Mitral-valve repair versus replacement for severe ischemic mitral regurgitation.

Published

Journal Article

BACKGROUND: Ischemic mitral regurgitation is associated with a substantial risk of death. Practice guidelines recommend surgery for patients with a severe form of this condition but acknowledge that the supporting evidence for repair or replacement is limited. METHODS: We randomly assigned 251 patients with severe ischemic mitral regurgitation to undergo either mitral-valve repair or chordal-sparing replacement in order to evaluate efficacy and safety. The primary end point was the left ventricular end-systolic volume index (LVESVI) at 12 months, as assessed with the use of a Wilcoxon rank-sum test in which deaths were categorized below the lowest LVESVI rank. RESULTS: At 12 months, the mean LVESVI among surviving patients was 54.6±25.0 ml per square meter of body-surface area in the repair group and 60.7±31.5 ml per square meter in the replacement group (mean change from baseline, -6.6 and -6.8 ml per square meter, respectively). The rate of death was 14.3% in the repair group and 17.6% in the replacement group (hazard ratio with repair, 0.79; 95% confidence interval, 0.42 to 1.47; P=0.45 by the log-rank test). There was no significant between-group difference in LVESVI after adjustment for death (z score, 1.33; P=0.18). The rate of moderate or severe recurrence of mitral regurgitation at 12 months was higher in the repair group than in the replacement group (32.6% vs. 2.3%, P<0.001). There were no significant between-group differences in the rate of a composite of major adverse cardiac or cerebrovascular events, in functional status, or in quality of life at 12 months. CONCLUSIONS: We observed no significant difference in left ventricular reverse remodeling or survival at 12 months between patients who underwent mitral-valve repair and those who underwent mitral-valve replacement. Replacement provided a more durable correction of mitral regurgitation, but there was no significant between-group difference in clinical outcomes. (Funded by the National Institutes of Health and the Canadian Institutes of Health; ClinicalTrials.gov number, NCT00807040.).

Full Text

Duke Authors

Cited Authors

  • Acker, MA; Parides, MK; Perrault, LP; Moskowitz, AJ; Gelijns, AC; Voisine, P; Smith, PK; Hung, JW; Blackstone, EH; Puskas, JD; Argenziano, M; Gammie, JS; Mack, M; Ascheim, DD; Bagiella, E; Moquete, EG; Ferguson, TB; Horvath, KA; Geller, NL; Miller, MA; Woo, YJ; D'Alessandro, DA; Ailawadi, G; Dagenais, F; Gardner, TJ; O'Gara, PT; Michler, RE; Kron, IL; CTSN,

Published Date

  • January 2, 2014

Published In

Volume / Issue

  • 370 / 1

Start / End Page

  • 23 - 32

PubMed ID

  • 24245543

Pubmed Central ID

  • 24245543

Electronic International Standard Serial Number (EISSN)

  • 1533-4406

Digital Object Identifier (DOI)

  • 10.1056/NEJMoa1312808

Language

  • eng

Conference Location

  • United States