COUNTERPOINT: Efficacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation

Dr Fattouch and colleagues present the first prospective randomized trial on the very controversial group of patients with chronic moderate ischemic mitral regurgitation (MR) undergoing coronary artery bypass (CAB). They randomized 100 patients with 2+ ischemic MR to CAB alone and combined CAB plus restrictive mitral annuloplasty. All patients had a prior myocardial infarction (MI) and decreased ventricular function (ejection fraction [EF], 42%), New York Heart Association (NYHA) class was 2.3, left ventricular end-diastolic diameter (LVEDD) was 59 mm, and pulmonary artery pressure was 40 mm Hg. The 5-year survival was 88.8% in the CAB-only group and 93.7% in the combined group. The combined group showed reverse remodeling with resolution of MR at 5 years (mean MR grade, 0.08 +/-0.2; LVEDD, 52 mm; left ventricular [LV] EF, 48%; pulmonary artery pressure, 26 mm Hg; and mean NYHA class, 0.6). The CAB-only group showed an insignificant improvement in functional parameters and worsening of MR in 35%. Exercise echocardiographic analysis was basically normal in the combined group but significantly impaired in the CAB-only group. These results are impressive.