Two-Year Outcomes of Surgical Treatment of Severe Ischemic Mitral Regurgitation

Wednesday, November 11, 2015

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Source

Source Name: New England Journal of Medicine

Source URL: http://www.nejm.org/doi/full/10.1056/NEJMoa1512913?query=OF

Author(s)

Daniel Goldstein, Alan J. Moskowitz, Annetine C. Gelijns, Gorav Ailawadi, Michael K. Parides, Louis P. Perrault, Judy W. Hung, Pierre Voisine, Francois Dagenais, A. Marc Gillinov, Vinod Thourani, Michael Argenziano, James S. Gammie, Michael Mack, Philippe Demers, Pavan Atluri, Eric A. Rose, Karen O’Sullivan, Deborah L. Williams, Emilia Bagiella, Robert E. Michler, Richard D. Weisel, Marissa A. Miller, Nancy L. Geller, Wendy C. Taddei-Peters, Peter K. Smith, Ellen Moquete, Jessica R. Overbey, Irving L. Kron, Patrick T. O’Gara, and Michael A. Acker for the CTSN

2 year outcomes of a randomized trial of MV repair vs MV replacement for severe ischemic MR are reported. LVESVI was similar between the two groups. Recurrent moderate or severe MR was higher in the repair group (59% vs 4%). The repair group suffered higher rates of heart failure and hospital readmission. Mortality rates were not different.

Comments

Submitted by Ovidio Garcia-Villarreal on Thu, 2015-11-12 18:18

A priori, It is increasingly overwhelming evidence against MV repair in such cases. it seems that we have to prefer the use of bioprosthetic mitral replacement instead of MV repair in CIMR. The key point is to avoid the use of oral anticoagulants.It has yet to define with certainty if the survival time in these patients is really decreased. I think this argument would be of real importance to place a mitral bioprosthesis in these patients regardless of age.

Submitted by Kyriacos Kolocassides on Fri, 2015-11-13 02:57

Very interesting study. Although "we feel" that replacement with complete preservation of the sub-valvular apparatus may be as good as a repair, it is important to study it. I am concerned with figure 2, because it shows that most recurrence of regurgitation in the repair group occurred by 30 days! Fig 2 says 30% by 30 days and 45% by 24 months. So the occurrence of MR after 2 years after a "successful" repair is in fact only 15%. This completely changes in my eyes the entire publication, bearing in mind repair was better initially in survival, and still just as good further along. We need an analysis without (which excludes) the 30% of patients who had a lot of MR at 30 days in the repair group. The point is to compare successful repair versus successful replacement. We are comparing successful replacement with 70% successful repair+30% not successful repair.