P335Utility of stress echocardiography in selecting the optimal mitral valve procedure in patients with moderate ischemic mitral regurgitation undergoing coronary artery bypass grafting


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Abstract

Optimal surgical management of moderate chronic ischemic mitral regurgitation (IMR) in patients (pts) qualified for coronary artery bypass grafting (CABG) is still controversial. This study aimed to prospectively assess the proposed diagnostic algorithm based on stress echo (ExE and dobutamine stress echo-DSE) for the appropriate surgicalprocedure: CABG alone or CABG+mitral annuloplasty (CABG+P) in pts with moderate IMR.Methods: A total of 100 pts aged 18-75, with a history of myocardial infarction and moderate IMR, eligible for CABG were included in a prospective study. Patients were referred for CABG (gr.1; n=74) or CABG+P (gr.2; n=26) based on clinical assessment, 2D echo at rest and exercise as well as myocardial viability analysis (low dose DSE). Effective regurgitation orifice area (EROA) was used for quantitative IMR assessment (moderate: EROA ≥10 and < 20 mm2). Prior to surgery tenting area (TA) and coaptation height (CH) were assessed. One year after the surgery each pts underwent the evaluation of cardiovascular events.Results: In both groups (CABG vs CABG+P) no significant differences were observed in:30-day (1% vs 8%; p=0.103) and 12-month mortality (3% vs 12%; p=0.075), hospitalizations due to the heart failure (HF) exacerbation (5% vs 15%;p=0.107), and incidence of stroke (1% vs 8%; p=0.103). Receiver-operating characteristics (ROC) curves demonstrated that in both groups preoperative TA was strong independent predictor of adverse outcomes (NYHA III/IV symptoms and HF hospitalizations) in 12 months follow-up. The best cut-off value for TA was 2 cm2 (sensitivity 83%, specificity 68%; AUC 0.72) in CABG group and 2.6 cm2 (sensitivity 100%, specificity 63%; AUC 0.776) in CABG+P group. The analysis of the complex end-point (deaths/CV hosp/stroke) revealed a statistically significant difference between CABG and CABG+P groups (9% vs 35%pts; p=0.003). The most important predicting factors for the complex endpoint were:presence of atrial fibrillation (AF) before surgery (p=0.035) and the size of tenting area (TA) of the mitral valve (p=0.005). Conclusions: 1. The strategy of the preoperative pts qualification (ExE, DSE), allows obtaining similar results with reference to 30-day and 12-month survival rates, incidence of HF hospitalizations and strokes, regardless of the surgical procedure performed.2. AF before the surgery and TA were strong predictors of cardiovascular events in 12-month follow-up.3. The application of proposed diagnostic algorithm may improve qualification of patients with moderate FIMR for a suitable type of surgical procedure.

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