Papillary Muscle Approximation vs. Restrictive Annuloplasty Alone for Severe Ischemic Mitral Regurgitation - Papillary Muscle Approximation vs. Restrictive Annuloplasty Alone for Severe Ischemic Mitral Regurgitation

Description:

The goal of the trial was to evaluate surgical techniques of papillary muscle approximation with restrictive mitral annuloplasty compared with mitral annuloplasty alone among patients undergoing surgery for ischemic mitral regurgitation.

Contribution to the Literature: This trial showed that papillary muscle approximation with restrictive mitral annuloplasty improved long-term left ventricular remodeling.

Study Design

  • Randomized
  • Parallel

Patients undergoing surgery for ischemic mitral regurgitation and multivessel coronary artery disease were randomized to papillary muscle approximation with restrictive mitral annuloplasty (n = 48) versus restrictive mitral annuloplasty alone (n = 48).

  • Total number of enrollees: 96
  • Duration of follow-up: 5 years
  • Mean patient age: 65 years
  • Percentage female: 37%
  • Percentage diabetics: 42%

Inclusion criteria:

  • Ischemic mitral regurgitation
  • Multivessel coronary artery disease

Exclusion criteria:

  • Structural mitral valve pathology, including myxomatous disease
  • Previous endocarditis
  • Rheumatic valve disease
  • Leaflet prolapse
  • Additional valvular or aortic surgery
  • Preoperative inotropic or mechanical support
  • Chronic renal replacement therapy

Principal Findings:

The primary outcome, mean change from baseline in left ventricular end-diastolic diameter, was -5.8 mm in the papillary muscle approximation group versus -0.2 mm in the mitral annuloplasty alone group (p < 0.001).

Secondary outcomes):

  • Mortality at 5 years: 22.9% vs. 29.2% (p = not significant), respectively for papillary muscle approximation versus mitral annuloplasty alone
  • Mitral regurgitation grade 3-4 at 5 years: 27.0% vs. 55.9% (p = 0.013), respectively for papillary muscle approximation versus mitral annuloplasty alone

Interpretation:

Among patients undergoing surgery for severe ischemic mitral regurgitation and multivessel coronary artery disease, papillary muscle approximation with restrictive mitral annuloplasty was superior at improving left ventricular geometry compared with restrictive mitral annuloplasty alone. While there was no difference in long-term mortality, papillary muscle approximation with restrictive mitral annuloplasty was associated with a lower incidence of long-term moderate to severe mitral regurgitation.

References:

Nappi F, Lusini M, Spadaccio C, et al. Papillary muscle approximation versus restrictive annuloplasty alone for severe ischemic mitral regurgitation. J Am Coll Cardiol 2016;67:2334-2346.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and Coronary Artery Disease, Interventions and Structural Heart Disease, Mitral Regurgitation

Keywords: Cardiac Surgical Procedures, Coronary Artery Disease, Heart Failure, Heart Valve Diseases, Ischemia, Mitral Valve Annuloplasty, Mitral Valve Insufficiency, Papillary Muscles, Tricuspid Valve, Ventricular Remodeling


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