Papillary Muscle Approximation Versus Restrictive Annuloplasty Alone for Severe Ischemic Mitral Regurgitation

Abstract Background Guidelines recommend surgery for patients with severe ischemic mitral regurgitation (MR). Nonrandomized studies suggest that subvalvular repair is associated with longer survival, but randomized studies are lacking. Objectives This study sought to investigate the benefit of papil...

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Bibliographic Details
Published in:Journal of the American College of Cardiology 2016-05, Vol.67 (20), p.2334-2346
Main Authors: Nappi, Francesco, MD, Lusini, Mario, MD, PhD, Spadaccio, Cristiano, MD, PhD, Nenna, Antonio, MD, Covino, Elvio, MD, Acar, Christophe, MD, PhD, Chello, Massimo, MD
Format: Article
Language:English
Subjects:
Cardiology
Cardiovascular
Cardiovascular disease
Coronary Artery Bypass
Coronary vessels
Echocardiography
Female
Follow-Up Studies
Heart attacks
Heart failure
Heart Failure - etiology
Heart Ventricles - diagnostic imaging
Humans
Internal Medicine
Italy - epidemiology
Male
Middle Aged
mitral valve annuloplasty
Mitral Valve Annuloplasty - instrumentation
Mitral Valve Annuloplasty - methods
mitral valve insufficiency
Mitral Valve Insufficiency - mortality
Mitral Valve Insufficiency - surgery
Mortality
myocardial infarction
Myocardial Ischemia - etiology
Myocardial Ischemia - surgery
myocardial revascularization
Papillary Muscles - surgery
Patient Readmission - statistics & numerical data
Prospective Studies
Quality of Life
Recurrence
Reoperation - statistics & numerical data
Stroke Volume
Surgery
undersizing annuloplasty
Values
Ventricular Remodeling
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Summary:Abstract Background Guidelines recommend surgery for patients with severe ischemic mitral regurgitation (MR). Nonrandomized studies suggest that subvalvular repair is associated with longer survival, but randomized studies are lacking. Objectives This study sought to investigate the benefit of papillary muscle surgery on long-term clinical outcomes of patients with ischemic MR. Methods Ninety-six patients with severe ischemic MR were randomized to either undersizing restrictive mitral annuloplasty (RA) or papillary muscle approximation with undersizing restrictive mitral annuloplasty (PMA) associated with complete surgical myocardial revascularization. The primary endpoint was change in left ventricular end-diastolic diameter (LVEDD) after 5 years, measured as the absolute difference from baseline, which was evaluated by paired Student t tests. Secondary endpoints included changes in echocardiographic parameters, overall mortality, the composite cardiac endpoint (major adverse cardiac and cerebrovascular events [MACCE]), and quality of life (QOL) during the 5-year follow-up. Results At 5 years, mean LVEDD was 56.5 ± 5.7 mm with PMA versus 60.6 ± 4.6 mm with RA (mean change from baseline −5.8 ± 4.1 mm and −0.2 ± 2.3 mm, respectively; p < 0.001). Ejection fraction was 44.1 ± 6% in the PMA group versus 39.9 ± 3.9% in the RA group (mean change from baseline 8.8 ± 5.9% and 2.5 ± 4.3%, respectively; p < 0.001). There was no statistically significant difference in mortality at 5 years, but freedom from MACCE favored PMA in the last year of follow-up. PMA significantly reduced tenting height, tenting area, and interpapillary distance soon after surgery and for the long-term, and significantly lowered moderate-to-severe MR recurrence. No differences were found in QOL measures. Conclusions Compared with RA only, PMA exerted a long-term beneficial effect on left ventricular remodeling and more effectively restored the mitral valve geometric configuration in ischemic MR, which improved long-term cardiac outcomes, but did not produce differences in overall mortality and QOL.
ISSN:0735-1097
1558-3597
DOI:10.1016/j.jacc.2016.03.478