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Risk of Ischemic Mitral Regurgitation Recurrence after Combined Valvular and Subvalvular Repair.

BACKGROUND: Mitral valve repair combined with papillary muscle approximation (MVr+PMA) may improve repair durability in severe ischemic mitral regurgitation (MR), when compared with MVr alone. We sought to identify preoperative transthoracic echocardiographic markers associated with MR recurrence after MVr+PMA.

METHODS: A post-hoc analysis was performed on patients with severe ischemic MR who underwent coronary artery bypass grafting with MVr+PMA, in the Papillary Muscle Approximation Randomized Trial. PMA was performed utilizing a 4-mm polytetrafluouroethylene graft placed around the papillary muscles. Linear regression analyses and receiver operating characteristic curves were used to identify echocardiographic variables and diagnostic models associated with recurrent MR.

RESULTS: There were 48 patients with a mean age of 63 ± 7 years, a left ventricular (LV) ejection fraction of 35 ± 5%, and an LV end-diastolic diameter of 63 ± 3 mm. Of these, 37 had baseline and 5-year follow-up echocardiograms, with moderate-to-severe MR recurring in 27%. Linear regression analyses revealed associations between preoperative pulmonary artery systolic pressure (standardized beta coefficient, β=0.49/mmHg, p=0.002), MV tenting area (β=0.47/cm2 , p=0.004), a symmetric MV tethering pattern (β=0.44, p=0.007), and LV end-diastolic diameter (β=0.37/mm, p=0.02), with follow-up MR grade. The presence of both an MV tenting area ≥ 3.1 cm2 (AUC=0.822) and LV end-diastolic diameter ≥ 64 mm (AUC=0.801) was the most robust discriminative model for moderate-to-severe MR recurrence (specificity=92%, sensitivity=69%, AUC=0.804, p=0.003).

CONCLUSIONS: In patients undergoing coronary artery bypass grafting with MVr+PMA, the extent of baseline MV apparatus and LV geometric remodeling identifies patients at increased risk for MR recurrence.

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