Abstract： Objective To evaluate the effect of a surgical method for treating mild- to moderate-ischemic mitral regurgitation（IMR） using a self-designed device during off-pump coronary artery bypass grafting（OPCAB）. Methods From September 2009 to August 2011, six patients（4 males, 2 females； age was 52-73 years） with mild- to moderate-IMR underwent OPCAB and concomitant mitral valvuloplasty using a self-designed device in Beijing An Zhen Hospital. Their degree of IMR, anteroposterior diameter of mitral annulus, left ventricular long-axis diameter, left ventricular short-axis diameter and left ventricular spherical index（left ventricular short-axis diameter/left ventricular long -axis diameter）were measured using transesophageal Doppler echocardiography before and after mitral valvuloplasty. Their mean aorta pressure, mean pulmonary artery pressure and central venous pressure were also measured via Swan-Ganz catheter before and after mitral valvuloplasty. Perioperative cardiac function indexes were compared. Results There was no in-hospital death. IMR of all patients disappeared postoperatively. After mitral valvuloplasty their anteroposterior diameter of mitral annulus（3.43±0.08 cm vs.3.68±0.08 cm；t=5.430, P=0.001）, left ventricular short-axis diameter（4.80±0.21 cm vs.5.53±0.11 cm；t=7.530, P=0.001）and left ventricular spherical index（0.64±0.02 vs.0.74±0.01；t=11.110, P=0.002）significantly decreased than those before mitral valvuloplasty . But their left ventricular long-axis diameter and hemodynamic indexes did not change significantly after mitral valvuloplasty. All the six patients were followed up at the out-patient department 3 months postoperatively without autonomous symptoms. Their heart function improved to I class（New York Heart Association）. Echocardiography showed 4 patients without IMR and 2 patients with trace of minimalIMR. Conclusion Off-pump surgical therapy for mild- to moderate- IMR during OPCAB can help the patients reverseremodeling of the left ventricle, avoid the risks of cardiopulmonary bypass and improve cardiac function with good short-term effects. This method may be a good choice for treating patients with IMR.
ObjectiveTo evaluate clinical outcomes of mitral valve replacement (MVR) combined with coronary artery bypass grafting (CABG) compared with CABG alone for patients with coronary artery disease and moderate ischemic mitral regurgitation (IMR). MethodsA systematic literature search for studies which were published from January 1990 to August 2013 from PubMed, Cochrane Library, China Academic Journals Full-text Database, Wanfang Data, and VIP Journal Database and compared CABG+MVR and CABG alone for IMR patients was performed. Quality of randomized controlled trials was assessed by Jada scale. Quality of case control studies was assessed by Newcastle-Ottawa Scale (NOS). RevMan 5.0 was used for meta-analysis. ResultsSix clinical trials including 2 randomized controlled trials and 4 case control studies were included in this study. Jadad scale for both 2 randomized controlled trials was 5 points and NOS for all the 4 case controlled studies was 8 points. Meta-analysis showed that there was no statistical difference in early postoperative mortality between the 2 groups[randomized controlled trials:RR=1.69, 95% CI (0.28, 10.10), P=0.57;case controlled studies:OR=0.48, 95% CI (0.21, 1.13), P=0.09]. There was no statistical difference in 1-year survival rate between the 2 groups[randomized controlled trials:RR=1.00, 95% CI (0.93, 1.08), P=0.92;case controlled studies:OR=1.72, 95% CI (0.60, 4.95), P=0.32]. There was no statistical difference in 5-year survival rate between the 2 groups[OR=1.12, 95% CI (0.68, 1.83), P=0.66]. LVEF of CABG+MVR patients was significantly higher than that of CABG alone patients[MD=1.38, 95% CI (0.17, 2.59), P=0.03]. Postoperative New York Heart Association (NYHA) class of CABG+MVR patients was significantly better than that of CABG alone patients[MD=-0.85, 95% CI (-1.14, -0.56), P < 0.01]. ConclusionCompared with CABG alone, MVR combined with CABG cannot significantly increase postoperative survival rate of the patients, but can improve postoperative heart function recovery and quality of life.
ObjectiveTo summarize the clinical experience in the treatment of Carpentier's type Ⅲb ischemic mitral regurgitation through the mitral valve repair versus mitral valve replacement, and to evaluate the early and midlong term effects. MethodsWe retrospectively analyzed the clinical data of 308 consecutive patients with type Ⅲb ischemic mitral regurgitation undergoing coronary artery bypass grafting (CABG) with mitral valve repair (a repair group, n=172) or with mitral valve replacement (a replacement group, n=136) in our hospital between January 2000 and March 2014. Among the 308 patients, 215 were males and 93 were females with mean age of 62.7±11.5 years(ranged 30-78 years). In the repair group, 170 patients underwent restrictive mitral annuloplasty (128 patients with total ring, 42 patients with C ring), and 2 patients underwent commissural constriction. In the replacement group, 11 patients underwent mechanical valve prosthesis and 125 patients underwent biological valve prosthesis. ResultsThe time of total aortic cross-clamp was 81.9±21.5 min. The time of total extracorporeal circulation was 122.0±31.3 min. Six patients died during the perioperative period. No significant differences were observed between the two groups in general information (P>0.05). There were no significant differences between the two groups in aortic cross-clamp time, total extracorporeal circulation time, numbers of bypass grafts and the usage rate of left internal mammary artery. The early result after the surgery showed that the incidence rates of low cardiac output and ventricular arrhythmia were significantly higher in the replacement group compared with those in the repair group. The patients were followed up for 1-85 months. No significant difference was revealed in the mid-long term survival rate between the two groups. The severity of mitral regurgitation and the rate of redo mitral valve replacement were significantly lower in the replacement group compared with those in the repair group (P<0.05). ConclusionThe early-term curative effect of valve repair is better than valve replacement for the treatment of Carpentier's type Ⅲb ischemic mitral regurgitation. In mid-long term, Chordal-sparing mitral valve replacement remains a low incidence of valve-related complications compared with mitral valve repair.
ObjectiveTo attempt an innovative mitral valvuloplasty by chained double stitching without shaping ring to repair ischemic mitral regurgitation (IMR) and to evaluate the clinical efficacy of this new procedure. MethodsWe retrospectively analyzed the clinical data of 12 patients with coronary artery disease and IMR underwent the innovative mitral valvuloplasty by chained double stitching without shaping ring in our hospital from August 2012 to December 2013. There were 10 males and 2 females at the mean age of 60±10 years ranging from 42 to 76 years. The cardiac functional parameters and condition of mitral regurgitation were compared among the period of preoperation, discharging and follow-up. ResultsTwelve patients were recovered and discharged from hospital with the New York Heart Association (NYHA) classification of heart function at class Ⅰ-Ⅱ. NYHA classification, grade of mitral regurgitation and regurgita- tion area were statistically improved on both the phase of discharge and follow-up compared with that of the pre-operation (P<0.05). Compared with preoperative left ventricular ejection fraction (LVEF), LVEF of discharging was statistically amelio- rative (P<0.05). And there was a statistic difference of NYHA classification of cardiac function in the phase of follow-up than that of discharging (P<0.05). ConclusionMitral valvuloplasty by chained double stitching without shaping ring is one reliable choice of treating IMR. The cardiac function and the living quality of the patients are statistically improved on the early stage and metaphase after operation, but long-term efficacy of this surgical procedure need be further assessed.
Ischemic mitral regurgitation is the common complication after myocardial infarction. Ischemic mitral regurgitation which can be described as the modification of the ventricle caused by myocardial infarction remarkably increases the risk of developing congestive heart failure and mortality after myocardial infarction. The imbalanced dynamic of tethering and occluding of the leaflets or the annular dilatation can result in ischemic mitral regurgitation. We have to diagnose, evaluate ischemic mitral regurgitation timely and perform surgical treatment effectively. It has significant meaning to improve the prognosis of patients.
Ischemic mitral regurgitation represents a common complication after myocardial infarction, the severity of the mitral regurgitation increases the risk of mortality. There is continuing debate regarding the management of moderate ischemic mitral regurgitation in patients undergoing surgical management. The debates lie in whether adding mitral valve surgery to coronary artery bypass grafting. So the review is about the analysis of existing evidence and expectation about it.
Objective To investigate surgical treatment and evaluate the curative effect in patients with moderate to severe ischemic mitral regurgitation (IMR). Methods The clinical data of the patients with coronary heart disease complicated with moderate to severe IMR who agreed to receive surgical treatment from June 2014 to June 2019 in our hospital were analyzed retrospectively. The patients were divided into two groups: a coronary artery bypass grafting (CABG) group and a CABG+mitral valve surgery (MVS) group. The preoperative and postoperative clinical data between the two groups were compared. Results Finally 105 patients were collected, including 75 males and 30 females, aged 40-79 (62.70±7.90) years. There were 34 patients in the CABG group, and 71 patients in the CABG+MVS group including 2 patients of mitral valvuloplasty and 29 patients of mitral valve replacement. Among the 105 patients, 5 died during the perioperative period and 2 died in 3 months after operation, all of whom were from the CABG+MVS group. There was no statistical difference in perioperative and postoperative 3-month mortality rate between the two groups (P=0.14). Eighty-seven patients were followed up in the medium and long term. There was no statistical difference in the degree of preoperative mitral insufficiency (MI) (P=0.59) and left atrium diameter (P=0.51) between the two groups, but the degree of postoperative MI in the CABG group was significantly higher than that in the CABG+MVS group (P<0.01). However, the left atrium diameter in the CABG group was significantly smaller than that in the CABG+MVS group (P<0.01). Paired analysis showed that systolic pulmonary artery pressure, left ventricular end-diastolic diameter, left ventricular end-systolic diameter, left ventricular ejection fraction and MI were significantly improved after operation (P<0.01); left atrium diameter was significantly improved after operation in the CABG group (P<0.01), but there was no statistical difference before and after operation in the CABG+MVS group (P=0.10). Conclusion For patients with moderate to severe IMR, CABG with mitral valve treatment can improve left ventricular remodeling, but can not significantly improve left atrial remodeling. Whether performing mitral valve treatment during CABG should be cautious. CABG alone is a safe and effective scheme for elderly patients with poor physical condition and low life expectancy.