Abstract
Objective
Reduction in left ventricular ejection fraction (LVEF) is common after mitral valve (MV) repair or replacement in patients with mitral regurgitation (MR). This study aims to evaluate the trajectory of postoperative LVEF reduction after MV surgery and determine whether this change in LVEF is associated with clinical outcomes.
Methods
This is a retrospective study of 625 patients who underwent MV surgery for moderate/severe MR between 2015 and 2023. Patients with aortic valve pathology, concomitant aortic procedures, endocarditis, and previous MV operations were excluded. Patients were divided into 4 quartiles on the basis of pre- and postoperative percent difference in LVEF. In-hospital outcomes and long-term mortality using Kaplan-Meier analysis were compared between groups. Cubic spline adjusted for preoperative LVEF was used to determine the impact of percent LVEF difference on mortality. Spaghetti plots depicted the trajectory in LVEF over a 2-year follow-up period.
Results
Patients were divided into percent LVEF reduction quartiles as follows: severely reduced (159 [25.4%], greater than −19%), moderately reduced (157 [25.1%], between −19% and −8%), stable (171 [27.4%], between −7% and +4%), and increased (138 [22.1%], greater than a +4%). Baseline characteristics were similar. There was no difference in the percent of patients undergoing MV repair versus replacement across LVEF reduction groups (P = .55). Postoperative outcomes were similar between groups, including reoperation for bleeding, stroke, and atrial fibrillation. Long-term survival probability over 7 years was similar between all 4 groups (P = .35). There was no significant change in hazards ratio for long-term mortality across range of LVEF differences. Patients with severely or moderately reduced LVEF postoperatively remained with a depressed LVEF during the 2-year follow-up period, whereas patients with the same or increased postoperative LVEF returned to baseline.
Conclusions
Reduction in LVEF is common after MV repair or replacement with effects persisting after 2 years. Changes in LVEF after MV operation do not appear to affect clinical outcomes and may by itself not accurately reflect myocardial dysfunction related to MR and subsequent intervention.
Key Words: mitral valve, left ventricular ejection fraction, reduction in LVEF after MV operation, mitral regurgitation
Trends in LVEF after MV operation.
Central Message.
Patients undergoing mitral valve operation experience reduced LVEF but without impact on long-term survival.
Perspective.
LVEF commonly decreases after mitral valve repair or replacement, and this can persist over 2 years. Short-term outcomes do not appear to differ linearly with percent LVEF change, and there is no significant impact on survival.
It is a well-characterized phenomenon that left ventricular ejection fraction (LVEF) can decrease after mitral valve (MV) operation for primary mitral regurgitation (MR), and lower preoperative LVEF is associated with inferior long-term survival after MV operation.1, 2, 3, 4, 5, 6 Acute reduction in LVEF after MV repair or replacement is thought to be attributable to the immediate loss of the low-resistance leak into the left atrium, leading to an acute change in left ventricular (LV) loading conditions.7 However, studies on the relative change in LVEF before and after MV repair or replacement in patients with moderate/severe MR and their long-term trends are lacking. Furthermore, whether the degree of change in LVEF differs between MV repair versus replacement remains unknown. The objective of this study is to examine the 2-year trajectory in LVEF in patients with moderate/severe MR undergoing MV repair/replacement and elucidate the impact of change in LVEF on mortality.
Methods
Ethical Statement
This study was approved by the institutional review boards of Columbia University Irving Medical Center with the waiver of consent (Columbia, AAAV2342, December 3, 2024).
Study Design
This is a single-center retrospective study involving 625 patients who underwent MV repair or replacement at Columbia University Irving Medical Center from July 6, 2015, to June 28, 2023. The end points were long-term mortality and LVEF postoperatively and over a 2-year period. Data were collected from the electronic medical records on all patients. Definitions of the postoperative complications followed those of the Society of Thoracic Surgeons Adult Cardiac Surgery Database.8 All-cause mortality during the follow-up period was collected through clinical encounters, and death information was supplemented through the Centers for Disease Control and Prevention National Death Index, accessed on November 25, 2024, and complete to December 31, 2022.9 Median length of follow-up was 4.24 [2.14-6.28] years with 89.6% completeness. Clinical follow-up information, including survival status was considered complete if known beyond 1-year postoperatively.
Study Population
There were 1996 total patients who underwent MV operations during our study period. Among these patients, 1308 were sequentially excluded as follows: less than moderate MR, moderate/severe MS, moderate/severe aortic stenosis or aortic regurgitation, concomitant aortic or AV procedure, previous MV procedure, Carpentier type IIIB mitral leaflet dysfunction, transcatheter procedure, rheumatic disease, hypertrophic cardiomyopathy, endocarditis, concomitant left ventricular assist device, other, and 30-day or operative mortality, as shown in Figure E1. This left 688 patients with moderate or severe MR, of whom 63 were excluded due to lack of available postoperative echo, leading to a final cohort of 625 patients. Two subgroup analyses were performed, the first including only patients with Carpentier class II disease, and the second excluding patients who underwent concomitant coronary artery bypass grafting (CABG).
Figure E1.
Inclusion and exclusion criteria. MR, Mitral regurgitation; MS, mitral stenosis; AS, aortic stenosis; AR, aortic regurgitation; AV, aortic valve; MV, mitral valve; LVAD, left ventricular assist device.
Patient Management
The indications for proceeding with surgery were determined by the attending surgeon and were determined on the basis of the most recent American Heart Association/American College of Cardiology guidelines.10 Management of cardiopulmonary bypass was standard for our study period and remained largely unchanged. The MV was repaired whenever appropriate; when replacement was necessary, the prosthetic valve was chosen on the basis of American Heart Association/American College of Cardiology guidelines as well as patient preference.
Statistical Analysis
The modified Simpson rule was used to calculate LVEF by the reading cardiologist. Percent LVEF difference was calculated as percent change between preoperative LVEF on transthoracic echocardiograms (TTEs) and postoperative LVEF on TTEs before discharge to capture the acute change in LVEF after MV operation. If multiple TTEs were performed before patient was discharged from the hospital, the last TTE before discharge was used to mitigate from temporal surgical effects on LVEF. The distribution of LVEF percent difference across patient cohort is shown in Figure 1; patients were stratified into quartiles on the basis of percent change in LVEF: severely reduced (greater than −19%), moderately reduced (−19% to −8%), stable (−7% to +4%), and increased (greater than +4%).
Figure 1.
Histogram of percent difference in LVEF with dashed lines at 25th percentile (−19%), 50th percentile (−7%), and 75th percentile (4%). LVEF, Left ventricular ejection fraction.
Categorical variables were reported as count and percentages and were compared using the χ2 test. Normality of continuous variables were assessed via the Shapiro-Wilk test. No continuous variables followed a normal distribution and thus were reported as median and interquartile range. Continuous variables were compared using the Kruskal-Wallis test. There was no missingness in patient demographics or operative characteristics; thus, data imputation was not performed.
Cox proportional hazards regression was used to construct a cubic spline for hazards ratio of mortality versus percent difference in LVEF (adjusted to preoperative LVEF). Survival of the cohort over time was estimated using the Kaplan-Meier (KM) method and each LVEF reduction group was compared using the log-rank test. Spaghetti plots were used to visualize trends in LVEF over a 2-year period stratified by each LVEF reduction group. Absolute difference in LVEF at 0-3 months, >3-6 months, >6-12 months, and >1-2 years and immediately postoperative was calculated and mean and 95% CI were graphed. Furthermore, patients were also divided into quartiles on the basis of preoperative LVEF (less than 55%, 55%-58%, 59%-63%, and greater than 63%) to construct boxplots of absolute LVEF difference (between preoperative and postoperative TTE) and postoperative LVEF. Statistical analyses for the current study were performed with R software, version 4.2.1 (R Foundation for Statistical Computing).
Results
Patient Characteristics
Of 625 patients included in the study, quartiles of LVEF percent difference groups are as follows: severely reduced (159 [25.4%], greater than −19%), moderately reduced (157 [25.1%], between −19% and −8%), stable (171 [27.4%], between −7% and +4%), and increased (138 [22.1%], greater than a +4%). Median age of the cohort was 65 years [interquartile range, 57-73 years] and 363 (58.1%) are male. Overall, baseline characteristics are similar across groups with some differences in age, hypertension, atrial fibrillation, cerebrovascular disease, preoperative LVEF, and tricuspid regurgitation (Table 1). There were no significant differences in severity of preoperative MR, etiology, or Carpentier class of MV disease. Between LVEF percent difference quartiles, preoperative ejection fraction (EF) was significantly different (P < .001) but not linear, ie, from severely reduced to increased groups the median preoperative LVEFs were 59%, 63%, 58%, and 55% (Table 1). Absolute LVEF difference and postoperative LVEF on the basis of quartiles of preoperative LVEF are shown in Figure 2.
Table 1.
Patient demographics
| Demographics | Overall | Severely reduced | Moderately reduced | Stable | Increased | P value |
|---|---|---|---|---|---|---|
| n | 625 | 159 | 157 | 171 | 138 | |
| Age, y, median [IQR] | 66 [57, 73] | 63 [56, 71] | 64 [56, 73] | 69 [60, 74] | 67 [57, 74] | .036 |
| Male sex, % | 363 (58.1) | 107 (67.3) | 88 (56.1) | 95 (55.6) | 73 (52.9) | .051 |
| BMI, median [IQR] | 25.4 [22.8, 28.7] | 24.8 [22.7, 28.8] | 26.2 [23.7, 28.4] | 25.7 [23.1, 29.0] | 25.2 [22.0, 29.0] | .248 |
| DM, % | 65 (10.4) | 14 (8.8) | 9 (5.7) | 23 (13.5) | 19 (13.8) | .058 |
| Dialysis, % | 5 (0.8) | 3 (1.9) | 1 (0.6) | 0 (0.0) | 1 (0.7) | .283 |
| HTN, % | 369 (59.0) | 84 (52.8) | 88 (56.1) | 103 (60.2) | 94 (68.1) | .048 |
| Dyslipidemia, % | 232 (37.1) | 46 (28.9) | 62 (39.5) | 68 (39.8) | 56 (40.6) | .104 |
| Tobacco use, % | 217 (34.7) | 48 (30.2) | 60 (38.2) | 58 (33.9) | 51 (37.0) | .45 |
| Chronic lung disease, % | 105 (16.8) | 27 (17.0) | 22 (14.0) | 28 (16.4) | 28 (20.3) | .552 |
| PVD, % | 18 (2.9) | 2 (1.3) | 5 (3.2) | 9 (5.3) | 2 (1.4) | .11 |
| Atrial fibrillation, % | 289 (46.2) | 76 (47.8) | 55 (35.0) | 86 (50.3) | 72 (52.2) | .011 |
| CVD, % | 43 (6.9) | 6 (3.8) | 8 (5.1) | 12 (7.0) | 17 (12.3) | .023 |
| Previous MI (%) | 26 (4.2) | 4 (2.5) | 4 (2.5) | 9 (5.3) | 9 (6.5) | .207 |
| Cardiac catheterization performed, % | 567 (90.7) | 140 (88.1) | 145 (92.4) | 158 (92.4) | 124 (89.9) | .468 |
| Number of diseased vessels, % | .222 | |||||
| None | 409 (71.9) | 110 (78.0) | 109 (75.2) | 111 (69.8) | 79 (63.7) | |
| One | 78 (13.7) | 14 (9.9) | 17 (11.7) | 25 (15.7) | 22 (17.7) | |
| Two | 41 (7.2) | 8 (5.7) | 9 (6.2) | 15 (9.4) | 9 (7.3) | |
| Three | 41 (7.2) | 9 (6.4) | 10 (6.9) | 8 (5.0) | 14 (11.3) | |
| Etiology, % | .099 | |||||
| Myxomatous degenerative prolapse/flail | 554 (88.6) | 151 (95.0) | 142 (90.4) | 147 (86.0) | 114 (82.6) | |
| Pure annular dilatation | 31 (5.0) | 2 (1.3) | 7 (4.5) | 9 (5.3) | 13 (9.4) | |
| Mitral annular calcification | 20 (3.2) | 3 (1.9) | 5 (3.2) | 9 (5.3) | 3 (2.2) | |
| Other | 10 (1.6) | 2 (1.3) | 2 (1.3) | 3 (1.8) | 3 (2.2) | |
| Ischemic cardiomyopathy | 6 (1.0) | 1 (0.6) | 1 (0.6) | 2 (1.2) | 2 (1.4) | |
| Congenital | 2 (0.3) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 2 (1.4) | |
| Tumor | 1 (0.2) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 1 (0.7) | |
| Nonischemic cardiomyopathy | 1 (0.2) | 0 (0.0) | 0 (0.0) | 1 (0.6) | 0 (0.0) | |
| LVEF, median [IQR] | 58 [55, 63] | 59 [55, 67] | 63 [59, 65] | 58 [55, 63] | 55 [48, 55] | <.001 |
| Severe preoperative MR, % | 560 (89.6) | 149 (93.7) | 139 (88.5) | 155 (90.6) | 117 (84.8) | .082 |
| Mitral valve dysfunction, % | .122 | |||||
| Carpentier type I | 36 (5.8) | 3 (1.9) | 8 (5.1) | 13 (7.6) | 12 (8.7) | |
| Carpentier type II | 503 (80.5) | 135 (84.9) | 129 (82.2) | 137 (80.1) | 102 (73.9) | |
| Carpentier type IIIA (nonstenotic) | 22 (3.5) | 3 (1.9) | 4 (2.5) | 9 (5.3) | 6 (4.3) | |
| Mixed (type II and IIIA) | 36 (5.8) | 11 (6.9) | 8 (5.1) | 9 (5.3) | 8 (5.8) | |
| Other/unknown | 28 (4.5) | 7 (4.4) | 8 (5.1) | 3 (1.8) | 0 (7.2) | |
| Atrial functional MR, % | 18 (2.9) | 1 (0.6) | 3 (1.9) | 8 (4.7) | 6 (4.3) | .092 |
| Preoperative TR, % | .043 | |||||
| None | 32 (5.2) | 13 (8.2) | 8 (5.1) | 8 (4.7) | 3 (2.2) | |
| Trivial/trace | 199 (32.0) | 56 (35.2) | 41 (26.3) | 62 (36.7) | 40 (29.2) | |
| Mild | 195 (31.4) | 46 (28.9) | 60 (38.5) | 51 (30.2) | 38 (27.7) | |
| Moderate | 139 (22.4) | 35 (22.0) | 34 (21.8) | 35 (20.7) | 35 (25.5) | |
| Severe | 56 (9.0) | 9 (5.7) | 13 (8.3) | 13 (7.7) | 21 (15.3) |
IQR, Interquartile range; BMI, body mass index; DM, diabetes mellitus; HTN, hypertension; PVD, peripheral vascular disease; CVD, cerebrovascular disease; MI, myocardial infarction; LVEF, left ventricular ejection fraction; MR, mitral regurgitation; TR, tricuspid regurgitation.
Figure 2.
Boxplot of LVEF difference (A) and postoperative LVEF (B) categorized by quintiles of preoperative LVEF. The upper and lower borders of the box indicate the upper and lower quartiles; the middle horizontal line represents the median; and the upper and lower whiskers show the upper and lower values within 1.5 times the interquartile range. Dots represent outliers. LVEF, Left ventricular ejection fraction.
Operative Details
Patients with stable and increased LVEF were more likely to have a previous cardiac procedure than those with moderately or severely reduced LVEF (P = .008), as seen in Table 2. More patients with stable and increased LVEF underwent concomitant TV procedure compared with patients with moderately or severely reduced LVEF (P = .001). MV annuloplasty size decreased significantly (P < .001) from percent LVEF decrease to increase in patients who underwent MV repair, but there was no difference in prosthetic valve size in patients who underwent MV replacement (P = .25) (Table 2). Median crossclamp time was 86 [65-112] minutes and was similar between groups (P = .16); the cohort with increased EF had longer cardiopulmonary bypass times, although this difference was not significant (P = .07). Other operative characteristics, including the number of patients who underwent MV replacement instead of repair, concomitant CABG, and rates of mechanical circulatory support, were similar.
Table 2.
Operative characteristics
| Characteristics | Overall | Severely reduced | Moderately reduced | Stable | Increased | P value |
|---|---|---|---|---|---|---|
| n | 625 | 159 | 157 | 171 | 138 | |
| Incidence, % | .008 | |||||
| Primary operation | 599 (95.8) | 157 (98.7) | 156 (99.4) | 160 (93.6) | 126 (91.3) | |
| First reoperation | 19 (3.0) | 2 (1.3) | 1 (0.6) | 9 (5.3) | 7 (5.1) | |
| Second reoperation | 5 (0.8) | 0 (0.0) | 0 (0.0) | 1 (0.6) | 4 (2.9) | |
| Third reoperation | 2 (0.3) | 0 (0.0) | 0 (0.0) | 1 (0.6) | 1 (0.7) | |
| Status, % | .916 | |||||
| Elective | 482 (77.1) | 126 (79.2) | 121 (77.1) | 132 (77.2) | 103 (74.6) | |
| Urgent | 140 (22.4) | 32 (20.1) | 35 (22.3) | 39 (22.8) | 34 (24.6) | |
| Emergent | 3 (0.5) | 1 (0.6) | 1 (0.6) | 0 (0.0) | 1 (0.7) | |
| Operative approach, % | .781 | |||||
| Sternotomy | 472 (75.5) | 116 (73.0) | 117 (74.5) | 131 (76.6) | 108 (78.3) | |
| Right minithoracotomy | 55 (8.8) | 20 (12.6) | 13 (8.3) | 11 (6.4) | 11 (8.0) | |
| Thoracotomy | 49 (7.8) | 14 (8.8) | 13 (8.3) | 15 (8.8) | 7 (5.1) | |
| Right thoracotomy | 28 (4.5) | 5 (3.1) | 7 (4.5) | 8 (4.7) | 8 (5.8) | |
| Partial sternotomy | 20 (3.2) | 4 (2.5) | 6 (3.8) | 6 (3.5) | 4 (2.9) | |
| Port access | 1 (0.2) | 0 (0.0) | 1 (0.6) | 0 (0.0) | 0 (0.0) | |
| Concomitant CABG, % | .076 | |||||
| None | 507 (81.1) | 138 (86.8) | 131 (83.4) | 136 (79.5) | 102 (73.9) | |
| Yes, planned | 117 (18.7) | 21 (13.2) | 26 (16.6) | 34 (19.9) | 36 (26.1) | |
| Yes, unplanned | 1 (0.2) | 0 (0.0) | 0 (0.0) | 1 (0.6) | 0 (0.0) | |
| Concomitant TV procedure, % | 118 (18.9) | 19 (11.9) | 29 (18.5) | 29 (17.0) | 41 (29.7) | .001 |
| Mechanical circulatory support, % | 27 (4.3) | 8 (5.0) | 7 (4.5) | 6 (3.5) | 6 (4.3) | .76 |
| CPB time, min, median [IQR] | 124 [98, 158] | 122 [95, 158] | 119 [96, 153] | 122 [97, 151] | 136 [103, 173] | .065 |
| Crossclamp time, min, median [IQR] | 86 [65, 112] | 83 [65, 115] | 85 [62, 107] | 85 [67, 112] | 91 [74, 116] | .159 |
| MV replacement, % | 151 (24.2) | 38 (23.9) | 33 (21.0) | 41 (24.0) | 39 (28.3) | .548 |
| MV implant type, % | .029 | |||||
| Annuloplasty | 467 (74.7) | 121 (76.1) | 120 (76.4) | 130 (76.0) | 96 (69.6) | |
| Bioprosthetic valve | 139 (22.2) | 30 (18.9) | 32 (20.4) | 41 (24.0) | 36 (26.1) | |
| Mechanical valve | 14 (2.2) | 8 (5.0) | 3 (1.9) | 0 (0.0) | 3 (2.2) | |
| None | 5 (0.8) | 0 (0.0) | 2 (1.3) | 0 (0.0) | 3 (2.2) | |
| Annuloplasty size, median [IQR] | 34 [30, 36] | 34 [32, 38] | 34 [30, 36] | 32 [30, 36] | 32 [30, 34] | <.001 |
| Prosthetic valve size, median [IQR] | 29 [27, 31] | 29 [27, 31] | 29 [27, 31] | 29 [27, 31] | 27 [27, 30] | .253 |
| Surgeon, anonymous, % | .139 | |||||
| A | 117 (18.8) | 23 (14.5) | 38 (24.2) | 34 (20.0) | 22 (15.9) | |
| B | 1 (0.2) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 1 (0.7) | |
| C | 20 (3.2) | 5 (3.1) | 2 (1.3) | 6 (3.5) | 7 (5.1) | |
| D | 37 (5.9) | 12 (7.5) | 11 (7.0) | 8 (4.7) | 6 (4.3) | |
| E | 79 (12.7) | 18 (11.3) | 23 (14.6) | 26 (15.3) | 12 (8.7) | |
| F | 1 (0.2) | 1 (0.6) | 0 (0.0) | 0 (0.0) | 0 (0.0) | |
| G | 29 (4.6) | 10 (6.3) | 2 (1.3) | 8 (4.7) | 9 (6.5) | |
| H | 189 (30.3) | 50 (31.4) | 50 (31.8) | 49 (28.8) | 40 (29.0) | |
| I | 125 (20.0) | 30 (18.9) | 28 (17.8) | 30 (17.6) | 37 (26.8) | |
| J | 26 (4.2) | 10 (6.3) | 3 (1.9) | 9 (5.3) | 4 (2.9) | |
| Cardioplegia, % | .169 | |||||
| del Nido | 8 (1.3) | 2 (1.3) | 1 (0.6) | 1 (0.6) | 4 (2.9) | |
| Blood | 543 (86.9) | 136 (85.5) | 132 (84.1) | 157 (91.8) | 118 (85.5) | |
| Unknown | 74 (11.8) | 21 (13.2) | 24 (15.3) | 13 (7.6) | 16 (11.6) | |
| Leaflet prolapse, % | .103 | |||||
| None | 56 (9.0) | 9 (5.7) | 11 (7.0) | 14 (8.2) | 22 (15.9) | |
| Anterior | 66 (10.6) | 13 (8.2) | 12 (7.6) | 24 (14.0) | 17 (12.3) | |
| Posterior | 324 (51.8) | 85 (53.5) | 87 (55.4) | 88 (51.5) | 64 (46.4) | |
| Both | 123 (19.7) | 34 (21.4) | 34 (21.7) | 31 (18.1) | 24 (17.4) | |
| Unknown | 56 (9.0) | 18 (11.3) | 13 (8.3) | 14 (8.2) | 11 (8.0) |
CABG, Coronary artery bypass graft; TV, tricuspid valve; CPB, cardiopulmonary bypass; IQR, interquartile range; MV, mitral valve.
Short-Term Outcomes of Patient Cohort
There were differences in grade of postoperative MR (P = .04), postoperative LVEF (P < .001), and rates of respiratory failure (P = .047), renal failure (P = .007), and dialysis (P = .02) across groups (Table 3). However, outcomes did not differ in a linear manner with difference in LVEF. There were no differences in other outcomes, including reoperation for bleeding, stroke, and atrial fibrillation.
Table 3.
Short-term outcomes
| Characteristics | Overall | Severely reduced | Moderately reduced | Stable | Increased | P value |
|---|---|---|---|---|---|---|
| n | 625 | 159 | 157 | 171 | 138 | |
| ICU stay, h, median [IQR] | 53 [29, 100] | 53 [29, 104] | 49 [27, 92] | 65 [31, 98] | 70 [30, 120] | .137 |
| Postoperative MR, % | .036 | |||||
| None | 165 (28.2) | 25 (17.1) | 49 (32.9) | 49 (31.0) | 42 (31.8) | |
| Trivial/trace | 304 (52.0) | 80 (54.8) | 73 (49.0) | 80 (50.6) | 71 (53.8) | |
| Mild | 89 (15.2) | 30 (20.5) | 23 (15.4) | 22 (13.9) | 14 (10.6) | |
| Moderate | 25 (4.3) | 9 (6.2) | 4 (2.7) | 7 (4.4) | 5 (3.8) | |
| Severe | 2 (0.3) | 2 (1.4) | 0 (0.0) | 0 (0.0) | 0 (0.0) | |
| Postoperative TR, % | .374 | |||||
| None | 28 (4.8) | 2 (1.4) | 11 (7.4) | 5 (3.2) | 10 (7.5) | |
| Trivial/trace | 278 (47.4) | 74 (50.3) | 66 (44.6) | 75 (47.5) | 63 (47.0) | |
| Mild | 197 (33.6) | 49 (33.3) | 52 (35.1) | 58 (36.7) | 38 (28.4) | |
| Moderate | 78 (13.3) | 21 (14.3) | 17 (11.5) | 19 (12.0) | 21 (15.7) | |
| Severe | 6 (1.0) | 1 (0.7) | 2 (1.4) | 1 (0.6) | 2 (1.5) | |
| Postoperative LVEF, median [IQR] | 55 [45, 58] | 38 [30, 48] | 55 [50, 58] | 58 [55, 61] | 62 [58, 63] | <.001 |
| Reoperation for bleeding, % | 19 (3.0) | 7 (4.4) | 5 (3.2) | 2 (1.2) | 5 (3.6) | .362 |
| Reoperation for valve dysfunction, % | 2 (0.3) | 0 (0.0) | 0 (0.0) | 1 (0.6) | 1 (0.7) | .552 |
| Postoperative MI, % | 2 (0.3) | 1 (0.6) | 1 (0.6) | 0 (0.0) | 0 (0.0) | .58 |
| Postoperative unplanned coronary artery intervention, % | 2 (0.3) | 1 (0.6) | 1 (0.6) | 0 (0.0) | 0 (0.0) | .58 |
| Stroke, % | 10 (1.6) | 1 (0.6) | 0 (0.0) | 4 (2.3) | 5 (3.6) | .053 |
| Respiratory failure, % | 65 (10.4) | 24 (15.1) | 13 (8.3) | 11 (6.4) | 17 (12.3) | .047 |
| Renal failure, % | 16 (2.6) | 2 (1.3) | 1 (0.6) | 4 (2.3) | 9 (6.5) | .007 |
| Dialysis, % | 10 (1.6) | 0 (0.0) | 1 (0.6) | 3 (1.8) | 6 (4.3) | .017 |
| Postoperative pacemaker, % | 32 (5.1) | 6 (3.8) | 10 (6.4) | 7 (4.1) | 9 (6.5) | .567 |
| Cardiac arrest, % | 11 (1.8) | 3 (1.9) | 5 (3.2) | 1 (0.6) | 2 (1.4) | .348 |
| Postoperative atrial fibrillation, % | 259 (41.4) | 66 (1.5) | 58 (36.9) | 72 (42.1) | 63 (45.7) | .503 |
| Readmission, % | 47 (7.5) | 8 (5.0) | 19 (12.1) | 9 (5.3) | 11 (8.0) | .059 |
ICU, Intensive care unit; IQR, interquartile range; MR, mitral regurgitation; TR, tricuspid regurgitation; LVEF, left ventricular ejection fraction; MI, myocardial infarction.
Impact of LVEF Difference on Long-Term Mortality
Cubic spline of Cox regression for mortality versus LVEF percent difference adjusted for preoperative LVEF shows no significant hazard ratio at any LVEF difference (Figure 3, A). The KM curve in Figure 3, B, shows no difference in mortality over 7 years across LVEF groups (P = .35).
Figure 3.
Cubic spline Cox regression for long-term mortality versus percent difference in LVEF adjusted for preoperative LVEF (A). Kaplan-Meier curve stratified by quintiles of percent difference in LVEF with 95% CI (B). LVEF, Left ventricular ejection fraction.
Trajectory of LVEF Over 2 Years
Over a 2-year period, patients with severely reduced LVEF appeared to remain with a depressed LVEF over time (Figure 4, A). Patients in the moderately reduced group similarly did not appear to fully recover their preoperative LVEF. Patients in the stable group kept a generally similar LVEF over the 2-year period. Patients in the increased group had a postoperative increase in LVEF, which remained elevated or dropped back to preoperative levels over the study period. Mean change in LVEF 0-3 months, >3-6 months, >6-12 months, and >1-2 years from postoperative suggests an increase until the 1-year period and subsequent decrease, although CIs are wide (Figure 4, B). The 2-year trend in MR is shown in Figure E2.
Figure 4.
Trend in LVEF over 2 years after operation, categorized by quartiles of percent difference in LVEF (A). Mean and 95% CI (represented by error bars) of change in LVEF at 0-3 months, >3-6 months, >6-12 months, and >1-2 years after operation (B). LVEF, Left ventricular ejection fraction.
Figure E2.
Trend in MR over 2 years after operation, categorized by quartiles of percent difference in LVEF. MR, Mitral regurgitation; LVEF, left ventricular ejection fraction.
Subgroup Analyses
Two subgroup analyses were performed, the first of which isolated patients with Carpentier class II primary degenerative mitral regurgitation as shown in Tables E1 and E2 and Figures E3 and E4. Similar trends are seen with no differences in mortality at any LVEF difference and similar preoperative characteristics. There are no differences in short-term outcomes across groups in this cohort, as seen in Table E3. The second subgroup analysis isolated patients who did not undergo concomitant CABG to mitigate any effects bypass grafts could have on postoperative LVEF. Patient and operative characteristics are shown in Tables E4 and E5. Like the other subgroup analysis, there are no differences in short-term outcomes across groups (Table E6). The distribution of percent difference in LVEF is similar (Figure E5), and there are no differences in mortality (Figure E6).
Figure E3.
Percent difference in LVEF among patients with Carpentier class II disease. LVEF, Left ventricular ejection fraction.
Figure E4.
Cubic spline Cox regression for long-term mortality versus percent difference in LVEF adjusted for preoperative LVEF for patients with Carpentier class II disease. LVEF, Left ventricular ejection fraction.
Figure E5.
Percent difference in LVEF in cohort excluding concomitant CABG. LVEF, Left ventricular ejection fraction; CABG, coronary artery bypass grafting.
Figure E6.
Cubic spline Cox regression for long-term mortality versus percent difference in LVEF adjusted for preoperative LVEF in cohort excluding concomitant CABG. LVEF, Left ventricular ejection fraction; CABG, coronary artery bypass grafting.
Discussion
The principal findings of this study are that (1) the majority of patients experience a decrease in LVEF after undergoing MV repair or replacement, (2) patients who experience this LVEF decrease after MV operation are unlikely to regain preoperative LVEF, and (3) these changes in LVEF may not be associated with long-term survival.
Patients undergoing surgical repair of MR tend to have a decrease in LVEF after the operation.4 Preoperative LVEF predicts postoperative LVEF, and our findings appear to confirm this trend.3,11 However, we add further insight into the LVEF changes experienced by each patient by calculating a percent change in LVEF, which accounts for a patient's baseline.6 Patients with preoperative pulmonary hypertension and a history of atrial fibrillation with degenerative MR undergoing MV repair are more likely to have LV dysfunction.12 More recent studies have looked at trends in LVEF after MV repair in patients with severe degenerative who started with a normal EF and found EF remained significantly lower even 10 years after surgery.5 Our study takes a detailed look at the trajectory of LVEF over a 2-year period and normalizes the postoperative EF to the preoperative EF by looking at a percent difference rather than an absolute value. We include patients who underwent MV repair and replacement and show the majority underwent a decrease in LVEF regardless of operation type.
We observed a long-term reduction in LVEF over a 2-year period, although the average change in LVEF starts to recover at the end of the 2-year observation time. The acute changes in LVEF do not impact long-term mortality, implying that EF may not be the best marker of myocardial dysfunction in patients undergoing MV operation.
Contrary to previous studies, the results of this study do not suggest that long-term mortality is affected by LVEF difference, demonstrated using cubic spline Cox regression of KM analysis.5 This may be due to use of postoperative LVEF in previous studies rather than percent LVEF difference, and only included patients with severe MR who started with normal LVEF.5 Although our results differ from older literature showing that postoperative LVEF affects mortality, this could be due to our normalization to preoperative LVEF and capturing the change more uniquely “per patient.” In addition, these findings may be a reflection of overall improved survival in MV surgery in contemporary times described recently.13,14
Limitations
Our study limitations are related to its retrospective and descriptive nature. Although this study has considerable sample size, the associations between LVEF percent difference and mortality cannot be viewed as causation, might not be generalizable and it may be underpowered to detect certain differences. There is also lack of complete long-term echocardiographic data for all patients during the 2-year study period, and more complete data might reveal clearer trends. For example, we are unable to performed mixed effects modeling using our spaghetti plots because of a lack of complete echo data. The dataset is also limited by lack of additional information such as left atrial/LV size and function that could provide insight into trend of long-term LV remodeling. Lack of information of LV end-diastolic volume precludes us from isolating the impact of MV repair/replacement on cardiac function. The dataset does not have information on postoperative medications including heart failure therapies or complete information regarding perioperative inotrope use that could impact LV function.
Conclusions
Reduction in LVEF is common after MV repair or replacement, with effects persisting after 2 years. Changes in LVEF do not appear to affect clinical outcomes and may by themselves not accurately reflect myocardial dysfunction related to MR.
Webcast
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Audio
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Conflict of Interest Statement
The authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
Supplementary Data
Audio
Video available at: https://www.jtcvs.org/article/S2666-2736(26)00385-2/fulltext.
Appendix E1
Table E1.
Patient characteristics of patients with Carpentier class II mitral valve disease
| Characteristics | Overall | Severely reduced | Moderately reduced | Stable | Increased | P value |
|---|---|---|---|---|---|---|
| n | 503 | 135 | 129 | 137 | 102 | |
| Age, y, median [IQR] | 65.00 [57.00, 73.00] | 63.00 [56.00, 70.00] | 64.00 [56.00, 73.00] | 69.00 [59.00, 73.00] | 66.50 [58.00, 74.00] | .072 |
| Male sex, % | 313 (62.2) | 90 (66.7) | 78 (60.5) | 85 (62.0) | 60 (58.8) | .613 |
| BMI, median [IQR] | 25.24 [22.85, 28.23] | 24.74 [22.63, 27.94] | 26.17 [23.62, 28.42] | 25.85 [23.15, 27.99] | 24.81 [22.40, 28.08] | .094 |
| DM, % | 45 (8.9) | 11 (8.1) | 5 (3.9) | 15 (10.9) | 14 (13.7) | .052 |
| Dialysis, % | 2 (0.4) | 2 (1.5) | 0 (0.0) | 0 (0.0) | 0 (0.0) | .14 |
| HTN, % | 285 (56.7) | 67 (49.6) | 72 (55.8) | 81 (59.1) | 65 (63.7) | .16 |
| Dyslipidemia, % | 188 (37.4) | 40 (29.6) | 50 (38.8) | 55 (40.1) | 43 (42.2) | .171 |
| Tobacco use, % | 172 (34.2) | 41 (30.4) | 48 (37.2) | 46 (33.6) | 37 (36.3) | .655 |
| Chronic lung disease, % | 67 (13.3) | 20 (14.8) | 14 (10.9) | 19 (13.9) | 14 (13.7) | .803 |
| PVD, % | 11 (2.2) | 2 (1.5) | 3 (2.3) | 6 (4.4) | 0 (0.0) | .128 |
| Atrial fibrillation, % | 224 (44.5) | 66 (48.9) | 42 (32.6) | 68 (49.6) | 48 (47.1) | .017 |
| CVD, % | 31 (6.2) | 5 (3.7) | 7 (5.4) | 9 (6.6) | 10 (9.8) | .271 |
| Previous MI, % | 14 (2.8) | 2 (1.5) | 1 (0.8) | 6 (4.4) | 5 (4.9) | .124 |
| Cardiac catheterization performed, % | 461 (91.7) | 118 (87.4) | 121 (93.8) | 128 (93.4) | 94 (92.2) | .207 |
| Number of diseased vessels, % | .358 | |||||
| None | 338 (73.2) | 93 (78.2) | 94 (77.7) | 89 (69.5) | 62 (66.0) | |
| One | 58 (12.6) | 11 (9.2) | 12 (9.9) | 19 (14.8) | 16 (17.0) | |
| Two | 36 (7.8) | 7 (5.9) | 8 (6.6) | 14 (10.9) | 7 (7.4) | |
| Three | 30 (6.5) | 8 (6.7) | 7 (5.8) | 6 (4.7) | 9 (9.6) | |
| LVEF, median [IQR] | 58.00 [55.00, 63.00] | 60.00 [55.00, 66.50] | 63.00 [60.00, 65.00] | 58.00 [55.00, 63.00] | 55.00 [50.00, 55.75] | <.001 |
| Severe preoperative MR, % | 463 (92.0) | 127 (94.1) | 118 (91.5) | 127 (92.7) | 91 (89.2) | .57 |
| Atrial functional MR, % | 3 (0.6) | 0 (0.0) | 0 (0.0) | 1 (0.7) | 2 (2.0) | .185 |
| Preoperative TR, % | .076 | |||||
| None | 30 (6.0) | 12 (8.9) | 7 (5.5) | 8 (5.9) | 3 (3.0) | |
| Trivial/trace | 170 (34.0) | 49 (36.3) | 35 (27.3) | 53 (39.0) | 33 (32.7) | |
| Mild | 165 (33.0) | 43 (31.9) | 52 (40.6) | 43 (31.6) | 27 (26.7) | |
| Moderate | 103 (20.6) | 24 (17.8) | 25 (19.5) | 28 (20.6) | 26 (25.7) | |
| Severe | 32 (6.4) | 7 (5.2) | 9 (7.0) | 4 (2.9) | 12 (11.9) |
IQR, Interquartile range; BMI, body mass index; DM, diabetes mellitus; HTN, hypertension; PVD, peripheral vascular disease; CVD, cerebrovascular disease; MI, myocardial infarction; LVEF, left ventricular ejection fraction; MR, mitral regurgitation; TR, tricuspid regurgitation.
Table E2.
Operative characteristics of patients with Carpentier class II mitral valve disease
| Characteristics | Overall | Severely reduced | Moderately reduced | Stable | Increased | P value |
|---|---|---|---|---|---|---|
| n | 503 | 135 | 129 | 137 | 102 | |
| Incidence, % | .243 | |||||
| Primary operation | 487 (96.8) | 133 (98.5) | 128 (99.2) | 131 (95.6) | 95 (93.1) | |
| First reoperation | 13 (2.6) | 2 (1.5) | 1 (0.8) | 5 (3.6) | 5 (4.9) | |
| Second reoperation | 1 (0.2) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 1 (1.0) | |
| Third reoperation | 2 (0.4) | 0 (0.0) | 0 (0.0) | 1 (0.7) | 1 (1.0) | |
| Status, % | .786 | |||||
| Elective | 405 (80.5) | 111 (82.2) | 105 (81.4) | 110 (80.3) | 79 (77.5) | |
| Urgent | 2 (0.4) | 1 (0.7) | 0 (0.0) | 0 (0.0) | 1 (1.0) | |
| Emergent | 96 (19.1) | 23 (17.0) | 24 (18.6) | 27 (19.7) | 22 (21.6) | |
| Operative approach, % | .786 | |||||
| Sternotomy | 369 (73.4) | 97 (71.9) | 94 (72.9) | 101 (73.7) | 77 (75.5) | |
| Right minithoracotomy | 47 (9.3) | 18 (13.3) | 11 (8.5) | 9 (6.6) | 9 (8.8) | |
| Thoracotomy | 43 (8.5) | 13 (9.6) | 11 (8.5) | 13 (9.5) | 6 (5.9) | |
| Right thoracotomy | 24 (4.8) | 4 (3.0) | 6 (4.7) | 8 (5.8) | 6 (5.9) | |
| Partial sternotomy | 19 (3.8) | 3 (2.2) | 6 (4.7) | 6 (4.4) | 4 (3.9) | |
| Port access | 1 (0.2) | 0 (0.0) | 1 (0.8) | 0 (0.0) | 0 (0.0) | |
| Concomitant CABG, % | .084 | |||||
| None | 411 (81.7) | 118 (87.4) | 110 (85.3) | 107 (78.1) | 76 (74.5) | |
| Yes, planned | 91 (18.1) | 17 (12.6) | 19 (14.7) | 29 (21.2) | 26 (25.5) | |
| Yes, unplanned | 1 (0.2) | 0 (0.0) | 0 (0.0) | 1 (0.7) | 0 (0.0) | |
| Concomitant TV procedure, % | 76 (15.1) | 13 (9.6) | 21 (16.3) | 16 (11.7) | 26 (25.5) | .004 |
| Mechanical circulatory support, % | 19 (3.8) | 5 (3.7) | 5 (3.9) | 5 (3.6) | 4 (4.0) | .999 |
| CPB time, min, median [IQR] | 124.00 [96.00, 158.00] | 123.50 [94.25, 157.25] | 118.00 [93.00, 154.00] | 122.50 [96.00, 155.00] | 134.50 [102.00, 170.00] | .239 |
| Crossclamp time, min, median [IQR] | 88.00 [64.00, 114.00] | 84.00 [62.00, 115.00] | 85.00 [61.00, 109.00] | 88.50 [67.75, 114.25] | 90.50 [74.25, 117.50] | .317 |
| MV replacement, % | 89 (17.7) | 24 (17.8) | 23 (17.8) | 22 (16.1) | 20 (19.6) | .917 |
| MV implant type, % | .236 | |||||
| Annuloplasty | 409 (81.3) | 111 (82.2) | 102 (79.1) | 115 (83.9) | 81 (79.4) | |
| Bioprosthetic valve | 83 (16.5) | 19 (14.1) | 24 (18.6) | 22 (16.1) | 18 (17.6) | |
| Mechanical valve | 8 (1.6) | 5 (3.7) | 1 (0.8) | 0 (0.0) | 2 (2.0) | |
| None | 3 (0.6) | 0 (0.0) | 2 (1.6) | 0 (0.0) | 1 (1.0) | |
| Annuloplasty size, median [IQR] | 34.00 [32.00, 36.00] | 34.00 [32.00, 38.00] | 34.00 [30.00, 36.00] | 34.00 [30.50, 36.00] | 32.00 [30.00, 34.00] | <.001 |
| Prosthetic valve size, median [IQR] | 29.00 [27.00, 31.00] | 29.00 [27.00, 31.00] | 29.00 [27.00, 31.00] | 29.00 [27.00, 31.00] | 28.00 [27.00, 31.00] | .847 |
| Surgeon, anonymous, % | .074 | |||||
| A | 93 (18.5) | 17 (12.6) | 36 (27.9) | 25 (18.4) | 15 (14.7) | |
| B | 18 (3.6) | 5 (3.7) | 2 (1.6) | 5 (3.7) | 6 (5.9) | |
| C | 30 (6.0) | 11 (8.1) | 8 (6.2) | 5 (3.7) | 6 (5.9) | |
| D | 66 (13.1) | 16 (11.9) | 19 (14.7) | 21 (15.4) | 10 (9.8) | |
| E | 21 (4.2) | 9 (6.7) | 1 (0.8) | 7 (5.1) | 4 (3.9) | |
| F | 161 (32.1) | 45 (33.3) | 38 (29.5) | 43 (31.6) | 35 (34.3) | |
| G | 96 (19.1) | 24 (17.8) | 23 (17.8) | 24 (17.6) | 25 (24.5) | |
| H | 17 (3.4) | 8 (5.9) | 2 (1.6) | 6 (4.4) | 1 (1.0) | |
| Cardioplegia, % | .328 | |||||
| del Nido | 438 (87.1) | 115 (85.2) | 107 (82.9) | 126 (92.0) | 90 (88.2) | |
| Blood | 6 (1.2) | 2 (1.5) | 1 (0.8) | 1 (0.7) | 2 (2.0) | |
| Unknown | 59 (11.7) | 18 (13.3) | 21 (16.3) | 10 (7.3) | 10 (9.8) | |
| Leaflet prolapse, % | .221 | |||||
| None | 17 (3.4) | 5 (3.7) | 5 (3.9) | 1 (0.7) | 6 (5.9) | |
| Anterior | 48 (9.5) | 8 (5.9) | 8 (6.2) | 19 (13.9) | 13 (12.7) | |
| Posterior | 293 (58.3) | 77 (57.0) | 79 (61.2) | 79 (57.7) | 58 (56.9) | |
| Both | 111 (22.1) | 32 (23.7) | 30 (23.3) | 29 (21.2) | 20 (19.6) | |
| Unknown | 34 (6.8) | 13 (9.6) | 7 (5.4) | 9 (6.6) | 5 (4.9) |
CABG, Coronary artery bypass grafting; TV, tricuspid valve; CPB, cardiopulmonary bypass; IQR, interquartile range; MV, mitral valve.
Table E3.
Short-term outcomes of patients with Carpentier class II mitral valve disease
| Characteristics | Overall | Severely reduced | Moderately reduced | Stable | Increased | P value |
|---|---|---|---|---|---|---|
| n | 503 | 135 | 129 | 137 | 102 | |
| ICU stay, h, median [IQR] | 50 [28, 95] | 50 [28, 99] | 49 [26, 85] | 53 [31, 91] | 58 [28, 100] | .364 |
| Postoperative MR, % | .074 | |||||
| None | 126 (26.6) | 20 (15.9) | 39 (32.0) | 39 (30.5) | 28 (28.9) | |
| Trivial/trace | 252 (53.3) | 72 (57.1) | 64 (52.5) | 62 (48.4) | 54 (55.7) | |
| Mild | 75 (15.9) | 27 (21.4) | 16 (13.1) | 20 (15.6) | 12 (12.4) | |
| Moderate | 18 (3.8) | 5 (4.0) | 3 (2.5) | 7 (5.5) | 3 (3.1) | |
| Severe | 2 (0.4) | 2 (1.6) | 0 (0.0) | 0 (0.0) | 0 (0.0) | |
| Postoperative TR, % | .762 | |||||
| None | 21 (4.4) | 2 (1.6) | 9 (7.4) | 4 (3.1) | 6 (6.1) | |
| Trivial/trace | 238 (50.2) | 66 (52.8) | 56 (45.9) | 65 (50.8) | 51 (51.5) | |
| Mild | 152 (32.1) | 39 (31.2) | 42 (34.4) | 44 (34.4) | 27 (27.3) | |
| Moderate | 59 (12.4) | 17 (13.6) | 14 (11.5) | 14 (10.9) | 14 (14.1) | |
| Severe | 4 (0.8) | 1 (0.8) | 1 (0.8) | 1 (0.8) | 1 (1.0) | |
| Postoperative EF, median [IQR] | 55 [47, 58] | 40 [33, 48] | 55 [53, 58] | 58 [55, 60] | 63 [58, 63] | <.001 |
| Reoperation for bleeding, % | 14 (2.8) | 6 (4.4) | 5 (3.9) | 1 (0.7) | 2 (2.0) | .227 |
| Reoperation for valve dysfunction, % | 2 (0.4) | 0 (0.0) | 0 (0.0) | 1 (0.7) | 1 (1.0) | .51 |
| Postoperative MI, % | 1 (0.2) | 0 (0.0) | 1 (0.8) | 0 (0.0) | 0 (0.0) | .407 |
| Postoperative unplanned coronary artery intervention, % | 2 (0.4) | 1 (0.7) | 1 (0.8) | 0 (0.0) | 0 (0.0) | .611 |
| Stroke, % | 7 (1.4) | 1 (0.7) | 0 (0.0) | 3 (2.2) | 3 (2.9) | .199 |
| Respiratory failure, % | 43 (8.5) | 17 (12.6) | 9 (7.0) | 7 (5.1) | 10 (9.8) | .138 |
| Renal failure, % | 8 (1.6) | 1 (0.7) | 0 (0.0) | 3 (2.2) | 4 (3.9) | .087 |
| Dialysis, % | 4 (0.8) | 0 (0.0) | 0 (0.0) | 2 (1.5) | 2 (2.0) | .2 |
| Postoperative pacemaker, % | 19 (3.8) | 4 (3.0) | 7 (5.4) | 5 (3.6) | 3 (2.9) | .702 |
| Cardiac arrest, % | 8 (1.6) | 3 (2.2) | 3 (2.3) | 1 (0.7) | 1 (1.0) | .641 |
| Postoperative atrial fibrillation, % | 212 (42.1) | 56 (41.5) | 48 (37.2) | 59 (43.1) | 49 (48.0) | .421 |
| Readmission, % | 36 (7.2) | 8 (5.9) | 13 (10.1) | 8 (5.8) | 7 (6.9) | .506 |
ICU, Intensive care unit; IQR, interquartile range; MR, mitral regurgitation; TR, tricuspid regurgitation; EF, ejection fraction; MI, myocardial infarction.
Table E4.
Patient characteristics of cohort excluding concomitant CABG
| Characteristics | Overall | Severely reduced | Moderately reduced | Stable | Increased | P value |
|---|---|---|---|---|---|---|
| n | 507 | 138 | 131 | 136 | 102 | |
| Age, y, median [IQR] | 64.00 [56.00, 72.00] | 62.00 [56.00, 70.00] | 62.00 [53.00, 71.50] | 68.00 [57.75, 74.00] | 65.50 [54.25, 72.00] | .017 |
| Male sex, % | 272 (53.6) | 89 (64.5) | 67 (51.1) | 65 (47.8) | 51 (50.0) | .026 |
| BMI, median [IQR] | 25.28 [22.88, 28.98] | 24.79 [22.72, 28.89] | 26.46 [23.74, 28.47] | 25.72 [23.10, 29.26] | 25.10 [22.10, 29.43] | .265 |
| DM, % | 42 (8.3) | 10 (7.2) | 7 (5.3) | 16 (11.8) | 9 (8.8) | .273 |
| Dialysis, % | 3 (0.6) | 2 (1.4) | 1 (0.8) | 0 (0.0) | 0 (0.0) | .361 |
| HTN, % | 271 (53.5) | 65 (47.1) | 69 (52.7) | 74 (54.4) | 63 (61.8) | .161 |
| Dyslipidemia, % | 168 (33.1) | 36 (26.1) | 47 (35.9) | 52 (38.2) | 33 (32.4) | .16 |
| Tobacco use, % | 171 (33.7) | 42 (30.4) | 46 (35.1) | 44 (32.4) | 39 (38.2) | .61 |
| Chronic lung disease, % | 78 (15.4) | 23 (16.7) | 16 (12.2) | 21 (15.4) | 18 (17.6) | .662 |
| PVD, % | 12 (2.4) | 1 (0.7) | 4 (3.1) | 6 (4.4) | 1 (1.0) | .159 |
| Atrial fibrillation, % | 226 (44.6) | 61 (44.2) | 41 (31.3) | 70 (51.5) | 54 (52.9) | .002 |
| CVD, % | 31 (6.1) | 5 (3.6) | 6 (4.6) | 7 (5.1) | 13 (12.7) | .018 |
| Previous MI, % | 9 (1.8) | 3 (2.2) | 0 (0.0) | 3 (2.2) | 3 (2.9) | .33 |
| Cardiac catheterization performed, % | 450 (88.8) | 119 (86.2) | 119 (90.8) | 123 (90.4) | 89 (87.3) | .558 |
| Number of diseased vessels, % | .614 | |||||
| None | 407 (90.0) | 110 (91.7) | 109 (91.6) | 109 (87.9) | 79 (88.8) | |
| One | 36 (8.0) | 10 (8.3) | 8 (6.7) | 11 (8.9) | 7 (7.9) | |
| Two | 4 (0.9) | 0 (0.0) | 0 (0.0) | 2 (1.6) | 2 (2.2) | |
| Three | 5 (1.1) | 0 (0.0) | 2 (1.7) | 2 (1.6) | 1 (1.1) | |
| LVEF, median [IQR] | 58 [55, 63] | 60 [55, 67] | 63 [60, 65] | 58 [55, 62] | 55 [50, 56] | <.001 |
| Severe preoperative MR, % | 461 (90.9) | 131 (94.9) | 117 (89.3) | 124 (91.2) | 89 (87.3) | .19 |
| Atrial functional MR, % | 15 (3.0) | 1 (0.7) | 0 (0.0) | 8 (5.9) | 6 (5.9) | .004 |
| Mitral valve disease, % | .068 | |||||
| Carpentier class I | 28 (5.5) | 3 (2.2) | 4 (3.1) | 13 (9.6) | 8 (7.8) | |
| Carpentier class II | 411 (81.1) | 118 (85.5) | 110 (84.0) | 107 (78.7) | 76 (74.5) | |
| Carpentier class IIIA | 20 (3.9) | 3 (2.2) | 3 (2.3) | 8 (5.9) | 6 (5.9) | |
| Mixed (type II and IIIA) | 28 (5.5) | 8 (5.8) | 7 (5.3) | 7 (5.1) | 6 (5.9) | |
| Other/unknown | 20 (3.9) | 6 (4.3) | 7 (5.3) | 1 (0.7) | 6 (5.9) | |
| Preoperative TR, % | .122 | |||||
| None | 29 (5.7) | 13 (9.4) | 5 (3.8) | 8 (5.9) | 3 (2.9) | |
| Trivial/trace | 159 (31.4) | 48 (34.8) | 36 (27.5) | 46 (34.1) | 29 (28.4) | |
| Mild | 168 (33.2) | 42 (30.4) | 52 (39.7) | 43 (31.9) | 31 (30.4) | |
| Moderate | 106 (20.9) | 28 (20.3) | 28 (21.4) | 27 (20.0) | 23 (22.5) | |
| Severe | 44 (8.7) | 7 (5.1) | 10 (7.6) | 11 (8.1) | 16 (15.7) |
CABG, Coronary artery bypass grafting; IQR, interquartile range; BMI, body mass index; DM, diabetes mellitus; HTN, hypertension; PVD, peripheral vascular disease; CVD, cerebrovascular disease; MI, myocardial infarction; LVEF, left ventricular ejection fraction; MR, mitral regurgitation; TR, tricuspid regurgitation.
Table E5.
Operative characteristics of cohort excluding concomitant CABG
| Characteristics | Overall | Severely reduced | Moderately reduced | Stable | Increased | P value |
|---|---|---|---|---|---|---|
| n | 507 | 138 | 131 | 136 | 102 | |
| Incidence, % | .002 | |||||
| Primary operation | 484 (95.5) | 136 (98.6) | 130 (99.2) | 128 (94.1) | 90 (88.2) | |
| First reoperation | 17 (3.4) | 2 (1.4) | 1 (0.8) | 7 (5.1) | 7 (6.9) | |
| Second reoperation | 5 (1.0) | 0 (0.0) | 0 (0.0) | 1 (0.7) | 4 (3.9) | |
| Third reoperation | 1 (0.2) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 1 (1.0) | |
| Status, % | .963 | |||||
| Elective | 402 (79.3) | 111 (80.4) | 103 (78.6) | 107 (78.7) | 81 (79.4) | |
| Urgent | 102 (20.1) | 26 (18.8) | 27 (20.6) | 29 (21.3) | 20 (19.6) | |
| Emergent | 3 (0.6) | 1 (0.7) | 1 (0.8) | 0 (0.0) | 1 (1.0) | |
| Operative approach, % | .86 | |||||
| Sternotomy | 354 (69.8) | 95 (68.8) | 91 (69.5) | 96 (70.6) | 72 (70.6) | |
| Right minithoracotomy | 55 (10.8) | 20 (14.5) | 13 (9.9) | 11 (8.1) | 11 (10.8) | |
| Thoracotomy | 49 (9.7) | 14 (10.1) | 13 (9.9) | 15 (11.0) | 7 (6.9) | |
| Right thoracotomy | 28 (5.5) | 5 (3.6) | 7 (5.3) | 8 (5.9) | 8 (7.8) | |
| Partial sternotomy | 20 (3.9) | 4 (2.9) | 6 (4.6) | 6 (4.4) | 4 (3.9) | |
| Port access | 1 (0.2) | 0 (0.0) | 1 (0.8) | 0 (0.0) | 0 (0.0) | |
| Concomitant TV procedure, % | 91 (17.9) | 16 (11.6) | 23 (17.6) | 23 (16.9) | 29 (28.4) | .009 |
| Mechanical circulatory support, % | 19 (3.8) | 6 (4.4) | 6 (4.6) | 4 (3.0) | 3 (3.0) | .869 |
| CPB time, min, median [IQR] | 118.00 [94.00, 153.00] | 120.00 [94.00, 155.00] | 109.00 [90.00, 147.50] | 118.50 [94.00, 146.00] | 127.00 [98.25, 164.75] | .214 |
| Crossclamp time, min, median [IQR] | 81.00 [61.00, 106.00] | 80.50 [62.00, 114.00] | 72.00 [59.00, 102.00] | 80.50 [59.00, 103.00] | 86.50 [66.75, 106.00] | .235 |
| MV replacement, % | 102 (20.1) | 29 (21.0) | 21 (16.0) | 27 (19.9) | 25 (24.5) | .447 |
| MV implant type, % | .163 | |||||
| Annuloplasty | 400 (78.9) | 109 (79.0) | 106 (80.9) | 109 (80.1) | 76 (74.5) | |
| Bioprosthetic valve | 91 (17.9) | 22 (15.9) | 20 (15.3) | 27 (19.9) | 22 (21.6) | |
| Mechanical valve | 13 (2.6) | 7 (5.1) | 3 (2.3) | 0 (0.0) | 3 (2.9) | |
| None | 3 (0.6) | 0 (0.0) | 2 (1.5) | 0 (0.0) | 1 (1.0) | |
| Annuloplasty size, median [IQR] | 34.00 [32.00, 36.00] | 34.00 [32.00, 38.00] | 34.00 [30.00, 36.00] | 34.00 [30.00, 36.00] | 32.00 [30.00, 34.00] | <.001 |
| Prosthetic valve size, median [IQR] | 29.00 [27.00, 31.00] | 29.00 [27.00, 31.00] | 29.00 [27.00, 30.00] | 27.00 [27.00, 31.00] | 27.00 [27.00, 31.00] | .361 |
| Surgeon, anonymous, % | .433 | |||||
| A | 100 (19.8) | 20 (14.5) | 33 (25.2) | 27 (20.0) | 20 (19.6) | |
| B | 1 (0.2) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 1 (1.0) | |
| C | 17 (3.4) | 5 (3.6) | 2 (1.5) | 4 (3.0) | 6 (5.9) | |
| D | 33 (6.5) | 11 (8.0) | 8 (6.1) | 8 (5.9) | 6 (5.9) | |
| E | 61 (12.1) | 16 (11.6) | 17 (13.0) | 20 (14.8) | 8 (7.8) | |
| F | 1 (0.2) | 1 (0.7) | 0 (0.0) | 0 (0.0) | 0 (0.0) | |
| G | 21 (4.2) | 8 (5.8) | 2 (1.5) | 7 (5.2) | 4 (3.9) | |
| H | 156 (30.8) | 41 (29.7) | 39 (29.8) | 41 (30.4) | 35 (34.3) | |
| I | 99 (19.6) | 27 (19.6) | 27 (20.6) | 24 (17.8) | 21 (20.6) | |
| J | 17 (3.4) | 9 (6.5) | 3 (2.3) | 4 (3.0) | 1 (1.0) | |
| Cardioplegia, % | .525 | |||||
| del Nido | 437 (86.2) | 118 (85.5) | 109 (83.2) | 124 (91.2) | 86 (84.3) | |
| Blood | 6 (1.2) | 2 (1.4) | 1 (0.8) | 1 (0.7) | 2 (2.0) | |
| Unknown | 64 (12.6) | 18 (13.0) | 21 (16.0) | 11 (8.1) | 14 (13.7) | |
| Leaflet prolapse, % | .043 | |||||
| None | 43 (8.5) | 7 (5.1) | 6 (4.6) | 14 (10.3) | 16 (15.7) | |
| Anterior | 47 (9.3) | 7 (5.1) | 10 (7.6) | 17 (12.5) | 13 (12.7) | |
| Posterior | 271 (53.5) | 78 (56.5) | 77 (58.8) | 70 (51.5) | 46 (45.1) | |
| Both | 97 (19.1) | 29 (21.0) | 27 (20.6) | 23 (16.9) | 18 (17.6) | |
| Unknown | 49 (9.7) | 17 (12.3) | 11 (8.4) | 12 (8.8) | 9 (8.8) |
CABG, Coronary artery bypass grafting; TV, tricuspid valve; CPB, cardiopulmonary bypass; IQR, interquartile range; MV, mitral valve.
Table E6.
Short-term outcomes of cohort excluding concomitant CABG
| Characteristics | Overall | Severely reduced | Moderately reduced | Stable | Increased | P value |
|---|---|---|---|---|---|---|
| n | 507 | 138 | 131 | 136 | 102 | |
| ICU stay, h, median [IQR] | 50.02 [27.48, 92.83] | 50.00 [27.12, 98.05] | 48.00 [26.18, 74.94] | 53.40 [28.60, 90.97] | 57.23 [28.92, 96.00] | .144 |
| Postoperative MR, % | .189 | |||||
| None | 126 (26.6) | 22 (17.6) | 36 (29.0) | 36 (28.6) | 32 (32.7) | |
| Trivial/trace | 247 (52.2) | 69 (55.2) | 63 (50.8) | 63 (50.0) | 52 (53.1) | |
| Mild | 75 (15.9) | 24 (19.2) | 21 (16.9) | 20 (15.9) | 10 (10.2) | |
| Moderate | 23 (4.9) | 8 (6.4) | 4 (3.2) | 7 (5.6) | 4 (4.1) | |
| Severe | 2 (0.4) | 2 (1.6) | 0 (0.0) | 0 (0.0) | 0 (0.0) | |
| Postoperative TR, % | .793 | |||||
| None | 18 (3.8) | 2 (1.6) | 8 (6.5) | 3 (2.4) | 5 (5.1) | |
| Trivial/trace | 224 (46.9) | 66 (51.2) | 53 (42.7) | 58 (46.0) | 47 (47.5) | |
| Mild | 170 (35.6) | 43 (33.3) | 46 (37.1) | 49 (38.9) | 32 (32.3) | |
| Moderate | 61 (12.8) | 17 (13.2) | 15 (12.1) | 15 (11.9) | 14 (14.1) | |
| Severe | 5 (1.0) | 1 (0.8) | 2 (1.6) | 1 (0.8) | 1 (1.0) | |
| Postoperative EF, median [IQR] | 55.00 [45.00, 58.00] | 39.50 [30.00, 48.00] | 55.00 [53.00, 58.00] | 57.50 [55.00, 60.00] | 63.00 [58.00, 63.00] | <.001 |
| Reoperation for bleeding, % | 11 (2.2) | 5 (3.6) | 3 (2.3) | 1 (0.7) | 2 (2.0) | .437 |
| Reoperation for valve dysfunction, % | 2 (0.4) | 0 (0.0) | 0 (0.0) | 1 (0.7) | 1 (1.0) | .501 |
| Postoperative MI, % | 1 (0.2) | 1 (0.7) | 0 (0.0) | 0 (0.0) | 0 (0.0) | .444 |
| Stroke, % | 7 (1.4) | 0 (0.0) | 0 (0.0) | 3 (2.2) | 4 (3.9) | .026 |
| Respiratory failure, % | 44 (8.7) | 22 (15.9) | 7 (5.3) | 8 (5.9) | 7 (6.9) | .005 |
| Renal failure, % | 7 (1.4) | 2 (1.4) | 1 (0.8) | 1 (0.7) | 3 (2.9) | .455 |
| Dialysis, % | 3 (0.6) | 0 (0.0) | 1 (0.8) | 1 (0.7) | 1 (1.0) | .754 |
| Postoperative pacemaker, % | 24 (4.7) | 6 (4.3) | 6 (4.6) | 5 (3.7) | 7 (6.9) | .702 |
| Cardiac arrest, % | 9 (1.8) | 3 (2.2) | 4 (3.1) | 1 (0.7) | 1 (1.0) | .463 |
| Postoperative atrial fibrillation, % | 198 (39.1) | 56 (40.6) | 44 (33.6) | 54 (39.7) | 44 (43.1) | .472 |
| Readmission, % | 40 (7.9) | 6 (4.3) | 17 (13.0) | 9 (6.6) | 8 (7.8) | .062 |
CABG, Coronary artery bypass grafting; ICU, intensive care unit; IQR, interquartile range; MR, mitral regurgitation; TR, tricuspid regurgitation; EF, ejection fraction; MI, myocardial infarction.
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