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(Circulation. 2005;112:I-293 – I-298.)
© 2005 American Heart Association, Inc.

Surgery for Coronary Artery Disease

Impact of Mitral Valve Regurgitation Evaluated by Intraoperative Transesophageal Echocardiography on Long-Term Outcomes After Coronary Artery Bypass Grafting

Jacob N. Schroder, MD; Matthew L. Williams, MD; Jonathan A. Hata, MD; Lawrence H. Muhlbaier, PhD; Madhav Swaminathan, MD; Joseph P. Mathew, MD; Donald D. Glower, MD; Christopher M. O’Connor, MD; Peter K. Smith, MD; Carmelo A. Milano, MD

From the Department of Surgery, Division of Cardiovascular and Thoracic Surgery (J.N.S., J.A.H., L.H.M., D.D.G., P.K.S., C.A.M.), Department of Anesthesiology, Division of Cardiac Anesthesia (M.S., J.P.M.), Department of Medicine, Division of Cardiology (C.M.O.), and Department of Biostatistics and Bioinformatics (L.H.M.), Duke University Medical Center, Durham, NC; the Department of Surgery (M.L.W.), Massachusetts General Hospital, Boston, MA; and the Duke University Clinical Research Institute (L.H.M.), Durham, NC.

Correspondence to Dr Carmelo A. Milano, Box 3043, Department of Surgery, Duke University Medical Center, Durham, NC 27703. E-mail milan002{at}mc.duke.edu

Background— It is unclear if mild or moderate mitral valve regurgitation (MR) should be repaired at the time of coronary artery bypass grafting (CABG). We sought to determine the long-term effect of uncorrected MR, measured by intraoperative transesophageal echocardiography (TEE), in CABG patients.

Methods and Results— Between May 1999 and September 2003, data were gathered for 3264 consecutive patients who underwent isolated CABG and had MR graded by intraoperative TEE. MR was graded on the following 5 levels: none, trace, mild, moderate, and severe. Patients who had severe MR or who underwent mitral valve surgery were eliminated from the analysis. The remaining patients were combined into the following 3 groups: none or trace, mild, and moderate MR. Preoperative and follow-up data were 99% complete. The median length of follow-up was 3.0 years. Multivariable analysis controlling for important preoperative risk factors was performed to determine predictors of death and death/hospitalization for heart failure. Increasing MR was a risk factor for death [hazard ratio (HR), 1.44; P<0.001] and death/heart failure hospitalization (HR, 1.34; P<0.01). When patients with moderate MR were eliminated from the analysis, mild MR was a risk factor for death (HR, 1.34; P=0.011) and death/hospitalization for heart failure (HR, 1.34; P<0.001).

Conclusions— Even mild MR, identified by intraoperative TEE, predicts worse outcomes after CABG. Revascularization alone did not eliminate the negative long-term effects of mild MR. CABG patients with uncorrected mild or moderate MR are at increased risk for death and heart-failure hospitalization; consideration for surgical repair or more aggressive medical management and follow-up is warranted.

Key Words: CABG surgery • coronary artery disease • mitral regurgitation • transesophageal echocardiography