Advertisement

Treatment Strategies for Acute Coronary Syndrome With Severe Mitral Regurgitation and Their Effects on Short- and Long-Term Prognosis

      Mitral regurgitation (MR) of even mild severity affects the prognosis of patients with acute coronary syndrome (ACS). The present study retrospectively analyzed 1,142 patients with ACS and MR of varying severity. Of the 95 patients with severe MR, 57 (60%) underwent primary percutaneous coronary intervention only and 38 (40%) underwent coronary artery bypass grafting (CABG) and mitral valve replacement (MVR). The severity of MR was significantly associated with the risk of heart failure but not with in-hospital or long-term mortality. In patients with severe MR, in-hospital mortality was no greater in those treated with CABG and MVR than in those treated with percutaneous coronary intervention alone. However, the incidence of long-term hard events (heart failure and all-cause mortality) was lower in those who had received the combined treatment. Multivariate analysis showed that, compared to percutaneous coronary intervention alone, CABG combined with MVR at the acute phase of ACS resulted in a significantly improved prognosis (odds ratio 0.172, 95% confidence interval 0.046 to 0.649, p = 0.009), even after adjusting for age, left ventricular filling pressure, and ejection fraction. In conclusion, the severity of MR in patients with ACS is associated with long-term heart failure events. Even at the acute phase of ACS, CABG combined with MVR results in an acceptable in-hospital mortality rate. The combined strategy also reduced the long-term hard events.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Lamas G.A.
        • Mitchell G.F.
        • Flaker G.C.
        • Smith Jr, S.C.
        • Gersh B.J.
        • Basta L.
        • Moyé L.
        • Braunwald E.
        • Pfeffer M.A.
        Clinical significance of mitral regurgitation after acute myocardial infarction: Survival and Ventricluar Enlargement Investigators.
        Circulation. 1997; 96: 827-833
        • Pastorius C.A.
        • Henry T.D.
        • Harris K.M.
        Long-term outcomes of patients with mitral regurgitation undergoing percutaneous coronary intervention.
        Am J Cardiol. 2007; 100: 1218-1223
        • Bursi F.
        • Enriquez-Sarano M.
        • Nkomo V.T.
        • Jacobsen S.J.
        • Weston S.A.
        • Meverden R.A.
        • Roger V.L.
        Heart failure and death after myocardial infarction in the community: the emerging role of mitral regurgitation.
        Circulation. 2005; 111: 295-301
        • Hillis G.S.
        • Møller J.E.
        • Pellikka P.A.
        • Bell M.R.
        • Casaclang-Verzosa G.C.
        • Oh J.K.
        Prognostic significance of echocardiographically defined mitral regurgitation early after acute myocardial infarction.
        Am Heart J. 2005; 150: 1268-1275
        • Pérez de Isla L.
        • Zamorano J.
        • Quezada M.
        • Almería C.
        • Rodrigo J.L.
        • Serra V.
        • Garcia Rubira J.C.
        • Ortiz A.F.
        • Macaya C.
        Functional mitral regurgitation after a first non–ST-segment elevation acute coronary syndrome: contribution to congestive heart failure.
        Eur Heart J. 2007; 28: 2866-2872
        • Perez de Isla L.
        • Zamorano J.
        • Quezada M.
        • Almería C.
        • Rodrigo J.L.
        • Serra V.
        • García Rubira J.C.
        • Ortiz A.F.
        • Macaya C.
        Prognostic significance of functional mitral regurgitation after a first non–ST-segment elevation acute myocardial infarction.
        Eur Heart J. 2006; 27: 2655-2660
        • Tcheng J.E.
        • Jackman Jr, J.D.
        • Nelson C.L.
        • Gardner L.H.
        • Smith L.R.
        • Rankin J.S.
        • Califf R.M.
        • Stack R.S.
        Outcome of patients sustaining acute ischemic mitral regurgitation during myocardial infarction.
        Ann Intern Med. 1992; 117: 18-24
        • Pellizzon G.G.
        • Grines C.L.
        • Cox D.A.
        • Stuckey T.
        • Tcheng J.E.
        • Garcia E.
        • Guagliumi G.
        • Turco M.
        • Lansky A.J.
        • Griffin J.J.
        • Cohen D.J.
        • Aymong E.
        • Mehran R.
        • O'Neill W.W.
        • Stone G.W.
        Importance of mitral regurgitation in patients undergoing percutaneous coronary intervention for acute myocardial infarction: the Controlled Abciximab and Device Investigation to Lower Late Angiography Complications (CADILLAC) trial.
        J Am Coll Cardiol. 2004; 43: 1368-1374
        • Persson A.
        • Hartford M.
        • Herlitz J.
        • Karlsson T.
        • Omland T.
        • Caidahl K.
        Long-term prognostic value of mitral regurgitation in acute coronary syndromes.
        Heart. 2010; 96: 1803-1808
        • Replogle R.L.
        • Campbell C.D.
        Surgery for mitral regurgitation associated with ischemic heart disease.
        Circulation. 1989; 79: 122-125
        • Morishita A.
        • Shimakura T.
        • Nonoyama M.
        • Takasaki T.
        Mitral valve replacement in ischemic mitral regurgitation.
        J Cardiovasc Surg. 2002; 43: 147-152
        • Perers E.
        • Caidahl K.
        • Herlitz J.
        • Sjölin M.
        • Karlson B.W.
        • Karlsson T.
        • Hartford M.
        Spectrum of acute coronary syndromes: history and clinical presentation in relation to sex and age.
        Cardiology. 2004; 102: 67-76
        • Hurrell D.G.
        • Nishimura R.A.
        • Ilstrup D.M.
        • Appleton C.P.
        Utility of preload alteration in assessment of left ventricular filling pressure by Doppler echocardiography: a simultaneous catheterization and Doppler echocardiographic study.
        J Am Coll Cardiol. 1997; 30: 459-467
        • Enriquez-Sarano M.
        • Tajik A.J.
        • Bailey K.R.
        • Seward J.B.
        Color flow imaging compared with quantitative Doppler assessment of severity of mitral regurgitation: influence of eccentricity of jet and mechanism of regurgitation.
        J Am Coll Cardiol. 1993; 21: 1211-1219
        • Ujino K.
        • Barnes M.E.
        • Cha S.S.
        • Langins A.P.
        • Bailey K.R.
        • Seward J.B.
        • Tsang T.S.
        Two-dimensional echocardiographic methods for assessment of left atrial volume.
        Am J Cardiol. 2006; 98: 1185-1188
        • Tsang T.S.
        • Barnes M.E.
        • Bailey K.R.
        • Leibson C.L.
        • Montgomery S.C.
        • Takemoto Y.
        • Diamond P.M.
        • Marra M.A.
        • Gersh B.J.
        • Wiebers D.O.
        • Petty G.W.
        • Seward J.B.
        Left atrial volume: important risk marker of incident atrial fibrillation in 1655 older men and women.
        Mayo Clin Proc. 2001; 76: 467-475
        • Enriquez-Sarano M.
        • Bailey K.R.
        • Seward J.B.
        • Tajik A.J.
        • Krohn M.J.
        • Mays J.M.
        Quantitative Doppler assessment of valvular regurgitation.
        Circulation. 1993; 87: 841-848
        • Grigioni F.
        • Enriquez-Sarano M.
        • Zehr K.J.
        • Bailey K.R.
        • Tajik A.J.
        Ischemic mitral regurgitation: long-term outcome and prognostic implications with quantitative Doppler assessment.
        Circulation. 2001; 103: 1759-1764
        • Schroder J.N.
        • Williams M.L.
        • Hata J.A.
        • Muhlbaier L.H.
        • Swaminathan M.
        • Mathew J.P.
        • Glower D.D.
        • O'Connor C.M.
        • Smith P.K.
        • Milano C.A.
        Impact of mitral valve regurgitation evaluated by intraoperative transesophageal echocardiography on long-term outcomes after coronary artery bypass grafting.
        Circulation. 2005; 112: I293-I298
        • Harris K.M.
        • Sundt III, T.M.
        • Aeppli D.
        • Sharma R.
        • Barzilai B.
        Can late survival of patients with moderate ischemic mitral regurgitation be impacted by intervention on the valve?.
        Ann Thorac Surg. 2002; 74: 1468-1475
        • Aklog L.
        • Filsoufi F.
        • Flores K.Q.
        • Chen R.H.
        • Cohn L.H.
        • Nathan N.S.
        • Byrne J.G.
        • Adams D.H.
        Does coronary artery bypass grafting alone correct moderate ischemic mitral regurgitation?.
        Circulation. 2001; 104: 168-175
        • Tahta S.A.
        • Oury J.H.
        • Maxwell J.M.
        • Hiro S.P.
        • Duran C.M.
        Outcome after mitral valve repair for functional ischemic mitral regurgitation.
        J Heart Valve Dis. 2002; 11: 11-19
        • Pu M.
        • Thomas J.D.
        • Gillinov M.A.
        • Griffin B.P.
        • Brunken R.C.
        Importance of ischemic and viable myocardium for patients with chronic ischemic mitral regurgitation and left ventricular dysfunction.
        Am J Cardiol. 2003; 92: 862-864
        • Campwala S.Z.
        • Wang N.
        • Pai R.G.
        Factors affecting regression of ischemic mitral regurgitation following isolated coronary artery bypass surgery.
        J Am Coll Cardiol. 2003; 41: 504A
        • Trichon B.H.
        • Glower D.D.
        • Shaw L.K.
        • Cabell C.H.
        • Anstrom K.J.
        • Felker G.M.
        • O'Connor C.M.
        Survival after coronary revascularization, with and without mitral valve surgery, in patients with ischemic mitral regurgitation.
        Circulation. 2003; 108: II-103-II-110
        • Zoghbi W.A.
        • Enriquez-Sarano M.
        • Foster E.
        • Grayburn P.A.
        • Kraft C.D.
        • Levine R.A.
        • Nihoyannopoulos P.
        • Otto C.M.
        • Quinones M.A.
        • Rakowski H.
        • Steward W.J.
        • Waggoner A.
        • Weissman N.J.
        • American Society of Echocardiography
        Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography.
        J Am Soc Echocardiogr. 2003; 16: 777-802