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Wrobel K, Stevens SR, Jones RH, Selzman CH, Lamy A, Beaver TM, Djokovic LT, Wang N, Velazquez EJ, Sopko G, Kron IL, DiMaio JM, Michler RE, Lee KL, Yii M, Leng CY, Zembala M, Rouleau JL, Daly RC, Al-Khalidi HR. Influence of Baseline Characteristics, Operative Conduct, and Postoperative Course on 30-Day Outcomes of Coronary Artery Bypass Grafting Among Patients With Left Ventricular Dysfunction: Results From the Surgical Treatment for Ischemic Heart Failure (STICH) Trial. Circulation 2015; 132:720-30. [PMID: 26304663 DOI: 10.1161/circulationaha.114.014932] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with severe left ventricular dysfunction, ischemic heart failure, and coronary artery disease suitable for coronary artery bypass grafting (CABG) are at higher risk for surgical morbidity and mortality. Paradoxically, those patients with the most severe coronary artery disease and ventricular dysfunction who derive the greatest clinical benefit from CABG are also at the greatest operative risk, which makes decision making regarding whether to proceed to surgery difficult in such patients. To better inform such decision making, we analyzed the Surgical Treatment for Ischemic Heart Failure (STICH) CABG population for detailed information on perioperative risk and outcomes. METHODS AND RESULTS In both STICH trials (hypotheses), 2136 patients with a left ventricular ejection fraction of ≤35% and coronary artery disease were allocated to medical therapy, CABG plus medical therapy, or CABG with surgical ventricular reconstruction. Relationships of baseline characteristics and operative conduct with morbidity and mortality at 30 days were evaluated. There were a total of 1460 patients randomized to and receiving surgery, and 346 (≈25%) of these high-risk patients developed a severe complication within 30 days. Worsening renal insufficiency, cardiac arrest with cardiopulmonary resuscitation, and ventricular arrhythmias were the most frequent complications and those most commonly associated with death. Mortality at 30 days was 5.1% and was generally preceded by a serious complication (65 of 74 deaths). Left ventricular size, renal dysfunction, advanced age, and atrial fibrillation/flutter were significant preoperative predictors of mortality within 30 days. Cardiopulmonary bypass time was the only independent surgical variable predictive of 30-day mortality. CONCLUSIONS CABG can be performed with relatively low 30-day mortality in patients with left ventricular dysfunction. Serious postoperative complications occurred in nearly 1 in 4 patients and were associated with mortality. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00023595.
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Affiliation(s)
- Krzysztof Wrobel
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Susanna R Stevens
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Robert H Jones
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Craig H Selzman
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Andre Lamy
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Thomas M Beaver
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Ljubomir T Djokovic
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Nan Wang
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Eric J Velazquez
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - George Sopko
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Irving L Kron
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - J Michael DiMaio
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Robert E Michler
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Kerry L Lee
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Michael Yii
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Chua Yeow Leng
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Marian Zembala
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Jean L Rouleau
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Richard C Daly
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.)
| | - Hussein R Al-Khalidi
- From Allenort Hospital, Warsaw, Poland and John Paul II Hospital, Krakow, Poland (K.W.); Duke Clinical Research Institute, Durham, NC (S.R.S.); Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC (R.H.J., E.J.V., K.L.L., H.R.A.); University of Utah, Salt Lake City, UT (C.H.S.); Hamilton General Hospital/McMaster University, Hamilton, ON, Canada (A.L.); Shands Hospital at the University of Florida, Gainesville (T.M.B.); Dedinje Cardiovascular Institute, Belgrade, Serbia (L.T.D.); Loma Linda University Medical Center, CA (N.W.); National Institutes of Health/National Heart, Blood, and Lung Institute, Bethesda, MD (G.S.); University of Virginia, Charlottesville (I.L.K.); Baylor University Medical Center, Dallas, TX (J.M.D.); Montefiore Medical Center and Albert Einstein College of Medicine, New York (R.E.M.); St. Vincent's Hospital Melbourne and University of Melbourne, Australia (M.Y.); National Heart Centre Singapore (C.Y.L.); Silesian Center for Heart Diseases in Zabrze, Poland (M.Z.); Montreal Heart Institute, University de Montréal, Canada (J.L.R.); and Mayo Clinic, Rochester, MN (R.C.D.).
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Castleberry AW, Williams JB, Daneshmand MA, Honeycutt E, Shaw LK, Samad Z, Lopes RD, Alexander JH, Mathew JP, Velazquez EJ, Milano CA, Smith PK. Surgical revascularization is associated with maximal survival in patients with ischemic mitral regurgitation: a 20-year experience. Circulation 2014; 129:2547-56. [PMID: 24744275 DOI: 10.1161/circulationaha.113.005223] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The optimal treatment for ischemic mitral regurgitation remains actively debated. Our objective was to evaluate the relationship between ischemic mitral regurgitation treatment strategy and survival. METHODS AND RESULTS We retrospectively reviewed patients at our institution diagnosed with significant coronary artery disease and moderate or severe ischemic mitral regurgitation from 1990 to 2009, categorized by medical treatment alone, percutaneous coronary intervention, coronary artery bypass grafting (CABG), or CABG plus mitral valve repair or replacement. Kaplan-Meier methods and multivariable Cox proportional hazards analyses were performed to assess the relationship between treatment strategy and survival, with the use of propensity scores to account for nonrandom treatment assignment. A total of 4989 patients were included: medical treatment alone=36%, percutaneous coronary intervention=26%, CABG=33%, and CABG plus mitral valve repair or replacement=5%. Median follow-up was 5.37 years. Compared with medical treatment alone, significantly lower mortality was observed in patients treated with percutaneous coronary intervention (adjusted hazard ratio, 0.83; 95% confidence interval, 0.76-0.92; P=0.0002), CABG (adjusted hazard ratio, 0.56; 95% confidence interval, 0.51-0.62; P<0.0001), and CABG plus mitral valve repair or replacement (adjusted hazard ratio, 0.69; 95% confidence interval, 0.57-0.82; P<0.0001). There was no significant difference in these results based on mitral regurgitation severity. CONCLUSIONS Patients with significant coronary artery disease and moderate or severe ischemic mitral regurgitation undergoing CABG alone demonstrated the lowest risk of death. CABG with or without mitral valve surgery was associated with lower mortality than either percutaneous coronary intervention or medical treatment alone.
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Affiliation(s)
- Anthony W Castleberry
- From the Department of Surgery; The Division of Cardiovascular and Thoracic Surgery (A.W.C., J.B.W., M.A.D., C.A.M., P.K.S.); Duke Clinical Research Institute (J.B.W., E.H., L.K.S., R.D.L., J.H.A., E.J.V.); Department of Medicine, Division of Cardiology (Z.S., R.D.L., J.H.A., E.J.V.); and Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Critical Care Medicine (J.P.M.), Duke Medicine, Durham, NC
| | - Judson B Williams
- From the Department of Surgery; The Division of Cardiovascular and Thoracic Surgery (A.W.C., J.B.W., M.A.D., C.A.M., P.K.S.); Duke Clinical Research Institute (J.B.W., E.H., L.K.S., R.D.L., J.H.A., E.J.V.); Department of Medicine, Division of Cardiology (Z.S., R.D.L., J.H.A., E.J.V.); and Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Critical Care Medicine (J.P.M.), Duke Medicine, Durham, NC
| | - Mani A Daneshmand
- From the Department of Surgery; The Division of Cardiovascular and Thoracic Surgery (A.W.C., J.B.W., M.A.D., C.A.M., P.K.S.); Duke Clinical Research Institute (J.B.W., E.H., L.K.S., R.D.L., J.H.A., E.J.V.); Department of Medicine, Division of Cardiology (Z.S., R.D.L., J.H.A., E.J.V.); and Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Critical Care Medicine (J.P.M.), Duke Medicine, Durham, NC
| | - Emily Honeycutt
- From the Department of Surgery; The Division of Cardiovascular and Thoracic Surgery (A.W.C., J.B.W., M.A.D., C.A.M., P.K.S.); Duke Clinical Research Institute (J.B.W., E.H., L.K.S., R.D.L., J.H.A., E.J.V.); Department of Medicine, Division of Cardiology (Z.S., R.D.L., J.H.A., E.J.V.); and Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Critical Care Medicine (J.P.M.), Duke Medicine, Durham, NC
| | - Linda K Shaw
- From the Department of Surgery; The Division of Cardiovascular and Thoracic Surgery (A.W.C., J.B.W., M.A.D., C.A.M., P.K.S.); Duke Clinical Research Institute (J.B.W., E.H., L.K.S., R.D.L., J.H.A., E.J.V.); Department of Medicine, Division of Cardiology (Z.S., R.D.L., J.H.A., E.J.V.); and Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Critical Care Medicine (J.P.M.), Duke Medicine, Durham, NC
| | - Zainab Samad
- From the Department of Surgery; The Division of Cardiovascular and Thoracic Surgery (A.W.C., J.B.W., M.A.D., C.A.M., P.K.S.); Duke Clinical Research Institute (J.B.W., E.H., L.K.S., R.D.L., J.H.A., E.J.V.); Department of Medicine, Division of Cardiology (Z.S., R.D.L., J.H.A., E.J.V.); and Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Critical Care Medicine (J.P.M.), Duke Medicine, Durham, NC
| | - Renato D Lopes
- From the Department of Surgery; The Division of Cardiovascular and Thoracic Surgery (A.W.C., J.B.W., M.A.D., C.A.M., P.K.S.); Duke Clinical Research Institute (J.B.W., E.H., L.K.S., R.D.L., J.H.A., E.J.V.); Department of Medicine, Division of Cardiology (Z.S., R.D.L., J.H.A., E.J.V.); and Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Critical Care Medicine (J.P.M.), Duke Medicine, Durham, NC
| | - John H Alexander
- From the Department of Surgery; The Division of Cardiovascular and Thoracic Surgery (A.W.C., J.B.W., M.A.D., C.A.M., P.K.S.); Duke Clinical Research Institute (J.B.W., E.H., L.K.S., R.D.L., J.H.A., E.J.V.); Department of Medicine, Division of Cardiology (Z.S., R.D.L., J.H.A., E.J.V.); and Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Critical Care Medicine (J.P.M.), Duke Medicine, Durham, NC
| | - Joseph P Mathew
- From the Department of Surgery; The Division of Cardiovascular and Thoracic Surgery (A.W.C., J.B.W., M.A.D., C.A.M., P.K.S.); Duke Clinical Research Institute (J.B.W., E.H., L.K.S., R.D.L., J.H.A., E.J.V.); Department of Medicine, Division of Cardiology (Z.S., R.D.L., J.H.A., E.J.V.); and Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Critical Care Medicine (J.P.M.), Duke Medicine, Durham, NC
| | - Eric J Velazquez
- From the Department of Surgery; The Division of Cardiovascular and Thoracic Surgery (A.W.C., J.B.W., M.A.D., C.A.M., P.K.S.); Duke Clinical Research Institute (J.B.W., E.H., L.K.S., R.D.L., J.H.A., E.J.V.); Department of Medicine, Division of Cardiology (Z.S., R.D.L., J.H.A., E.J.V.); and Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Critical Care Medicine (J.P.M.), Duke Medicine, Durham, NC
| | - Carmelo A Milano
- From the Department of Surgery; The Division of Cardiovascular and Thoracic Surgery (A.W.C., J.B.W., M.A.D., C.A.M., P.K.S.); Duke Clinical Research Institute (J.B.W., E.H., L.K.S., R.D.L., J.H.A., E.J.V.); Department of Medicine, Division of Cardiology (Z.S., R.D.L., J.H.A., E.J.V.); and Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Critical Care Medicine (J.P.M.), Duke Medicine, Durham, NC
| | - Peter K Smith
- From the Department of Surgery; The Division of Cardiovascular and Thoracic Surgery (A.W.C., J.B.W., M.A.D., C.A.M., P.K.S.); Duke Clinical Research Institute (J.B.W., E.H., L.K.S., R.D.L., J.H.A., E.J.V.); Department of Medicine, Division of Cardiology (Z.S., R.D.L., J.H.A., E.J.V.); and Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Critical Care Medicine (J.P.M.), Duke Medicine, Durham, NC.
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