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Ann Thorac Surg 1987;44:607-613
© 1987 The Society of Thoracic Surgeons

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Articles

Factors Influencing Early and Late Survival in Patients with Combined Mitral Valve Replacement and Myocardial Revascularization and in Those with Isolated Replacement

From the Department of Surgery, Montreal Heart Institute, Montreal, Que, Canada

Accepted for publication June 8, 1987.

^* Address reprint requests to Dr. Grondin, Department of Surgery, Montreal Heart Institute, 5000 Belanger St, Montreal, Que, Canada HIT 1C8

During a 5 1/2-year period, 251 patients underwent mitral valve replacement (MVR) at our institution: 76 had combined MVR and coronary artery bypass grafting (CABG), and 175 without major coronary artery disease (CAD) had isolated MVR. In-hospital mortality for MVR + CABG was 13.2% (10/76); it was 8.6% (6/70) when patients with preoperative mechanical support were excluded, 7.9% (5/63) for elective operations, and 8.2% (5/61) for nonischemic mitral disease. Overall, in-hospital mortality for isolated MVR was 6.3% (11/175); it was 4.4% (7/161) excluding patients requiring mechanical support and 3.1% (5/157) for elective operations.

Of a host of clinical characteristics in patients with MVR + CABG, few were found to influence in-hospital mortality: age greater than 60 years, degree of incapacitation (New York Heart Association Functional Class IV), previous history of myocardial infarction or congestive heart failure, cardiac enlargement (cardiothoracic index greater than 50%), and ischemic mitral disease (33.3% in-hospital mortality; p < 0.05). Of the invasive variables, only one influenced in-hospital mortality: wall motion score greater than 10 (31.6% in-hospital mortality; p < 0.01). Of the operative variables studied, the number of grafts (3 or more: 33.3% in-hospital mortality; p < 0.05), the need for mechanical support (47.4% in-hospital mortality; p < 0.0001), and emergency operation (38.5% in-hospital mortality; p < 0.005) had a significant effect on mortality. The type of mitral lesion, the type of prosthesis, the extent of CAD or the completeness of revascularization, the presence of pulmonary hypertension, and atrial fibrillation appeared to have no influence.

Survival at 6 years was 83 ± 5% for patients having MVR + CABG and 89 ± 2% for those having isolated MVR (p < 0.03). Of the following variables—ejection fraction, extent of CAD, completeness of revascularization, etiology of lesion, and wall motion score—only the last strongly influenced late survival in patients with MVR + CABG.

In summary, in-hospital mortality is higher among patients having MVR + CABG, especially if urgent operation or mechanical support is needed and multiple bypass grafts are performed. Age and cardiac enlargement also play a role. Once CAD is corrected, that is, when most— but not necessarily all—diseased arteries are bypassed, overall survival does not differ from that of patients with isolated MVR and no major CAD. The single most important variable for early and late survival in MVR + CABG appears to be wall motion score at cineventriculography.

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