Combined functional mitral valve surgery and coronary artery bypass grafting in patients with severe impaired left ventricles is still a challenge

Objectives: The goal of this study was to analyze the outcome of complex mitral valve (MV) pathology and concomitant coronary arterial bypass graft (CABG) in patients with severe ischemic cardiomyopathy.

Methods: Within the last decade 380 patients (288 male) with severe functional MV pathology and systolic dysfunction (mean ejection fraction 24.84 ± 6.18%) underwent MV surgery combined with CABG. Mean logistic Euro Score was 19.1%. Of all patients 18.7% were in cardiac shock, 10% were in a critical preoperative state and 12.1% were operated on as an emergency. Operative data, 30-day mortality and long-term outcome, MV related re-intervention and complications were retrospectively gathered. Follow-up was made with a mean time span of 1328 days (range 7 – 4198).

Results: MV repair could be done in 88% of patients, mostly using Carpentier-Edwards Physio Ring Modell 4450 and Carpentier-Edwards IMR Etilogix-Ring in 57.6% and 24.8%. Of the 45 patients with MV replacement, 32 received a biological and 13 a mechanical valve. Operation-, bypass- and cross clamp time was 326.1 ± 77.5, 134.8 ± 47.0 and 80.7 ± 28.3 minutes respectively. Postoperatively, 20% of the patients needed an intra-aortic-ballon-pump (IABP) and 2.6% were obtained with an ECMO. The 30 day mortality was 12.9% with a follow up of 99.5%. Long term mortality at 1, 5 and 10 years was 25%, 41.1% and 51.3% respectively. MV-related reoperation rate was 7.4%. MV replacement was done in 10 patients (2.6%) and MV repair in 2 patients (0.5%) with a mean postoperative reoperation time of 591 and 55 days respectively. A revision of CABG was necessary in 4 patients (1.1%) at a median of 0.5 days postoperatively. 13 reoperations were done for other purposes such as aortic valve replacement, ventricular assist devices implantation or heart transplantation.

Conclusion: Considering the impaired LV function and the clinical scenario of these patients, the combined complex MV surgery in addition to CABG is still challenging. However, a appropriate early and long-term outcome can be obtained.