The value of adding sub-valvular procedures for chronic ischemic mitral regurgitation surgery: a meta-analysis

Abstract

Background:

The most performed repair technique for the treatment of chronic ischemic mitral regurgitation in patients referred for bypass grafting remains restricted annuloplasty. However, it is associated with a high rate of failure, especially if severe tenting exists.

Objectives:

To understand if adjunctive sub-valvular mitral procedures may provide better repair performance.

Methods:

A systematic literature review identified six studies of which five fulfilled the criteria for meta-analysis. Outcomes for a total of 404 patients (214 had adjunctive sub-valvular procedures and 190 restricted annuloplasty) were meta-analyzed using random effects modeling. Heterogeneity and subgroup sensitivity analysis were assessed. Primary endpoints were: late recurrence of moderate mitral regurgitation, left ventricle remodeling and coaptation depth at follow-up. Secondary endpoints were: early mortality, mid-term survival and operative outcomes.

Results:

Sub-valvular procedure technique was associated with a significantly lower late recurrence of mitral regurgitation (Odds ratio (OR) 0.34, 95% Confidence Interval (CI) [0.18, 0.65], p=0.0009), smaller left ventricle end-systolic diameter (Weighted Mean Difference (WMD) -4.06, 95% CI [-6.10, -2.03], p=0.0001) and reduced coaptation depth (WMD -2.36, 95% CI [-5.01, -0.71], p=0.009). These findings were consistent, even in studies that included patients at high risk for repair failure (coaptation depth >10 mm and tenting area >2.5 cm²). A low degree of heterogeneity was observed. There was no difference in terms of early mortality and mid-term survival; sub-valvular technique was associated with prolonged cardiopulmonary and cross-clamp time.

Conclusions:

Adding sub-valvular procedures when repairing ischemic chronic mitral valve regurgitation may be associated with better durability, even in the case of the presence of predictors for late failure.

Perspective:

Surgical sub-valvular adjunctive procedures have to be considered in the case of the presence of echocardiographic predictors for late failure.

Keywords

mitral regurgitation mitral valve repair ischemic mitral valve statistics meta-analysis

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References

Bolling

Deeb

Brunsting

Bach

DS.

Early outcome of mitral valve reconstruction in patients with end-stage cardiomyopathy. J Thorac Cardiovas Surg 1995; 109: 676–682; discussion 682–673.

Levine

Schwammenthal

Ischemic mitral regurgitation on the threshold of a solution: from paradoxes to unifying concepts. Circulation 2005; 112: 745–758.

Acker

Parides

Perrault

et al . Mitral-valve repair versus replacement for severe ischemic mitral regurgitation. New Engl J Med 2014; 370: 23–32.

Fattouch

Castrovinci

Murana

Moscarelli

Speziale

Surgical management of moderate ischemic mitral valve regurgitation: where do we stand?

World Journal of Cardiology 2014; 6: 1218–1222.

Moher

Liberati

Tetzlaff

Altman

; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 2009; 339: b2535.

Stroup

Berlin

Morton

et al . Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 2000; 283: 2008–2012.

The Cochrane Collaboration. Cochrane handbook for systematic reviews of interventions version 5.1.0 [updated March 2011] 2011.

Wakasa

Shingu

Ooka

Katoh

Tachibana

Matsui

Surgical strategy for ischemic mitral regurgitation adopting subvalvular and ventricular procedures. Ann Thorac Cardiovasc Surg 2015; 21: 370–377.

Calafiore

Refaie

Iaco

et al . Chordal cutting in ischemic mitral regurgitation: a propensity-matched study. J Thorac Cardiovasc Surg 2014; 148: 41–46.

10.

Fattouch

Lancellotti

Castrovinci

et al . Papillary muscle relocation in conjunction with valve annuloplasty improve repair results in severe ischemic mitral regurgitation. J Thorac Cardiovasc Surg 2012; 143: 1352–1355.

11.

Langer

Kunihara

Hell

et al . Ring+string: successful repair technique for ischemic mitral regurgitation with severe leaflet tethering. Circulation 2009; 120: S85–91.

12.

Borger

Murphy

Alam

et al . Initial results of the chordal-cutting operation for ischemic mitral regurgitation. J Thorac Cardiovasc Surg 2007; 133: 1483–1492.

13.

Manabe

Shimokawa

Fukui

Tabata

Takanashi

Impact of papillary muscle approximation on mitral valve configuration in the surgical correction of ischemic mitral regurgitation. Thorac Cardiov Surg 2012; 60: 269–274.

14.

Smith

Puskas

Ascheim

et al . Surgical treatment of moderate ischemic mitral regurgitation. New Engl J Med 2014; 371: 2178–2188.

15.

Moscarelli

Punjabi

. Predictors of recurrent chronic ischemic mitral regurgitation after mitral valve repair surgery. In: Fattouch

Lancellotti

Angelini

. eds. Secondary mitral valve regurgitation. Springer; 2015: 185–191.

16.

Bertrand

Gutermann

Smeets

et al . Functional impact of transmitral gradients at rest and during exercise after restrictive annuloplasty for ischemic mitral regurgitation. J Thorac Cardiovasc Surg 2014; 148: 183–187.