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Ann Thorac Surg 2009;87:1721-1727. doi:10.1016/j.athoracsur.2009.03.066
© 2009 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

Repair of Ischemic Mitral Regurgitation: Comparison Between Flexible and Rigid Annuloplasty Rings

Shuli Silberman, MDa,*, Marc W. Klutstein, MDb, Tsipora Sabag, MDa, Avraham Oren, MDc, Daniel Fink, MDa, Ofer Merin, MDa, Daniel Bitran, MDa

a Department of Cardiothoracic Surgery, Shaare Zedek Medical Center, Jerusalem, Israel
b Department of Cardiology, Shaare Zedek Medical Center, Jerusalem, Israel
c Center for Clinical Quality and Safety, Hadassah Medical Center, Jerusalem, Israel

Accepted for publication March 25, 2009.

* Address correspondence to Dr Silberman, Department of Cardiothoracic Surgery, Shaare Zedek Medical Center, PO Box 3235, Jerusalem, 91031, Israel (Email: ssilberman{at}szmc.org.il).

Presented at the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009.


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Discussion
 References
 
Background: The surgical treatment of ischemic mitral regurgitation (MR) usually involves implantation of an annuloplasty ring. We compared results of mitral valve repair using a flexible or a rigid annuloplasty ring in patients with ischemic MR undergoing coronary artery bypass graft surgery.

Methods: There were 169 patients. A flexible ring was implanted in 117 and a rigid ring in 52. Age and clinical profile, degree of left ventricular dysfunction, and degree of MR (mean 3.2) were similar between groups.

Results: Operative mortality was 9% in each group. Follow-up (58 ± 30 months for flexible group and 14 ± 7 months for rigid group) was available for 91%. For the flexible and rigid ring groups, respectively, mean New York Heart Association functional class was 1.9 and 1.6, with 33% and 14% in classes III to IV (p = 0.03); mean MR grade was 1.25 and 0.7 (p = 0.006). There was no difference in left ventricle function or dimensions. At follow-up, 29 patients (34%) in the flexible group had residual MR of moderate degree or greater compared with 6 (15%) in the rigid group (p = 0.03). Mean tricuspid incompetence gradient was 39 and 34 mm Hg (p = nonsignificant); however, the degree of reduction was greater in the rigid group (p = 0.001). Late mortality was observed in 32 patients, all in the flexible group.

Conclusions: Clinical and hemodynamic results are better with rigid mitral annuloplasty rings compared with flexible rings. That result may be due to ring design, which dictates not only the annular diameter but also annular configuration. Longer follow-up is needed to determine differences in survival.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Discussion
 References
 
Ischemic mitral regurgitation (MR), by definition, is MR secondary to myocardial damage with left ventricular remodeling and absence of structural deformation of the mitral valve. The presence of ischemic MR has a negative prognostic effect on patient survival [1–3]. Although the pathology is that of the left ventricle (LV) [4, 5], the mainstay of surgical correction is performing a restrictive annuloplasty, usually with an annuloplasty ring [5, 6]. There are various rings on the market, including flexible, rigid, partial (posterior), or whole rings. The outcome of surgical repair may be altered by the ring type, and hence may have prognostic implications. We compared results of mitral valve repair using a flexible or a rigid annuloplasty ring in patients with ischemic MR undergoing coronary artery bypass graft surgery (CABG) and mitral valve repair. Endpoints included postoperative MR, reduction of tricuspid incompetence (TI) gradient, and New York Heart Association (NYHA) class.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Discussion
 References
 
Patients
Between 1995 and 2006, 169 patients referred for coronary artery bypass underwent CABG with concomitant mitral valve repair in our department. A flexible ring (Duran Ring; Medtronic, Minneapolis, MN) was implanted in 117 and a rigid ring (Physio; Edwards Lifesciences, Irvine, CA) in 52. Indication for mitral valve annuloplasty was the presence of MR of moderate or greater degree, and only patients with ischemic etiology of MR are included in this study. Age and clinical profile, degree of left ventricular dysfunction and degree of MR (mean 3.2) were similar between both groups (Table 1). The mean additive European System for Cardiac Operative Risk Evaluation (EuroSCORE) [7] was 8.9 for both groups, with a predicted mortality of 18% by logistic calculation. Our Institutional Ethics Committee approved the study, and waived the need to obtain patient consent.


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  		Table 1 Preoperative Data
 
Surgical Technique
All patients were connected to cardiopulmonary bypass with ascending aorta and right atrial or bicaval cannulation. Patients were either actively cooled or temperature was allowed to drift. Myocardial protection was achieved using cold or tepid blood cardioplegia delivered antegrade or retrograde, or both. Coronary bypass was performed to all major territories as long as there appeared to be viable myocardium and the coronary arteries were not too small or too heavily calcified. Viability studies were not performed on a routine basis. Coronary bypass grafting was performed initially, after which the mitral valve was exposed through a left atriotomy, and an annuloplasty ring was implanted. Throughout the initial period (1996 to 2004) only flexible rings were implanted because of availability, after which both ring types were available, and choice of ring was at the surgeon's discretion. In all patients, an annuloplasty was the sole procedure performed for the mitral valve and the surgical technique did not vary over the years. Concomitant procedures included aortic valve replacement in 7 patients, tricuspid valve annuloplasty in 20, resection of left ventricular aneurysm in 7, and "other" in 3.

Echocardiography
Echocardiography data presented are from transthoracic examinations. Transesophageal echocardiograms were performed routinely during surgery, but the data were not used in our analysis. Echocardiograms were analyzed by certified experienced cardiologists. The following measurements were prospectively collected: left atrial size, left ventricular end-systolic diameter (LVESD) and end-diastolic diameter (LVEDD) in parasternal long axis, global LV function, and regional wall motion. The method of grading of MR included regurgitant jet area by color Doppler, diameter of the vena contracta, quantitative assessment by the proximal isovelocity surface area method, and the presence of reverse flow in the pulmonic veins [8]. The severity of tricuspid regurgitation was assessed by visual estimation of the jet area. The TI gradient was measured to evaluate the pulmonary arterial pressure.

Data and Follow-Up
Patient data were collected on the standard computerized Society of Thoracic Surgeons database (Summit Vista for Windows, Version 1.97, Summit Medical Systems, Europe). Collected data included demographic, preoperative, operative, and early postoperative data. This information was collected during hospitalization. Follow-up data were obtained from outpatient clinic, echocardiography laboratory, contact with family physician, and telephone interviews. For patients for whom follow-up was unavailable, the ministry of interior was contacted to establish whether the patient was alive, so that follow-up for survival was 100% complete. Echocardiograms used for comparison between the two groups were those performed early (discharge to 1 month) and at 6 to 12 months after surgery.

Statistical Analysis
Data were imported and analyzed using JMP software (SAS Institute, Cary, NC). Continuous variables were compared using the nonparametric Wilcoxon test and are presented as mean ± SD. Nominal and categorical values were compared using the {chi}2 likelihood ratio or Fisher's exact tests. Univariate and multivariate Cox proportional hazard functions were used to determine predictors for late mortality. Linear regression was used to compare the degree of MR as a function of postoperative interval. This was graphically presented using a smoothing spline with lambda = 5.443. Predictors for outcomes found to be of statistical significance by univariate analysis were subject to stepwise multivariate logistic regression to determine predictors for operative mortality and postoperative MR.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Discussion
 References
 
Preoperative clinical and echocardiographic data were similar between the two groups (Table 1). Surgical data are presented in Table 2. Patients in the rigid ring group received slightly more bypass grafts (p = 0.03). In 10 patients, no bypass grafts were implanted for the following reasons: prior angioplasty with patent arteries in 4, previous CABG with patent grafts in 4, and large LV scar or aneurysm in 3. Ring size was 25.7 ± 1 mm in the flexible group and 26.1 ± 0.6 mm in the rigid group. Although clinically similar, this was found to be statistically significant (p = 0.002), possibly because labeled sizes are exclusive: one ring type is labeled in only odd numbers, while the other is labeled in only even numbered sizes. Intraoperative transesophageal echocardiogram showed good function of the mitral valve (MR grade 0 to 1) after repair in all patients.


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  		Table 2 Surgical Data
 
Overall operative mortality was 9%, 10 patients (9%) in the flexible group and 5 (9%) in the rigid group (p = nonsignificant). Causes of death were cardiac in 4 patients, sepsis in 8, and stroke in 3. Predictors for operative mortality by univariate analysis were age, NYHA functional class renal failure, and peripheral vascular disease; however, by multivariate analysis, only renal failure (p = 0.02) and peripheral vascular disease (p = 0.004) were predictive for mortality.

Follow-up was available in 140 patients (91% of operative survivors). For the flexible and rigid groups, respectively, follow-up was available in 100 (93%) and 40 (85%; p = nonsignificant), and late echocardiogram in 86 (80%) and 39 (83%). Mean follow-up was 58 ± 30 months (median, 60; range, 8 to 110) in the flexible group and 14 ± 7 months (median, 15; range, 3 to 26) in the rigid group. Thirty-two patients (30%) in the flexible group died during follow-up at 36 ± 30 months after surgery. Of these, 9 (28%) were within the first year, and 14 (44%) were within the first 2 years. By Kaplan-Meier estimates 1-, 3-, and 5-year survival was 84%, 79%, and 75%, respectively, for the flexible group. At time of follow-up, there were no deaths in the rigid group (p = 0.03; Fig 1). By multivariate Cox proportional hazard, age (p = 0.002) and ring type (p = 0.008) were found to be predictors for late mortality (Table 3).


Figure 1
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  		Fig 1. Kaplan-Meier survival estimates. Number of patients at risk are written along the x-axis.

 

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  		Table 3 Predictors of Late Mortality
 
In both groups, there was a similar improvement in LV dimensions; however, overall systolic function did not improve. For the flexible and rigid groups, respectively, postoperative LVESD was 4.02 ± 0.8 cm and 3.91 ± 1.0 cm, and LVEDD was 5.43 ± 0.7 cm and 5.33 ± 0.7 cm (p = nonsignificant). Both groups showed improvement in mean NYHA class, although a larger number of patients remained in NYHA class III and IV in the flexible group (23 of 67 [34%] versus 5 of 40 [13%]; p = 0.03). Improvement in MR (Fig 2) was significantly better in the rigid group (p = 0.006), with MR grade 1.25 ± 1 in the flexible group and 0.7 ± 1 in the rigid group (p = 0.01). The development of recurrent MR is represented in Figure 3. Most cases of recurrence occurred by 6 to 12 months, after which the repair seems to stabilize. Overall, 35% of patients with a flexible ring remained with moderate or greater MR, as opposed to only 15% in the rigid group. There were no cases with resultant mitral stenosis in either group. The reduction of TI gradient was also significantly better in the rigid group (p = 0.001; Fig 4). Ring size did not have any effect on development of late MR or on TI gradient. By multivariate analysis, predictors for late MR were preoperative LVESD and ring type (Table 4). Concomitant procedures had no effect on outcomes.


Figure 2
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  		Fig 2. Change in grade of mitral regurgitation (MR) according to preoperative and postoperative (6 to 12 months) echocardiograms.

 

Figure 3
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  		Fig 3. Smoothing spline fit represents the development of recurrent mitral regurgitation (MR) as a function of months after surgery.

 

Figure 4
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  		Fig 4. Change in tricuspid incompetence (TI) gradient according to preoperative and postoperative (6 to 12 months) echocardiograms.

 

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  		Table 4 Predictors of Residual Mitral Regurgitation (MR)
 
Effect of Reverse Remodeling
At time of follow-up, reduction in LVESD of more than 5% occurred in 46% of patients in the flexible group compared with 53% in the rigid group (p = nonsignificant). By univariate analysis, this reduction in LV dimensions was associated with a greater reduction in TI gradient after surgery (p = 0.03). Any greater reduction in LV systolic diameter had no further effect on TI gradient. The effect of change in LV diastolic diameter had a similar effect, although did not reach statistical significance. We found no correlation between reduction in LV diameter to the presence of late MR. By stepwise logistic regression, reverse remodeling was not associated with late MR or reduction in TI gradient. We found no difference in survival between patients with or without reverse remodeling.

Timing of Surgery
Eighteen patients were operated on within 1 week of admission for MI. No cases were due to papillary muscle rupture. One patient died of stroke. Early surgery was not associated with operative mortality, nor was it associated with late MR.

Effect of Atrial Fibrillation
Chronic atrial fibrillation was present in 28 patients. We found no correlation between the presence of atrial fibrillation and postsurgical MR or TI gradient.


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Discussion
 References
 
The importance of achieving a good repair of MR during surgery for coronary disease has aroused much debate in the literature. There is agreement that severe MR should be addressed [9, 10]. With regard to moderate MR, there are no hard data supporting improved survival with repair. It has been shown that in patients undergoing CABG only, moderate MR has a negative impact on survival [11, 12]. Therefore, some investigators recommend a mitral procedure at the time of CABG as MR does not reliably resolve after CABG alone and is associated with reduced survival [13, 14]. Others do not show a survival benefit with concomitant mitral annuloplasty in patients with moderate MR undergoing CABG [10, 12, 15–18]. These studies are retrospective, and have shown no increase in operative risk with a concomitant mitral procedure [15, 16]. Many of the patients in these series who did undergo a mitral procedure had more diffuse coronary artery disease, more severe LV dysfunction, and a greater degree of MR than those who did not have a mitral repair. Yet the results were similar, suggesting that mitral repair did offer some advantage to a "sicker" group of patients. These data support the notion that mitral valve repair is advantageous to patients with ischemic MR undergoing CABG, including those with only moderate MR. That is especially true for patients with reduced LV function [19].

While there is active debate in the literature whether mitral valve repair will affect survival, there are few data regarding the importance of residual or recurrent ischemic MR after surgical correction. Hausmann and colleagues [20] found reduced survival among patients undergoing CABG with concomitant mitral repair who remained with MR grade greater than 1. However, they did not implant annuloplasty rings; therefore, it is difficult to project their results to current methods. Failure of a good initial result could be attributed to ongoing remodeling of the left ventricle [21]. In this case, the type of ring may have an impact on the results. McGee and coworkers [22] found that recurrent MR is usually evident by 6 months after surgery, after which the MR stabilizes. We too found that almost all failures are apparent by 6 months. In the McGee study [22], the researchers did not see any effect of annuloplasty type on survival, although they could not preclude any survival effect of other annuloplasty techniques. Since MR is a predictor for reduced survival [1–3, 13, 14], we might assume that improving surgical technique and achieving a better repair should have a positive impact on survival.

Braun and associates [23] found that preoperative LVEDD of 65 mm or less or LVESD of 51 mm or less were predictive for reverse LV remodeling, and this conferred a survival advantage [24]. We could not demonstrate any direct influence of ring type on reverse remodeling nor could we correlate between reverse remodeling and survival.

In our study, we have shown a hemodynamic advantage to performing mitral annuloplasty with rigid rings as opposed to flexible rings. Overall, reduction in the degree of MR was observed with both ring types, but there was a more pronounced reduction with the rigid rings. There was also a decreased incidence of recurrent MR in the rigid group. In addition, the reduction of TI gradient was apparent in the rigid group and almost absent in the flexible group. We believe these results to be due to ring design. Although both rings determine annular size, the rigid ring also dictates annular shape, with emphasis on anteroposterior to lateral diameter ratio. Moreover, the rigid rings implanted in our series were slightly larger than the flexible rings, lending further support to the advantage of ring design. In the long run, these differences may translate to better survival.

The best way to resolve the issue of whether to repair the valve, and by which method to perform the repair, is by conducting a prospective randomized study, with lengthy follow-up enabling detection of survival differences. This study may be difficult to conduct as ring designs continue to evolve, so that by the time any significant results are available, they may be irrelevant. Disappointment with nonrepair coupled with increased comfort in performing annuloplasty in patients with ischemic MR has led us to repair ischemic MR of moderate or greater degree at the time of CABG. Exceptions are patients with friable tissue, in whom difficult exposure of the valve may lead to excessive tissue trauma. In our minds, it is not any more a question of whether or not to repair the valve. Rather, it is how to improve the quality of the repair.

The main limitations of this study include its retrospective nature, as well as the temporal difference in usage of the two ring types. Surgical technique, however, did not vary, so that we do not believe these had any effect on results. Another limitation is the recording of echocardiography data. More detailed information, such as coaptation height, tenting area, tethering height, sphericity index, and so forth, may shed better insight. Because these data were not routinely recorded in the past, and digital data storage was available only recently, retrieval of this information was difficult. Finally, the follow-up period may be too short to detect true survival differences.

In conclusion, both flexible and rigid annuloplasty rings enable good results for repair of ischemic MR. However, there are some differences in favor of using rigid rings, the most prominent being a more stable repair with less late failure.


   Discussion
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Discussion
References
 
DR EDWARD D. VERRIER (Seattle, WA): This is an interesting evolution. I remember 20 years ago there was all of the excitement about flexible rings being much more physiologic than putting this rigid ring in, and maybe we have come full circle. The difficulty, of course, here is that functional MR, almost like the last presentation, there is so much judgment that goes into revascularization alone and the severity of the MR, whether there is underlying pathology, and we are hurt here a little bit because it is a concomitant series where the flexible is really the early phases of it, and there is a learning curve that we have all gone through with ischemic MR. So whether this reflects the learning curve of your unit and the ability to make good decisions in this complex group of patients is a little bit difficult rather than it simply being the ring. Having said that, though, I am hoping that we can have some further good discussion.

DR ROBERT A. DION (Genk, Belgium): As you may know, we have published our series of ischemic mitral regurgitation in a few journals, and one of the endpoints after surgery was the length of coaptation. For us, a length of coaptation of 8 mm was absolutely mandatory to avoid the recurrence of mitral regurgitation. Did you measure the length of coaptation after surgery? After surgery, we measure not only the absence of mitral regurgitation but we measure also the gradient and the length of coaptation. Did you measure the length of coaptation, did you compare it between flexible and rigid rings, and do you have a clue, a technical reason, for the difference in results?

DR SILBERMAN: I was actually expecting this question from someone. We did look at our echoes to try to look at the coaptation distance, tethering height and so on. Unfortunately, in the early experience, all the echoes were recorded on tape and only recently do we have digital recordings that could be brought up again and looked at. We did not have full information on this, so I don't have an answer to that question. I am sorry.

DR DION: Thank you. What you will find has been described in the results of Steve Bolling's series, and he has abandoned using a flexible ring and he went back to a rigid ring. So I think your study is certainly very well done. Thank you.

DR EDWARD B. SAVAGE (St. Louis, MO): First, a quick comment. I like the term ischemia-induced mitral regurgitation, because the mitral valve degenerates, it has changes due to rheumatic disease, but it doesn't become ischemic.

I have a few brief questions for you. First of all, related to Dr Verrier's comment, do you have the ring sizes? I know each of these was measured for a certain size ring, and do you have the sizes for comparison? In other words, did you use a smaller ring size as time went on, because I didn't see ring size in your data. The second is, what type of rigid ring are you using? Are you using the special "ischemic" ring or are you using a symmetrical ring? And the third question is, what implication do you think your results have relative to the paper that was published by the Cleveland Clinic a couple of years ago with a 20% or 30% failure rate after repair of ischemia-induced mitral regurgitation?

DR SILBERMAN: I did show a slide with the ring sizes. They were quite similar. We were undersizing from the beginning. I could not get any statistical comparison between the sizes. I am not sure if it is because of the labeling of the rings, even numbers versus odd numbers, but the mean sizes were 25.7 and 26.1—I don't remember the exact number.

DR SAVAGE: But very close?

DR SILBERMAN: They were very close. Anyway, we did look at it and we got some funny statistical evaluation of it. We were using complete flexible rings, not bands, and just a regular rigid ring, not any special dedicated ring for ischemia-induced MR. And, sorry, the last question?

DR SAVAGE: Have you looked back at that series from the Cleveland Clinic a couple of years ago where they had such a high failure rate of 20% to 30%?

DR SILBERMAN: Are you talking about Dr McGee's paper using, I think, pericardial strips, posterior bands?

DR SAVAGE: No. They looked at all their repair experience for ischemia-induced mitral regurgitation. I am sorry if you are not familiar with it. But in that paper, I don't remember if they used rigid rings or flexible rings and what the breakdown was, and I would be curious to know, because if they used a lot of flexible rings as opposed to rigid, you may have basically told us why their failure rate was so high and that we can continue to go on and do simple annuloplasty in many of these cases.

DR SILBERMAN: Sorry, I don't think I can compare.

DR SAVAGE: Thank you.

DR HAROLD G. ROBERTS (Plantation, FL): I gathered from your talk that you only did pure annuloplasty, no other adjunctive maneuvers. I also noticed that both the flexible and the rigid series often had trace or mild residual MR, although much less so in the rigid. My question to you is, do you now use any additional maneuvers such as closing the indentation between P2 and P3 and a posteromedial commissuroplasty? These kind of things can give you absolutely zero MR when you come out of the operating room. I believe that is really imperative, since these types of repairs, MR secondary to annular dilatation, have a tendency to degrade with time.

DR SILBERMAN: Well, actually we were happy with our results in the operating room, and we were happy with our results within the first month after surgery. What I presented was the later follow-up data, in other words, around 6 months, where we found the failure rate. Patients did not leave the operating room with moderate MR or greater. If it failed, we would do something about it.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Discussion
 References
 

  1. Grigioni F, Enriquez-Sarano M, Zehr KJ, Bailey KR, Tajik AJ. Ischemic mitral regurgitation: long-term outcome and prognostic implications with quantitative Doppler assessment Circulation 2001;103:1759-1764.[Abstract/Free Full Text]
  2. Bursi F, Enriquez-Sarano M, Nkomo VT, et al. Heart failure and death after myocardial infarction in the community: the emerging role of mitral regurgitation Circulation 2005;111:295-301.[Abstract/Free Full Text]
  3. Lamas GA, Mitchell GF, Flaker GC, et al. Clinical significance of mitral regurgitation after acute myocardial infarction Circulation 1997;96:827-833.[Abstract/Free Full Text]
  4. Levine RA, Schwammental E. Ischemic mitral regurgitation on the threshold of a solution: From paradoxes to unifying concepts Circulation 2005;112:745-758.[Free Full Text]
  5. Bach DS, Bolling SF. Early improvement in congestive heart failure after correction of secondary mitral regurgitation in end-stage cardiomyopathy Am Heart J 1995;129:1165-1170.[Medline]
  6. Bolling SF, Deeb GM, Brunsting LA, Bach DS. Early outcome of mitral valve reconstruction in patients with end-stage cardiomyopathy J Thorac Cardiovasc Surg 1995;109:676-683.[Abstract/Free Full Text]
  7. Roques F, Nashef SAM, Michel P, et al. Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19030 patients Eur J Cardiothorac Surg 1999;15:816-823.[Abstract/Free Full Text]
  8. Zoghbi WA, Enriquez-Sarano M, Foster E, et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography J Am Soc Echocardiogr 2003;16:777-802.[Medline]
  9. Bonow RO, Carabello BA, Chatterjee K, et al. 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): developed in collaboration with the Society of Cardiovascular Anesthesiologists; endorsed by the Society for Cardiovascular Angiography and Intervention and the Society of Thoracic Surgeons. Circulation 2006;114:e84-e231.[Free Full Text]
  10. Kang DH, Kim MJ, Kang SJ, et al. Mitral valve repair versus revascularization alone in the treatment of ischemic mitral regurgitation Circulation 2006;114:I499-I503.[Medline]
  11. Di Mauro M, Di Giammarco G, Vitolla G, et al. Impact of no-to-moderate mitral regurgitation on late results after isolated coronary artery bypass grafting in patients with ischemic cardiomyopathy Ann Thorac Surg 2006;81:2128-2134.[Abstract/Free Full Text]
  12. Grossi EA, Crooke GA, DiGiorgi PL, et al. Impact of moderate functional mitral insufficiency in patients undergoing surgical revascularization Circulation 2006;114:I573-I576.[Medline]
  13. Lam BK, Gillinov AM, Blackstone EH, et al. Importance of moderate mitral regurgitation Ann Thorac Surg 2005;79:462-470.[Abstract/Free Full Text]
  14. Prifti E, Bonacchi M, Frati G, Leacche GGM, Proietti P, Babatasi G. Should mild-to-moderate and moderate ischemic mitral regurgitation be corrected in patients with impaired left ventricular function undergoing simultaneous coronary revascularization? J Cardiac Surg 2007;16:473-483.
  15. Diodato MD, Moon MR, Pasque MK, et al. Repair of ischemic mitral regurgitation does not increase mortality or improve long-term survival in patients undergoing coronary artery revascularization: a propensity analysis Ann Thorac Surg 2004;78:794-799.[Abstract/Free Full Text]
  16. Wong DR, Agnihotri AK, Hung JW, et al. Long-term survival after surgical revascularization for moderate ischemic mitral regurgitation Ann Thorac Surg 2005;80:570-577.[Abstract/Free Full Text]
  17. Wu AH, Aaronson KD, Bolling SF, Pagani FD, Welch K, Koelling TM. Impact of mitral valve annuloplasty on mortality risk in patients with mitral regurgitation and left ventricular systolic dysfunction J Am Coll Cardiol 2005;45:381-387.[Abstract/Free Full Text]
  18. Mihaljevic T, Lam BK, Rajeswaran J, et al. Impact of mitral valve annuloplasty combined with revascularization in patients with functional ischemic mitral regurgitation J Am Coll Cardiol 2007;49:2191-2201.[Abstract/Free Full Text]
  19. Calafiore AM, Mazzei V, Iaco AL, et al. Impact of ischemic mitral regurgitation on long-term outcome of patients with ejection fraction above 0.30 undergoing first isolated myocardial revascularization Ann Thorac Surg 2008;86:458-465.[Abstract/Free Full Text]
  20. Hausman H, Siniawski H, Hetzer R. Mitral valve reconstruction and replacement for ischemic mitral insufficiency: seven years follow-up J Heart Valve Dis 1999;8:536-542.[Medline]
  21. Hung J, Papakostas L, Tahta SA, et al. Mechanism of recurrent ischemic mitral regurgitation after annuloplasty: continued LV remodeling as a moving target Circulation 2004;110:II85-II90.[Medline]
  22. McGee EC, Gillinov AM, Blackstone EH, et al. Recurrent mitral regurgitation after annuloplasty for functional ischemic mitral regurgitation J Thorac Cardiovasc Surg 2004;128:916-924.[Abstract/Free Full Text]
  23. Braun J, Bax JJ, Versteegh MIM, et al. Preoperative left ventricular dimensions predict reverse remodeling following restrictive mitral annuloplasty in ischemic mitral regurgitation Eur J Cardiothorac Surg 2005;27:847-853.[Abstract/Free Full Text]
  24. Braun J, van de Veire NR, Klautz RJM, et al. Restrictive mitral annuloplasty cures ischemic mitral regurgitation and heart failure Ann Thorac Surg 2008;85:430-437.[Abstract/Free Full Text]



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