Key result
Adjunctive sub-valvular procedures cut late MR recurrence by ~66% versus restricted annuloplasty alone.
Why the study?
Do adjunctive sub-valvular mitral procedures reduce late recurrence of mitral regurgitation and improve left ventricular remodeling compared to restricted annuloplasty alone in patients with chronic ischemic mitral regurgitation?
Meta-Analysis (n=404)
Do adjunctive sub-valvular mitral procedures reduce late recurrence of mitral regurgitation and improve left ventricular remodeling compared to restricted annuloplasty alone in patients with chronic ischemic mitral regurgitation?
Odds Ratio: 0.34 (95% CI 0.18–0.65)
p-value: p=0.0009
Adding sub-valvular procedures to restricted annuloplasty for chronic ischemic mitral regurgitation significantly reduces late MR recurrence and improves LV remodeling without increasing early mortality.
Adjunctive subvalvular procedures may reduce late MR recurrence and improve remodeling; supports randomized trials before changing practice.
Background: The most performed repair technique for the treatment of chronic ischemic mitral regurgitation in patients referred for bypass grafting remains restricted annuloplasty. However, it is associated with a high rate of failure, especially if severe tenting exists. Objectives: To understand if adjunctive sub-valvular mitral procedures may provide better repair performance. Methods: A systematic literature review identified six studies of which five fulfilled the criteria for meta-analysis. Outcomes for a total of 404 patients (214 had adjunctive sub-valvular procedures and 190 restricted annuloplasty) were meta-analyzed using random effects modeling. Heterogeneity and subgroup sensitivity analysis were assessed. Primary endpoints were: late recurrence of moderate mitral regurgitation, left ventricle remodeling and coaptation depth at follow-up. Secondary endpoints were: early mortality, mid-term survival and operative outcomes. Results: Sub-valvular procedure technique was associated with a significantly lower late recurrence of mitral regurgitation (Odds ratio (OR) 0.34, 95% Confidence Interval (CI) [0.18, 0.65], p=0.0009), smaller left ventricle end-systolic diameter (Weighted Mean Difference (WMD) -4.06, 95% CI [-6.10, -2.03], p=0.0001) and reduced coaptation depth (WMD -2.36, 95% CI [-5.01, -0.71], p=0.009). These findings were consistent, even in studies that included patients at high risk for repair failure (coaptation depth >10 mm and tenting area >2.5 cm 2 ). A low degree of heterogeneity was observed. There was no difference in terms of early mortality and mid-term survival; sub-valvular technique was associated with prolonged cardiopulmonary and cross-clamp time. Conclusions: Adding sub-valvular procedures when repairing ischemic chronic mitral valve regurgitation may be associated with better durability, even in the case of the presence of predictors for late failure. Perspective: Surgical sub-valvular adjunctive procedures have to be considered in the case of the presence of echocardiographic predictors for late failure.
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Moscarelli et al. (2017) conducted a meta-analysis in Chronic ischemic mitral regurgitation (cIMR) (n=404). Adjunctive sub-valvular procedures (SVP) vs. Restricted annuloplasty (RA) alone was evaluated on Late recurrence of moderate mitral regurgitation (≥2+) (OR 0.34, 95% CI 0.18, 0.65, p=0.0009). Adjunctive sub-valvular procedures significantly reduced the late recurrence of mitral regurgitation compared to restricted annuloplasty alone (OR 0.34).
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