstract] [Full Text] [PDF]
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D. Glower, G. Ailawadi, M. Argenziano, M. Mack, A. Trento, A. Wang, D. S. Lim, W. Gray, P. Grayburn, J. Dent, et al. EVEREST II randomized clinical trial: Predictors of mitral valve replacement in de novo surgery or after the MitraClip procedure J. Thorac. Cardiovasc. Surg., April 1, 2012; 143(4_suppl): S60 - S63. [Abstract] [Full Text] [PDF]
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V. M. Wong, J. F. Wenk, Z. Zhang, G. Cheng, G. Acevedo-Bolton, M. Burger, D. A. Saloner, A. W. Wallace, J. M. Guccione, M. B. Ratcliffe, et al. The Effect of Mitral Annuloplasty Shape in Ischemic Mitral Regurgitation: A Finite Element Simulation Ann. Thorac. Surg., March 1, 2012; 93(3): 776 - 782. [Abstract] [Full Text] [PDF]
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Writing Committee Members, L. D. Hillis, P. K. Smith, J. L. Anderson, J. A. Bittl, C. R. Bridges, J. G. Byrne, J. E. Cigarroa, V. J. DiSesa, L. F. Hiratzka, et al. 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: Executive summary: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines J. Thorac. Cardiovasc. Surg., January 1, 2012; 143(1): 4 - 34. [Full Text] [PDF]
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|
|
|
|
|
P. Klein, J. Braun, E. R. Holman, M. I. M. Versteegh, H. F. Verwey, R. A. E. Dion, J. J. Bax, and R. J. M. Klautz Management of mitral regurgitation during left ventricular reconstruction for ischemic heart failure Eur J Cardiothorac Surg, January 1, 2012; 41(1): 74 - 81. [Abstract] [Full Text] [PDF]
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 |
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 L. D. Hillis, P. K. Smith, J. L. Anderson, J. A. Bittl, C. R. Bridges, J. G. Byrne, J. E. Cigarroa, V. J. DiSesa, L. F. Hiratzka, A. M. Hutter Jr, et al. Special Article: 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Anesth. Analg., January 1, 2012; 114(1): 11 - 45. [Full Text] [PDF]
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Writing Committee Members, L. D. Hillis, P. K. Smith, J. L. Anderson, J. A. Bittl, C. R. Bridges, J. G. Byrne, J. E. Cigarroa, V. J. DiSesa, L. F. Hiratzka, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Circulation, December 6, 2011; 124(23): e652 - e735. [Full Text] [PDF]
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Writing Committee Members, L. D. Hillis, P. K. Smith, J. L. Anderson, J. A. Bittl, C. R. Bridges, J. G. Byrne, J. E. Cigarroa, V. J. DiSesa, L. F. Hiratzka, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Circulation, December 6, 2011; 124(23): 2610 - 2642. [Full Text] [PDF]
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J. D. Robb, M. Minakawa, K. J. Koomalsingh, T. Shuto, A. S. Jassar, S. J. Ratcliffe, R. C. Gorman, and J. H. Gorman III Posterior leaflet augmentation improves leaflet tethering in repair of ischemic mitral regurgitation, Eur J Cardiothorac Surg, December 1, 2011; 40(6): 1501 - 1507. [Abstract] [Full Text] [PDF]
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V. Chan, M. Ruel, and T. G. Mesana Mitral Valve Replacement Is a Viable Alternative to Mitral Valve Repair for Ischemic Mitral Regurgitation: A Case-Matched Study Ann. Thorac. Surg., October 1, 2011; 92(4): 1358 - 1366. [Abstract] [Full Text] [PDF]
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M. H. Mandegar, B. Saidi, M. A. Yousefnia, F. Alaeddini, and F. Roshanali Long-term effect of papillary muscle approximation combined with ventriculoplasty on left ventricle function in patients with ischemic cardiomyopathy and functional mitral regurgitation Eur J Cardiothorac Surg, September 1, 2011; 40(3): 756 - 760. [Abstract] [Full Text] [PDF]
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S. L. Nielsen, M. Lomholt, P. Johansen, S. B. Hansen, N. T. Andersen, and J. M. Hasenkam Mitral ring annuloplasty relieves tension of the secondary but not primary chordae tendineae in the anterior mitral leaflet J. Thorac. Cardiovasc. Surg., March 1, 2011; 141(3): 732 - 737. [Abstract] [Full Text] [PDF]
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C. M. Vassileva, T. Boley, S. Markwell, and S. Hazelrigg Meta-analysis of short-term and long-term survival following repair versus replacement for ischemic mitral regurgitation Eur J Cardiothorac Surg, March 1, 2011; 39(3): 295 - 303. [Abstract] [Full Text] [PDF]
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M. O. Murphy, C. Rao, P. P. Punjabi, and T. Athanasiou In patients undergoing mitral surgery for ischaemic mitral regurgitation is it preferable to repair or replace the mitral valve? Interact CardioVasc Thorac Surg, February 1, 2011; 12(2): 218 - 227. [Abstract] [Full Text] [PDF]
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 A. V. Shpektor and E. Y. Vasilieva Chapter 43 Mechanical complications of myocardial infarction The ESC Textbook of Acute and Intensive Cardiac Care, December 1, 2010; 1(1): med-9780199584314-chapter - med-9780199584314-chapter. [Abstract] [Full Text] [PDF]
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K. Matsuzaki, M. Morita, H. Hamamoto, M. Noma, J. D. Robb, M. J. Gillespie, J. H. Gorman III, and R. C. Gorman Elimination of Ischemic Mitral Regurgitation Does Not Alter Long-Term Left Ventricular Remodeling in the Ovine Model Ann. Thorac. Surg., September 1, 2010; 90(3): 788 - 794. [Abstract] [Full Text] [PDF]
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M. A. Yousefnia, A. Dehestani, B. Saidi, F. Roshanali, M. H. Mandegar, and F. Alaeddini Papillary Muscle Repositioning in Valve Replacement for Left Ventricular Dysfunction: Ischemic Mitral Regurgitation Ann. Thorac. Surg., August 1, 2010; 90(2): 497 - 502. [Abstract] [Full Text] [PDF]
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D. J. LaPar, S. Hennessy, E. Fonner, J. A. Kern, I. L. Kron, and G. Ailawadi Does Urgent or Emergent Status Influence Choice in Mitral Valve Operations? An Analysis of Outcomes From the Virginia Cardiac Surgery Quality Initiative Ann. Thorac. Surg., July 1, 2010; 90(1): 153 - 160. [Abstract] [Full Text] [PDF]
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M. Pocar, D. Passolunghi, A. Moneta, A. Di Mauro, A. Bregasi, R. Mattioli, and F. Donatelli Baseline left ventricular function and surgical annular stiffening to predict outcome and reverse left ventricular remodeling after undersized annuloplasty for intermediate-degree ischemic mitral regurgitation J. Thorac. Cardiovasc. Surg., June 1, 2010; 139(6): 1529 - 1538. [Abstract] [Full Text] [PDF]
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|
|
|
J. F. Wenk, Z. Zhang, G. Cheng, D. Malhotra, G. Acevedo-Bolton, M. Burger, T. Suzuki, D. A. Saloner, A. W. Wallace, J. M. Guccione, et al. First Finite Element Model of the Left Ventricle With Mitral Valve: Insights Into Ischemic Mitral Regurgitation Ann. Thorac. Surg., May 1, 2010; 89(5): 1546 - 1553. [Abstract] [Full Text] [PDF]
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W. Bouma, I. C. C. van der Horst, I. J. Wijdh-den Hamer, M. E. Erasmus, F. Zijlstra, M. A. Mariani, and T. Ebels Chronic ischaemic mitral regurgitation. Current treatment results and new mechanism-based surgical approaches Eur J Cardiothorac Surg, January 1, 2010; 37(1): 170 - 185. [Abstract] [Full Text] [PDF]
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|
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M. Penicka, H. Linkova, O. Lang, R. Fojt, V. Kocka, M. Vanderheyden, and J. Bartunek Predictors of Improvement of Unrepaired Moderate Ischemic Mitral Regurgitation in Patients Undergoing Elective Isolated Coronary Artery Bypass Graft Surgery Circulation, October 13, 2009; 120(15): 1474 - 1481. [Abstract] [Full Text] [PDF]
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|
|
|
M. V. Badiwala, S. Verma, and V. Rao Surgical Management of Ischemic Mitral Regurgitation Circulation, September 29, 2009; 120(13): 1287 - 1293. [Full Text] [PDF]
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|
|
|
|
|
J. Magne, N. Girerd, M. Senechal, P. Mathieu, F. Dagenais, J. G. Dumesnil, E. Charbonneau, P. Voisine, and P. Pibarot Mitral Repair versus Replacement for Ischemic Mitral Regurgitation: Comparison of Short-Term and Long-Term Survival Circulation, September 15, 2009; 120(11_suppl_1): S104 - S111. [Abstract] [Full Text] [PDF]
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Z. Makhija and J. Desai Early and mid-term functional and survival benefits in ischaemic versus degenerative mitral valve repair using Duran flexible ring: a single surgeon series Interact CardioVasc Thorac Surg, September 1, 2009; 9(3): 471 - 475. [Abstract] [Full Text] [PDF]
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|
|
|
K. Fattouch, F. Guccione, R. Sampognaro, G. Panzarella, E. Corrado, E. Navarra, D. Calvaruso, and G. Ruvolo 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., August 1, 2009; 138(2): 278 - 285. [Abstract] [Full Text] [PDF]
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|
|
|
|
|
H. Suma, H. Tanabe, T. Uejima, T. Isomura, and T. Horii Surgical ventricular restoration combined with mitral valve procedure for endstage ischemic cardiomyopathy Eur J Cardiothorac Surg, August 1, 2009; 36(2): 280 - 285. [Abstract] [Full Text] [PDF]
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|
|
|
 |
|
 E. Agricola, A. Ielasi, M. Oppizzi, P. Faggiano, L. Ferri, A. Calabrese, E. Vizzardi, O. Alfieri, and A. Margonato Long-term prognosis of medically treated patients with functional mitral regurgitation and left ventricular dysfunction Eur J Heart Fail, June 1, 2009; 11(6): 581 - 587. [Abstract] [Full Text] [PDF]
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|
|
|
M. Flynn, R. Curtin, E. R. Nowicki, J. Rajeswaran, S. D. Flamm, E. H. Blackstone, and T. Mihaljevic Regional wall motion abnormalities and scarring in severe functional ischemic mitral regurgitation: A pilot cardiovascular magnetic resonance imaging study. J. Thorac. Cardiovasc. Surg., May 1, 2009; 137(5): 1063 - 70.e2. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L. R. Sajja, G. Mannam, B. R. S. Dandu, S. Pathuri, S. Sompalli, and A. Anjaneyulu Outcomes of Mitral Valve Repair for Chronic Ischemic Mitral Regurgitation Asian Cardiovascular and Thoracic Annals, February 1, 2009; 17(1): 29 - 34. [Abstract] [Full Text] [PDF]
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|
|
2006 WRITING COMMITTEE MEMBERS, R. O. Bonow, B. A. Carabello, K. Chatterjee, A. C. de Leon Jr, D. P. Faxon, M. D. Freed, W. H. Gaasch, B. W. Lytle, R. A. Nishimura, et al. 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons Circulation, October 7, 2008; 118(15): e523 - e661. [Full Text] [PDF]
|
|
|
|
|
|
C. A. Milano, M. A. Daneshmand, J. S. Rankin, E. Honeycutt, M. L. Williams, M. Swaminathan, L. Linblad, L. K. Shaw, D. D. Glower, and P. K. Smith Survival Prognosis and Surgical Management of Ischemic Mitral Regurgitation Ann. Thorac. Surg., September 1, 2008; 86(3): 735 - 744. [Abstract] [Full Text] [PDF]
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|
 |
|
 S. Gelsomino, R. Lorusso, C. Rostagno, S. Caciolli, G. Bille, G. De Cicco, S. Romagnoli, C. Porciani, P. Stefano, and G. F. Gensini Prognostic value of Doppler-derived mitral deceleration time on left ventricular reverse remodelling after undersized mitral annuloplasty Eur Heart J Cardiovasc Imaging, September 1, 2008; 9(5): 631 - 640. [Abstract] [Full Text] [PDF]
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|
|
G. Ailawadi, B. R. Swenson, M. E. Girotti, L. M. Gazoni, B. B. Peeler, J. A. Kern, L. M. Fedoruk, and I. L. Kron Is Mitral Valve Repair Superior to Replacement in Elderly Patients? Ann. Thorac. Surg., July 1, 2008; 86(1): 77 - 86. [Abstract] [Full Text] [PDF]
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|
|
|
|
|
T. A. Timek, D. Liang, G. T. Daughters, N. B. Ingels Jr., and D. C. Miller Effect of local annular interventions on annular and left ventricular geometry Eur J Cardiothorac Surg, June 1, 2008; 33(6): 1049 - 1054. [Abstract] [Full Text] [PDF]
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|
|
|
|
|
T. D. Crabtree, M. S. Bailey, M. R. Moon, N. Munfakh, M. K. Pasque, J. S. Lawton, N. Moazami, K. A. Aubuchon, A. S. Al-Dadah, and R. J. Damiano Jr Recurrent Mitral Regurgitation and Risk Factors for Early and Late Mortality After Mitral Valve Repair for Functional Ischemic Mitral Regurgitation Ann. Thorac. Surg., May 1, 2008; 85(5): 1537 - 1543. [Abstract] [Full Text] [PDF]
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|
|
|
A. M. Gillinov, E. H. Blackstone, E. R. Nowicki, W. Slisatkorn, G. Al-Dossari, D. R. Johnston, K. M. George, P. L. Houghtaling, B. Griffin, J. F. Sabik III, et al. Valve repair versus valve replacement for degenerative mitral valve disease J. Thorac. Cardiovasc. Surg., April 1, 2008; 135(4): 885 - 893. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Gelsomino, R. Lorusso, I. Capecchi, C. Rostagno, S. Romagnoli, G. Bille, G. De Cicco, C. Tetta, P. Stefano, and G. F. Gensini Left Ventricular Reverse Remodeling After Undersized Mitral Ring Annuloplasty in Patients With Ischemic Regurgitation Ann. Thorac. Surg., April 1, 2008; 85(4): 1319 - 1330. [Abstract] [Full Text] [PDF]
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|
R. Lorusso, S. Gelsomino, G. De Cicco, C. Beghi, C. Russo, M. De Bonis, A. Colli, and A. Sala Mitral valve surgery in emergency for severe acute regurgitation: analysis of postoperative results from a multicentre study Eur J Cardiothorac Surg, April 1, 2008; 33(4): 573 - 582. [Abstract] [Full Text] [PDF]
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|
|
|
|
|
E. Agricola, M. Oppizzi, M. Pisani, A. Meris, F. Maisano, and A. Margonato Ischemic mitral regurgitation: mechanisms and echocardiographic classification Eur Heart J Cardiovasc Imaging, March 1, 2008; 9(2): 207 - 221. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. W.M. Fedak, P. M. McCarthy, and R. O. Bonow Evolving Concepts and Technologies in Mitral Valve Repair Circulation, February 19, 2008; 117(7): 963 - 974. [Full Text] [PDF]
|
|
|
|
|
|
J. Braun, N. R. van de Veire, R. J.M. Klautz, M. I.M. Versteegh, E. R. Holman, J. J.M. Westenberg, E. Boersma, E. E. van der Wall, J. J. Bax, and R. A.E. Dion Restrictive Mitral Annuloplasty Cures Ischemic Mitral Regurgitation and Heart Failure Ann. Thorac. Surg., February 1, 2008; 85(2): 430 - 437. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. Gelsomino, R. Lorusso, G. De Cicco, I. Capecchi, C. Rostagno, S. Caciolli, S. Romagnoli, U. Da Broi, P. Stefano, and G. F. Gensini Five-year echocardiographic results of combined undersized mitral ring annuloplasty and coronary artery bypass grafting for chronic ischaemic mitral regurgitation Eur. Heart J., January 2, 2008; 29(2): 231 - 240. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. Kolh Surgical correction of ischaemic mitral regurgitation still a long way to go Eur. Heart J., January 2, 2008; 29(2): 147 - 149. [Full Text] [PDF]
|
|
|
|
|
|
P. L. DiGiorgi, F. G. Baumann, A. M. O'Leary, C. F. Schwartz, E. A. Grossi, G. H. Ribakove, S. B. Colvin, A. C. Galloway, and J. B. Grau Mitral Valve Disease Presentation and Surgical Outcome in African-American Patients Compared With White Patients Ann. Thorac. Surg., January 1, 2008; 85(1): 89 - 93. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Enriquez-Sarano, V. T. Nkomo, and H. Michelena Principles and Practice of Echocardiography in Cardiac Surgery , January 1, 2008; 3(2008): 315 - 348. [Full Text]
|
|
|
|
|
|
W. Y. Szeto, R. C. Gorman, J. H. Gorman III, and M. A. Acker Ischemic Mitral Regurgitation , January 1, 2008; 3(2008): 785 - 802. [Full Text]
|
|
|
|
|
|
J. I. Fann, N. B. Ingels Jr., and D. C. Miller Pathophysiology of Mitral Valve Disease , January 1, 2008; 3(2008): 973 - 1012. [Full Text]
|
|
|
|
|
|
P. Lancellotti, E. Donal, B. Cosyns, G. Van Camp, J.-L. Monin, E. Brochet, A. Berrebi, P. Pibarot, C. Chauvel, C. Hassager, et al. Effects of surgery on ischaemic mitral regurgitation: a prospective multicentre registry (SIMRAM registry) Eur Heart J Cardiovasc Imaging, January 1, 2008; 9(1): 26 - 30. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Di Mauro, A. M. Calafiore, M. Penco, S. Romano, G. Di Giammarco, and S. Gallina Mitral valve repair for dilated cardiomyopathy: predictive role of right ventricular dysfunction Eur. Heart J., October 2, 2007; 28(20): 2510 - 2516. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Sirivella and I. Gielchinsky Results of Coronary Bypass and Valve Operations for Mitral Valve Regurgitation Asian Cardiovascular and Thoracic Annals, October 1, 2007; 15(5): 396 - 404. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. M. Gazoni, J. A. Kern, B. R. Swenson, J. M. Dent, P. W. Smith, D. P. Mulloy, T. B. Reece, L. M. Fedoruk, T. C. Lisle, B. B. Peeler, et al. A Change in Perspective: Results for Ischemic Mitral Valve Repair Are Similar to Mitral Valve Repair for Degenerative Disease Ann. Thorac. Surg., September 1, 2007; 84(3): 750 - 758. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. Fayad, T. Modine, and H. Warembourg Ring, string, chordal cutting: All or nothing? J. Thorac. Cardiovasc. Surg., August 1, 2007; 134(2): 551 - 552. [Full Text] [PDF]
|
|
|
|
|
|
E. Votta, F. Maisano, S. F. Bolling, O. Alfieri, F. M. Montevecchi, and A. Redaelli The Geoform Disease-Specific Annuloplasty System: A Finite Element Study Ann. Thorac. Surg., July 1, 2007; 84(1): 92 - 101. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. M. Fedoruk, C. G. Tribble, J. A. Kern, B. B. Peeler, and I. L. Kron Predicting Operative Mortality After Surgery for Ischemic Cardiomyopathy Ann. Thorac. Surg., June 1, 2007; 83(6): 2029 - 2035. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
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]
|
|
|
|
|
|
G. Di Giammarco, R. Liberi, M. Giancane, C. Canosa, S. Gallina, A. Di Francesco, G. Spira, and M. Di Mauro Recurrence of functional mitral regurgitation in patients with dilated cardiomyopathy undergoing mitral valve repair: how to predict it Interact CardioVasc Thorac Surg, June 1, 2007; 6(3): 340 - 344. [Abstract] [Full Text] [PDF]
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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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A. S.Y. Chang, N. G. Smedira, C. L. Chang, M. M. Benavides, U. Myhre, J. Feng, E. H. Blackstone, and B. W. Lytle Cardiac surgery after mediastinal radiation: Extent of exposure influences outcome J. Thorac. Cardiovasc. Surg., February 1, 2007; 133(2): 404 - 413. [Abstract] [Full Text] [PDF]
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J. Shuhaiber and R. J. Anderson Meta-analysis of clinical outcomes following surgical mitral valve repair or replacement Eur J Cardiothorac Surg, February 1, 2007; 31(2): 267 - 275. [Abstract] [Full Text] [PDF]
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Authors/Task Force Members, A. Vahanian, H. Baumgartner, J. Bax, E. Butchart, R. Dion, G. Filippatos, F. Flachskampf, R. Hall, B. Iung, et al. Guidelines on the management of valvular heart disease: The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology Eur. Heart J., January 26, 2007; (2007) ehl428v1. [Full Text] [PDF]
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J. O. O'Neill, R. C. Starling, P. M. McCarthy, N. M. Albert, B. W. Lytle, J. Navia, J. B. Young, and N. Smedira The impact of left ventricular reconstruction on survival in patients with ischemic cardiomyopathy Eur J Cardiothorac Surg, November 1, 2006; 30(5): 753 - 761. [Abstract] [Full Text] [PDF]
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 S M Tuladhar and P P Punjabi Surgical reconstruction of the mitral valve Heart, October 1, 2006; 92(10): 1373 - 1377. [Abstract] [Full Text] [PDF]
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M. Gheorghiade, G. Sopko, L. De Luca, E. J. Velazquez, J. D. Parker, P. F. Binkley, Z. Sadowski, K. S. Golba, D. L. Prior, J. L. Rouleau, et al. Navigating the Crossroads of Coronary Artery Disease and Heart Failure Circulation, September 12, 2006; 114(11): 1202 - 1213. [Full Text] [PDF]
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S. Sirivella and I. Gielchinsky Clinical outcomes of surgery of mitral valve regurgitation and coronary artery bypass grafting Interact CardioVasc Thorac Surg, August 1, 2006; 5(4): 392 - 397. [Abstract] [Full Text] [PDF]
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M. G. St. John Sutton and R. C. Gorman Surgery for Asymptomatic Severe Mitral Regurgitation in the Elderly: Early Surgery or Wait and Watch? Circulation, July 25, 2006; 114(4): 258 - 260. [Full Text] [PDF]
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M. T. Spoor, A. Geltz, and S. F. Bolling Flexible Versus Nonflexible Mitral Valve Rings for Congestive Heart Failure: Differential Durability of Repair Circulation, July 4, 2006; 114(1_suppl): I-67 - I-71. [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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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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C. Athanasuleas, W. Siler, G. Buckberg, and the RESTORE Group Myocardial protection during surgical ventricular restoration Eur J Cardiothorac Surg, April 1, 2006; 29(Supplement_1): S231 - S237. [Abstract] [Full Text] [PDF]
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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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Determinants of operative mortality in valvular heart surgery. J. Thorac. Cardiovasc. Surg., March 1, 2006; 131(3): 547 - 557.
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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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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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R. De Simone, I. Wolf, S. Mottl-Link, R. Hoda, B. Mikhail, F.-U. Sack, H.-P. Meinzer, and S. Hagl A clinical study of annular geometry and dynamics in patients with ischemic mitral regurgitation: new insights into asymmetrical ring annuloplasty Eur J Cardiothorac Surg, March 1, 2006; 29(3): 355 - 361. [Full Text] [PDF]
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R. C. Gorman and J. H. Gorman III Why Should We Repair Ischemic Mitral Regurgitation? Ann. Thorac. Surg., February 1, 2006; 81(2): 785 - 785. [Full Text] [PDF]
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J. J. Pilla, A. S. Blom, J. H. Gorman III, D. J. Brockman, J. Affuso, L. M. Parish, H. Sakamoto, B. M. Jackson, M. A. Acker, and R. C. Gorman Early Postinfarction Ventricular Restraint Improves Borderzone Wall Thickening Dynamics During Remodeling Ann. Thorac. Surg., December 1, 2005; 80(6): 2257 - 2262. [Abstract] [Full Text] [PDF]
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