Surgical management of ischemic mitral regurgitation: indications, procedures, and future prospects

Patch detachment after mitral valve repair with posterior leaflet augmentation: a case report

Mitral valve (MV) repair is indicated for patients with severe MR. We report a case of acute MR caused by patch detachment after posterior leaflet augmentation in MV repair. A 65-year-old male underwent MV repair with posterior leaflet augmentation and coronary artery bypass graft 1 month prior to this study. An inverted T-shaped incision was made on the posterior mitral leaflet (PML), and a piece of autologous fresh pericardium was sewn in the PML defect. Seven days after hospital discharge, he started feeling chest pain and presented with pulseless electrical activity. Ultrasonic cardiography showed severe mitral regurgitation (MR), which was suggestive of acute MR. We performed emergency reoperation. The edge of the autologous pericardial patch was detached from the anterior papillary muscle, and MV replacement was performed. He was discharged from the hospital 55 days after the reoperation and returned to his normal daily life. We conclude that avoidance of tension focalization during MV repair may be important.

Comparison of five-year outcomes of coronary artery bypass grafting versus percutaneous coronary intervention in patients with left ventricular ejection fractions≤50% versus >50% (from the CREDO-Kyoto PCI/CABG Registry Cohort-2)

Coronary heart disease is a major risk factor for left ventricular (LV) systolic dysfunction. However, limited data are available regarding long-term benefits of percutaneous coronary intervention (PCI) in the era of drug-eluting stent or coronary artery bypass grafting (CABG) in patients with LV systolic dysfunction with severe coronary artery disease. We identified 3,584 patients with 3-vessel and/or left main disease of 15,939 patients undergoing first myocardial revascularization enrolled in the CREDO-Kyoto PCI/CABG Registry Cohort-2. Of them, 2,676 patients had preserved LV systolic function, defined as an LV ejection fraction (LVEF) of >50% and 908 had impaired LV systolic function (LVEF≤50%). In patients with preserved LV function, 5-year outcomes were not different between PCI and CABG regarding propensity score-adjusted risk of all-cause and cardiac deaths. In contrast, in patients with impaired LV systolic function, the risks of all-cause and cardiac deaths after PCI were significantly greater than those after CABG (hazard ratio 1.49, 95% confidence interval 1.04 to 2.14, p=0.03 and hazard ratio 2.39, 95% confidence interval 1.43 to 3.98, p<0.01). In both patients with moderate (35%<LVEF≤50%) and severe (LVEF≤35%) LV systolic dysfunction, the risk of cardiac death after PCI was significantly greater than that after CABG (hazard ratio 2.25, 95% confidence interval 1.15 to 4.40, p=0.02 and hazard ratio 4.42, 95% confidence interval 1.48 to 13.24, p=0.01). Similarly, the risk of all-cause death tended to be greater after PCI than after CABG in both patients with moderate and severe LV systolic dysfunction without significant interaction (hazard ratio 1.57, 95% confidence interval 0.96 to 2.56, p=0.07 and hazard ratio 1.42, 95% confidence interval 0.71 to 2.82, p=0.32; interaction p=0.91). CABG was associated with better 5-year survival outcomes than PCI in patients with impaired LV systolic function (LVEF≤50%) with complex coronary disease in the era of drug-eluting stents. In both patients with moderate (35%<LVEF≤50%) and severe (LVEF≤35%) LV systolic dysfunction, CABG tended to have better survival outcomes than PCI.