Differential Impact of Mitral Valve Repair on Outcome of Coronary Artery Bypass Grafting with or without Surgical Ventricular Reconstruction in the Surgical Treatment for Ischemic Heart Failure (STICH) Trial

ABSTRACT

Background: This study examined the impact of mitral valve repair (MVRe) on survival of patients with moderate or severe (≥2+) MR and ischemic cardiomyopathy randomized to coronary artery bypass grafting (CABG) versus CABG+surgical ventricular reconstruction (SVR) in the STICH trial.

Methods: Among patients with moderate or severe MR and ischemic cardiomyopathy undergoing CABG or CABG+SVR, the impact of MVRe on mortality between the two treatment arms was compared.

Results: Among 867 patients with assessment of baseline MR severity, 211 had moderate or severe MR. After excluding 7 patients who underwent mitral valve replacement, 50, 44, 62, and 48 patients underwent CABG, CABG+MVRe, CABG+SVR, and CABG+SVR+MVRe, respectively. Four-year mortality rates were lower following CABG+MVRe than CABG alone (16% vs. 55%; adjusted hazard ratio [HR] 0.30; 95% CI 0.13–0.71). In contrast, the CABG+SVR+MVRe and CABG+SVR groups had similar 4-year mortality of 39% vs. 39% (adjusted HR 0.88; 95% CI 0.46–1.70). MVRe had a more favorable effect on survival in patients undergoing CABG alone compared to CABG+SVR (p = 0.013). Baseline MR severity was similar between patients that received CABG+MVRe and those that underwent CABG+SVR+MVRe. A larger proportion of patients demonstrated a reduction in MR between 4 and 24 months after CABG+MVRe compared to CABG+SVR+MVRe (50.0% versus 25.0%, p = 0.023).

Conclusion: In patients with moderate or severe MR and ischemic cardiomyopathy undergoing CABG, MVRe appears to have a favorable effect on survival. The addition of SVR to CABG may attenuate the anticipated benefits of MVRe by limiting the long-term reduction of MR with MVRe.

KEYWORDS:

• Mitral regurgitation
• mitral valve repair
• heart failure
• left ventricular dysfunction
• ischemic cardiomyopathy
• coronary artery bypass grafting
• surgical ventricular reconstruction

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Clinical Trial Registration

Unique identifier: NCT00023595 (http://www.clinicaltrials.gov).

Disclosure statement

Paul A. Grayburn: Research Grants (PI/Consultant): Abbott Vascular, Boston Scientific, Medtronic, Edwards Lifesciences, Tendyne, ValTech Cardio, Neochord – significant

Eric J. Velazquez: Research Grants (PI/Consultant): NHLBI, Alnylam Pharmaceuticals, Pfizer, Amgen, Novartis – significant

Honoraria (Speaker): Expert Exchange – significant

All other authors: None

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Additional information

Funding

This work was supported by grants U01-HL69015, U01-HL69013, and R01-HL10583 from the National Heart, Lung, and Blood Institute/National Institutes of Health. The views expressed in this manuscript do not necessarily reflect those of the NHLBI or the NIH.