Is repair preferable to replacement for ischemic mitral regurgitation?

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Presentation transcript:

Is repair preferable to replacement for ischemic mitral regurgitation? A.Marc Gillinov, MDa, Per Nils Wierup, MDa*, Eugene H. Blackstone, MDa,b, Ehab S. Bishay, MDa, Delos M. Cosgrove, MDa, Jennifer White, MSb, Bruce W. Lytle, MDa, Patrick M. McCarthy, MDb The Journal of Thoracic and Cardiovascular Surgery Volume 122, Issue 6, Pages 1125-1141 (December 2001) DOI: 10.1067/mtc.2001.116557 Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 1 Sites of left ventricular wall motion abnormalities in patients with ischemic mitral regurgitation. Schematic representation of short-axis view of left ventricle corresponding to labeled figure below. Papillary muscles are denoted by circles. The Journal of Thoracic and Cardiovascular Surgery 2001 122, 1125-1141DOI: (10.1067/mtc.2001.116557) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 2 Survival after mitral valve surgery for all patients with ischemic mitral regurgitation. Each symbol represents a death according to Kaplan-Meier estimator. Vertical bars enclose asymmetric 68% confidence limits. Solid lines represent parametric survival estimates; these are enclosed between dashed 68% confidence limits. Numbers in parentheses are numbers of patients traced beyond that point. The Journal of Thoracic and Cardiovascular Surgery 2001 122, 1125-1141DOI: (10.1067/mtc.2001.116557) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 3 Survival for matched quintiles after mitral valve repair and mitral valve replacement. Because of the small number of patients with mitral valve replacement in quintiles III through V, these quintiles are grouped together. Presentation follows format of Figure 2. P values are for log-rank test. A, Quintile I; B, quintile II; C, quintiles III through V. The Journal of Thoracic and Cardiovascular Surgery 2001 122, 1125-1141DOI: (10.1067/mtc.2001.116557) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 4 Predicted survivals after mitral valve repair and replacement for two different patients according to multi-variable equation in Table 6. Figure shows impacts of complex regurgitant jet and lateral wall motion abnormality on survival. A, 65-year-old patient with moderate left ventrucular dysfunction, no renal dysfunction, no inferior wall motion abnormality, requiring emergency surgery. No ITA graft was used, there was no complex regurgitant jet, and there was no lateral wall motion abnormality. Survival would be better with valve repair than with valve replacement. B, Similar patient but with complex regurgitant jet and lateral wall motion abnormality. Survival predicted to be generally poor, with no advantage of repair. The Journal of Thoracic and Cardiovascular Surgery 2001 122, 1125-1141DOI: (10.1067/mtc.2001.116557) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 5 Survival according to cause of ischemic mitral regurgitation. According to univariate analysis, patients with papillary muscle rupture appear to have superior survival. Depiction as in Figure 2. The Journal of Thoracic and Cardiovascular Surgery 2001 122, 1125-1141DOI: (10.1067/mtc.2001.116557) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 6 Cumulative distribution of differences in 7-year survival between mitral valve repair and replacement. Patients to right of 0 difference are predicted to benefit from mitral valve repair. A, Overall cumulative distribution; B, cumulative distribution of survival differences for patients with actual repair(solid line) and actual replacement (dashed line). The Journal of Thoracic and Cardiovascular Surgery 2001 122, 1125-1141DOI: (10.1067/mtc.2001.116557) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 7 Freedom from mitral valve replacement after mitral valve repair. Depiction as in Figure 2. The Journal of Thoracic and Cardiovascular Surgery 2001 122, 1125-1141DOI: (10.1067/mtc.2001.116557) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Appendix V, Fig. 1. Simulated mitral valve repair (solid line) for patients actually undergoing replacement (squares depict Kaplan-Meier estimates and confidence limits, as in Figure 2). Simulated curve was obtained from patient-specific estimates, as described in Appendices II and V. The Journal of Thoracic and Cardiovascular Surgery 2001 122, 1125-1141DOI: (10.1067/mtc.2001.116557) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Appendix V, Fig. 2. Simulated mitral valve replacement(solid line) for patients actually undergoing repair (circles depict Kaplan-Meier estimates and confidence limits, as in Figure 2). Simulated curve was obtained from patient-specific estimates, as described in Appendices II and V. The Journal of Thoracic and Cardiovascular Surgery 2001 122, 1125-1141DOI: (10.1067/mtc.2001.116557) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions