Operative therapy for mitral insufficiency from coronary artery disease.

This report reviews the results of combined coronary bypass and Carpentier-type mitral valve reconstruction in 115 patients with ischemic mitral insufficiency. Overall operative mortality was 15.7%. Factors that increased operative risk in the overall valve repair population of 638 patients included ischemic etiology, previous cardiac surgery, NYHA functional classification, and age. Variables predicting increased risk of late cardiac death were ischemic etiology, concomitant procedures, and pulmonary hypertension. Late survival was diminished in ischemic patients, but 10-year freedom from reoperation was 93%, suggesting excellent durability after repair for ischemic mitral insufficiency. These results are compared with published reports of operative treatment for mitral insufficiency from coronary artery disease. Guidelines for use of coronary bypass alone versus coronary bypass in association with valve repair or replacement are developed. In most patients with moderate to severe mitral insufficiency secondary to coronary artery disease, the valvular pathology must be corrected, and valve repair with ring annuloplasty is the preferred method. Preoperative planning based on transesophageal echocardiography and cardiac catheterization data is essential for proper operative strategy, and attention to cardioplegia delivery and techniques to minimize reperfusion injury are necessary for optimal results. With these guidelines, late results are excellent after operative treatment for ischemic mitral insufficiency.