Clinical efficacy of different surgical approaches for moderate-to-severe ischemic mitral regurgitation: A systematic review and network meta-analysis_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

WEI Zhili ¹ , DONG Shuai ² , LI Xuhua ¹ , CHEN Yang ¹ , LIU Shidong ² ,  SONG Bing ²

1. The First Clinical Medical College of Lanzhou University, Lanzhou, 730000, P. R. China;
2. Department of Cardiovascular Surgery, The First Hospital of Lanzhou University, Lanzhou, 730000, P. R. China;

Corresponding author：

SONG Bing, Email: songbinldyy@163.com

Keywords：

Coronary artery bypass grafting; mitral valve repair; mitral valve replacement; ischemic mitral regurgitation; systematic review/network meta-analysis

DOI：

10.7507/1007-4848.202403026

Video：

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Objective To systematically evaluate the therapeutic effects of different surgical procedures for ischemic mitral regurgitation (IMR). Methods Computer searches were conducted in CNKI, Wanfang, VIP, CBM, PubMed, The Cochrane Library, EMbase, and Web of Science, with the search time limit from the inception of the databases to February 2024. Two researchers independently screened the literature, extracted data, used the Cochrane bias risk assessment tool to evaluate the quality of the included studies, and used Stata 17.0 software to analyze the data. Results A total of 19 randomized controlled trials involving 6139 patients were finally included, involving six surgical procedures, and the overall quality of the included studies was relatively high. The results of the network Meta-analysis showed that the 30-day all-cause mortality rate of mitral valve repair (MVr) was significantly lower than that of coronary artery bypass grafting (CABG) [OR=0.24, 95%CI (0.07, 0.87)], mitral valve replacement (MVR) [OR=0.43, 95%CI (0.23, 0.79)], CABG+MVR [OR=0.21, 95%CI (0.04, 0.95)] and transcatheter mitral valve edge-to-edge repair (TEER) using MitraClip [OR=0.13, 95%CI (0.02, 0.87)]. The 30-day all-cause mortality rate of CABG+MVr was significantly lower than that of CABG [OR=0.56, 95%CI (0.33, 0.93)] and CABG+MVR [OR=0.48, 95%CI (0.24, 0.94)], and the best probability ranking results showed that MVR might be the most effective in reducing the 30-day all-cause mortality rate. The incidence of renal complications in CABG+MVr was significantly lower than that in CABG+MVR [OR=0.42, 95%CI (0.21, 0.83)]; the best probability ranking results showed that CABG+MVr might be the most effective in reducing renal complications. Conclusion The current limited evidence suggests that CABG+MVr and MVR may be the best surgical intervention methods for IMR patients at present. Due to the limitations of the number and quality of included studies, the above conclusions still need to be verified by more high-quality studies.

1.	Zoghbi WA, Adams D, Bonow RO, et al. Recommendations for noninvasive evaluation of native valvular regurgitation: A report from the American Society of Echocardiography developed in collaboration with the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr, 2017, 30(4): 303-371.
2.	Bursi F, Enriquez-Sarano M, Nkomo VT, et al. Heart failure and death after myocardial infarction in the community: The emerging role of mitral regurgitation. Circulation, 2005, 111(3): 295-301.
3.	Perez de Isla L, Zamorano J, Quezada M, et al. Prognostic significance of functional mitral regurgitation after a first non-ST-segment elevation acute coronary syndrome. Eur Heart J, 2006, 27(22): 2655-2660.
4.	Grossi EA, Goldberg JD, LaPietra A, et al. Ischemic mitral valve reconstruction and replacement: Comparison of long-term survival and complications. J Thorac Cardiovasc Surg, 2001, 122(6): 1107-1124.
5.	Di Salvo TG, Acker MA, Dec GW, et al. Mitral valve surgery in advanced heart failure. J Am Coll Cardiol, 2010, 55(4): 271-282.
6.	Jouan J, Tapia M, C Cook R, et al. Ischemic mitral valve prolapse: Mechanisms and implications for valve repair. Eur J Cardiothorac Surg, 2004, 26(6): 1112-1117.
7.	Krishnaswamy A, Marc Gillinov A, Griffin BP. Ischemic mitral regurgitation: Pathophysiology, diagnosis, and treatment. Coron Artery Dis, 2011, 22(5): 359-370.
8.	Carpentier A. Cardiac valve surgery: The "French correction". J Thorac Cardiovasc Surg, 1983, 86(3): 323-337.
9.	Borger MA, Alam A, Murphy PM, et al. Chronic ischemic mitral regurgitation: Repair, replace or rethink? Ann Thorac Surg, 2006, 81(3): 1153-1161.
10.	Velazquez EJ, Lee KL, Deja MA, et al. Coronary-artery bypass surgery in patients with left ventricular dysfunction. N Engl J Med, 2011, 364(17): 1607-1616.
11.	Castleberry AW, Williams JB, Daneshmand MA, et al. Surgical revascularization is associated with maximal survival in patients with ischemic mitral regurgitation: A 20-year experience. Circulation, 2014, 129(24): 2547-2556.
12.	Schroder JN, Williams ML, Hata JA, et al. Impact of mitral valve regurgitation evaluated by intraoperative transesophageal echocardiography on long-term outcomes after coronary artery bypass grafting. Circulation, 2005, 112(9 Suppl): I293-I298.
13.	Campwala SZ, Bansal RC, Wang N, et al. Mitral regurgitation progression following isolated coronary artery bypass surgery: Frequency, risk factors, and potential prevention strategies. Eur J Cardiothorac Surg, 2006, 29(3): 348-353.
14.	Liu S, Wang L, Li J, et al. Comparative study of coronary artery bypass grafting combined with off-pump mitral valvuloplasty versus coronary artery bypass grafting alone in patients with moderate ischemic mitral regurgitation. Perfusion, 2023, 38(2): 330-336.
15.	Kragelund C, Grønning B, Køber L, et al. N-terminal pro-B-type natriuretic peptide and long-term mortality in stable coronary heart disease. N Engl J Med, 2005, 352(7): 666-675.
16.	Acker MA, Parides MK, Perrault LP, et al. Mitral-valve repair versus replacement for severe ischemic mitral regurgitation. N Engl J Med, 2014, 370(1): 23-32.
17.	Chan KM, Punjabi PP, Flather M, et al. Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation: Final results of the Randomized Ischemic Mitral Evaluation (RIME) trial. Circulation, 2012, 126(21): 2502-2510.
18.	Dufendach K, Aranda-Michel E, Sultan I, et al. Outcomes of mitral valve surgery for severe ischemic mitral regurgitation. J Card Surg, 2020, 35(2): 390-396.
19.	Fattouch K, Dioguardi P, Guccione F, et al. 10-year results of mitral repair and coronary bypass for ischemic regurgitation: A randomized trial. Ann Thorac Surg, 2022, 113(3): 816-822.
20.	Gimpel D, Cheung M, Bassin L, et al. Operative results of mitral valve repair and replacement in chronic ischaemic mitral valve regurgitation. Heart Lung Circ, 2020, 29(11): 1713-1724.
21.	Jeong DS, Lee HY, Kim WS, et al. Off pump coronary artery bypass versus mitral annuloplasty in moderate ischemic mitral regurgitation. Ann Thorac Cardiovasc Surg, 2012, 18(4): 322-330.
22.	Ji Q, Zhao Y, Shen J, et al. Elderly patients with moderate chronic ischemic mitral regurgitation: Coronary artery bypass grafting alone or concomitant mitral annuloplasty? Cardiol Res Pract, 2019: 1846904.
23.	Khallaf A, Elzayadi M, Alkady H, et al. Results of coronary artery bypass grafting alone versus combined surgical revascularization and mitral repair in patients with moderate ischemic mitral regurgitation. Heart Surg Forum, 2020, 23(3): E270-E275.
24.	Lee ML, Chen TH, Huang HD, et al. Mitral valve repair versus replacement in patients with ischemic mitral regurgitation. J Thorac Dis, 2018, 10(5): 2820-2828.
25.	Li B, Chen S, Sun H, et al. Mitral valve annuloplasty versus replacement for severe ischemic mitral regurgitation. Sci Rep, 2018, 8(1): 1537.
26.	Li B, Wu H, Sun H, et al. Long-term outcomes of mitral valve annuloplasty versus subvalvular sparing replacement for severe ischemic mitral regurgitation. Cardiol J, 2019, 26(3): 265-274.
27.	Michler RE, Smith PK, Parides MK, et al. Two-year outcomes of surgical treatment of moderate ischemic mitral regurgitation. N Engl J Med, 2016, 374(20): 1932-1941.
28.	Qiu ZB, Chen X, Xu M, et al. Efficacy of mitral valve repair versus replacement in severe ischemic mitral regurgitation. Zhonghua Yi Xue Za Zhi, 2017, 97(22): 1705-1709.
29.	Sá MP, Soares EF, Santos CA, et al. Mitral valve replacement combined with coronary artery bypass graft surgery in patients with moderate-to-severe ischemic mitral regurgitation. Rev Port Cardiol, 2013, 32(2): 131-137.
30.	Silberman S, Oren A, Klutstein MW, et al. Does mitral valve intervention have an impact on late survival in ischemic cardiomyopathy? IMAJ, 2006, 8(1): 17-20.
31.	Toktas F, Yavuz S, Ozsin KK, et al. Mitral valve repair for ischemic moderate mitral regurgitation in patients undergoing coronary artery bypass grafting. Saudi Med J, 2016, 37(8): 853-859.
32.	Tribak M, Konaté M, Ould Hbib B, et al. Impact of mitral annuloplasty combined with surgical revascularization in ischemic mitral regurgitation. Ann Cardiol Angeiol (Paris), 2018, 67(1): 25-31.
33.	Wang X, Ma Y, Liu J, et al. Outcomes of transcatheter edge-to-edge mitral valve repair with percutaneous coronary intervention vs. surgical mitral valve repair with coronary artery bypass grafting. Front Cardiovasc Med, 2022, 9: 953875.
34.	Bax JJ, Braun J, Somer ST, et al. Restrictive annuloplasty and coronary revascularization in ischemic mitral regurgitation results in reverse left ventricular remodeling. Circulation, 2004, 110(11 Suppl 1): Ⅱ103-Ⅱ108.
35.	Salmasi MY, Harky A, Chowdhury MF, et al. Should the mitral valve be repaired for moderate ischemic mitral regurgitation at the time of revascularization surgery? J Card Surg, 2018, 33(7): 374-384.
36.	Adler DS, Goldman L, O'Neil A, et al. Long-term survival of more than 2, 000 patients after coronary artery bypass grafting. Am J Cardiol, 1986, 58(3): 195-202.
37.	Refaie M, Alshehri M, Sharaa M, et al. One-year outcomes of concomitant mitral reduction annuloplasty repair with coronary artery bypass grafting for moderate ischemic mitral regurgitation. J Egypt Soc Cardio-Thorac Surg, 2018, 26(3): 171-177.

1. Zoghbi WA, Adams D, Bonow RO, et al. Recommendations for noninvasive evaluation of native valvular regurgitation: A report from the American Society of Echocardiography developed in collaboration with the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr, 2017, 30(4): 303-371.
2. Bursi F, Enriquez-Sarano M, Nkomo VT, et al. Heart failure and death after myocardial infarction in the community: The emerging role of mitral regurgitation. Circulation, 2005, 111(3): 295-301.
3. Perez de Isla L, Zamorano J, Quezada M, et al. Prognostic significance of functional mitral regurgitation after a first non-ST-segment elevation acute coronary syndrome. Eur Heart J, 2006, 27(22): 2655-2660.
4. Grossi EA, Goldberg JD, LaPietra A, et al. Ischemic mitral valve reconstruction and replacement: Comparison of long-term survival and complications. J Thorac Cardiovasc Surg, 2001, 122(6): 1107-1124.
5. Di Salvo TG, Acker MA, Dec GW, et al. Mitral valve surgery in advanced heart failure. J Am Coll Cardiol, 2010, 55(4): 271-282.
6. Jouan J, Tapia M, C Cook R, et al. Ischemic mitral valve prolapse: Mechanisms and implications for valve repair. Eur J Cardiothorac Surg, 2004, 26(6): 1112-1117.
7. Krishnaswamy A, Marc Gillinov A, Griffin BP. Ischemic mitral regurgitation: Pathophysiology, diagnosis, and treatment. Coron Artery Dis, 2011, 22(5): 359-370.
8. Carpentier A. Cardiac valve surgery: The "French correction". J Thorac Cardiovasc Surg, 1983, 86(3): 323-337.
9. Borger MA, Alam A, Murphy PM, et al. Chronic ischemic mitral regurgitation: Repair, replace or rethink? Ann Thorac Surg, 2006, 81(3): 1153-1161.
10. Velazquez EJ, Lee KL, Deja MA, et al. Coronary-artery bypass surgery in patients with left ventricular dysfunction. N Engl J Med, 2011, 364(17): 1607-1616.
11. Castleberry AW, Williams JB, Daneshmand MA, et al. Surgical revascularization is associated with maximal survival in patients with ischemic mitral regurgitation: A 20-year experience. Circulation, 2014, 129(24): 2547-2556.
12. Schroder JN, Williams ML, Hata JA, et al. Impact of mitral valve regurgitation evaluated by intraoperative transesophageal echocardiography on long-term outcomes after coronary artery bypass grafting. Circulation, 2005, 112(9 Suppl): I293-I298.
13. Campwala SZ, Bansal RC, Wang N, et al. Mitral regurgitation progression following isolated coronary artery bypass surgery: Frequency, risk factors, and potential prevention strategies. Eur J Cardiothorac Surg, 2006, 29(3): 348-353.
14. Liu S, Wang L, Li J, et al. Comparative study of coronary artery bypass grafting combined with off-pump mitral valvuloplasty versus coronary artery bypass grafting alone in patients with moderate ischemic mitral regurgitation. Perfusion, 2023, 38(2): 330-336.
15. Kragelund C, Grønning B, Køber L, et al. N-terminal pro-B-type natriuretic peptide and long-term mortality in stable coronary heart disease. N Engl J Med, 2005, 352(7): 666-675.
16. Acker MA, Parides MK, Perrault LP, et al. Mitral-valve repair versus replacement for severe ischemic mitral regurgitation. N Engl J Med, 2014, 370(1): 23-32.
17. Chan KM, Punjabi PP, Flather M, et al. Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation: Final results of the Randomized Ischemic Mitral Evaluation (RIME) trial. Circulation, 2012, 126(21): 2502-2510.
18. Dufendach K, Aranda-Michel E, Sultan I, et al. Outcomes of mitral valve surgery for severe ischemic mitral regurgitation. J Card Surg, 2020, 35(2): 390-396.
19. Fattouch K, Dioguardi P, Guccione F, et al. 10-year results of mitral repair and coronary bypass for ischemic regurgitation: A randomized trial. Ann Thorac Surg, 2022, 113(3): 816-822.
20. Gimpel D, Cheung M, Bassin L, et al. Operative results of mitral valve repair and replacement in chronic ischaemic mitral valve regurgitation. Heart Lung Circ, 2020, 29(11): 1713-1724.
21. Jeong DS, Lee HY, Kim WS, et al. Off pump coronary artery bypass versus mitral annuloplasty in moderate ischemic mitral regurgitation. Ann Thorac Cardiovasc Surg, 2012, 18(4): 322-330.
22. Ji Q, Zhao Y, Shen J, et al. Elderly patients with moderate chronic ischemic mitral regurgitation: Coronary artery bypass grafting alone or concomitant mitral annuloplasty? Cardiol Res Pract, 2019: 1846904.
23. Khallaf A, Elzayadi M, Alkady H, et al. Results of coronary artery bypass grafting alone versus combined surgical revascularization and mitral repair in patients with moderate ischemic mitral regurgitation. Heart Surg Forum, 2020, 23(3): E270-E275.
24. Lee ML, Chen TH, Huang HD, et al. Mitral valve repair versus replacement in patients with ischemic mitral regurgitation. J Thorac Dis, 2018, 10(5): 2820-2828.
25. Li B, Chen S, Sun H, et al. Mitral valve annuloplasty versus replacement for severe ischemic mitral regurgitation. Sci Rep, 2018, 8(1): 1537.
26. Li B, Wu H, Sun H, et al. Long-term outcomes of mitral valve annuloplasty versus subvalvular sparing replacement for severe ischemic mitral regurgitation. Cardiol J, 2019, 26(3): 265-274.
27. Michler RE, Smith PK, Parides MK, et al. Two-year outcomes of surgical treatment of moderate ischemic mitral regurgitation. N Engl J Med, 2016, 374(20): 1932-1941.
28. Qiu ZB, Chen X, Xu M, et al. Efficacy of mitral valve repair versus replacement in severe ischemic mitral regurgitation. Zhonghua Yi Xue Za Zhi, 2017, 97(22): 1705-1709.
29. Sá MP, Soares EF, Santos CA, et al. Mitral valve replacement combined with coronary artery bypass graft surgery in patients with moderate-to-severe ischemic mitral regurgitation. Rev Port Cardiol, 2013, 32(2): 131-137.
30. Silberman S, Oren A, Klutstein MW, et al. Does mitral valve intervention have an impact on late survival in ischemic cardiomyopathy? IMAJ, 2006, 8(1): 17-20.
31. Toktas F, Yavuz S, Ozsin KK, et al. Mitral valve repair for ischemic moderate mitral regurgitation in patients undergoing coronary artery bypass grafting. Saudi Med J, 2016, 37(8): 853-859.
32. Tribak M, Konaté M, Ould Hbib B, et al. Impact of mitral annuloplasty combined with surgical revascularization in ischemic mitral regurgitation. Ann Cardiol Angeiol (Paris), 2018, 67(1): 25-31.
33. Wang X, Ma Y, Liu J, et al. Outcomes of transcatheter edge-to-edge mitral valve repair with percutaneous coronary intervention vs. surgical mitral valve repair with coronary artery bypass grafting. Front Cardiovasc Med, 2022, 9: 953875.
34. Bax JJ, Braun J, Somer ST, et al. Restrictive annuloplasty and coronary revascularization in ischemic mitral regurgitation results in reverse left ventricular remodeling. Circulation, 2004, 110(11 Suppl 1): Ⅱ103-Ⅱ108.
35. Salmasi MY, Harky A, Chowdhury MF, et al. Should the mitral valve be repaired for moderate ischemic mitral regurgitation at the time of revascularization surgery? J Card Surg, 2018, 33(7): 374-384.
36. Adler DS, Goldman L, O'Neil A, et al. Long-term survival of more than 2, 000 patients after coronary artery bypass grafting. Am J Cardiol, 1986, 58(3): 195-202.
37. Refaie M, Alshehri M, Sharaa M, et al. One-year outcomes of concomitant mitral reduction annuloplasty repair with coronary artery bypass grafting for moderate ischemic mitral regurgitation. J Egypt Soc Cardio-Thorac Surg, 2018, 26(3): 171-177.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Latest ArticlesClinical efficacy of different surgical approaches for moderate-to-severe ischemic mitral regurgitation: A systematic review and network meta-analysis

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