Surgical Strategies in Moderate Ischemic Mitral Insufficiency in Patients Undergoing Coronary Artery Bypass Graft
Surgical Strategies in Moderate Ischemic Mitral Insufficiency in Patients Undergoing Coronary Artery Bypass Graft
Ischemic mitral regurgitation (IMR) is a common complication of myocardial infarction, with a
 reported prevalence of 13-59%. Approximately one-third of these patients have at least
 moderate MR .
Ischemic mitral regurgitation (IMR) is a common complication of myocardial infarction, with a
 reported prevalence of 13-59%. Approximately one-third of these patients have at least
 moderate MR .

 The mechanism of IMR is complex and multifactorial.IMR results from the distortion and
 remodeling of the left ventricle after myocardial infarction ,where the papillary muscles are
 displaced away from the annular plane. Coupled with annular flattening, enlargement, and
 decreased contraction, this spatial deformation exerts traction on the chordae tendineae,
 leading to mal-coaptation of the structurally normal mitral valve and subsequently to
 secondary MR. Furthermore, the MR-related left ventricular(LV) volume overload promotes LV
 remodeling, resulting in exacerbation of the MR (MR begets more MR) . Two patterns of leaflet
 tethering have been reported in secondary MR: asymmetric tethering and symmetric tethering.
 Asymmetric tethering occurs with regional LV remodeling, resulting in displacement of the
 posterior papillary muscle in a lateral direction. Symmetric tethering generally results from
 global LV remodeling, resulting in apical tethering of both the anterior and posterior
 papillary muscles.

 Most studies show that severe IMR is not usually improved by revascularization alone and that
 residual MR is associated with an increased mortality risk. It is generally accepted that
 severe IMR should be corrected at the time of Coronary artery bypass grafting(CABG).

 Surgical correction of moderate IMR at the time of coronary revascularization is still an
 unresolved controversy.CABG alone did reduce MR at follow-up; nevertheless, CABG alone cannot
 be sufficient to eliminate MR in all cases , Adding mitral valve annuloplasty to CABG may
 eliminate MR immediately after surgery; however, recurrent MR did occur after CABG plus
 mitral valve annuloplasty, and no benefit for long-term survival was observed. There was also
 a tendency toward higher morbidity and mortality in CABG plus mitral valve procedure as
 compared with CABG alone in high-risk patients with moderate IMR. The latest American
 Association for Thoracic Surgery (AATS)guidelines suggested that for moderate IMR, mitral
 valve repair with an undersized complete rigid ring annuloplasty "may be considered" during
 CABG surgery, but not necessarily "preferred" over revascularization alone.Therefore ,the
 benefits of adding mitral valve procedure to CABG for treating moderate IMR have not been
 clearly established.

 This study is aiming to determine the short term morbidity in patients undergoing CABG alone
 and comparing them with patients undergoing concomitant MV repair by assessment of morbidity
 and mortality in both groups postoperatively .
Inclusion Criteria:

 -  All patient with multi-vessel coronary artery disease with moderate degree of ischemic
 mitral regurgitation .

 -  Patient undergone surgery using cardiopulmonary bypass.

 -  Patient done on elective basis

 Exclusion Criteria:

 -  CABG done by off-pump technique.

 -  patients not candidates for complete revascularization.

 -  patients with other valvular affection other than mitral valve.

 -  Patients done on emergency basis.

 -  patient known to have Rheumatic valvular heart disease.