Treatment strategies for patients with ischemic mitral regurgitation: a systematic review and meta-analysis.

BACKGROUND

Treatments for ischemic mitral regurgitation (IMR) include coronary artery bypass grafting combined with mitral valve replacement (CABG + MVR), percutaneous coronary intervention (PCI) alone, and PCI combined with transcatheter edge-to-edge repair (TEER), but comparative evidence remains limited. We aimed to systematically evaluate perioperative characteristics, in-hospital and long-term outcomes of these strategies.

MATERIALS AND METHODS

This PRISMA 2020-compliant systematic review and meta-analysis searched PubMed, EMBASE, Web of Science, Cochrane Library, and ClinicalTrials.gov through 12 November 2024. We included studies reporting outcomes for CABG + MVR, PCI alone, or PCI + TEER in IMR, excluding non-human studies, reviews, case reports, editorials, etc. The endpoints included in-hospital/30-day mortality, long-term mortality, cardiovascular mortality, procedural metrics (cardiopulmonary bypass and cross-clamp time), hospital stay, ICU stay, reoperation, readmission, cerebrovascular events, atrial fibrillation, and low cardiac output syndrome (LCOS). Data were pooled using random-effects models.

RESULTS

Thirty-three studies (1 randomized controlled trial, 32 cohorts; n = 3001 patients: 1355 CABG + MVR, 1617 PCI, and 29 PCI + TEER) were analyzed. In-hospital/30-day mortality was 13.8% (95% CI 3.9%-31.7%) for PCI + TEER, 11.8% (95% CI 8.4%-16.5%) for CABG + MVR, and 9.4% (95% CI 7.7%-11.5%) for PCI. Five-year mortality was 37.5% for CABG + MVR vs. 41.8% for PCI. The pooled cardiopulmonary bypass and cross-clamp time for CABG + MVR was 140.2 minutes and 101.0 minutes, respectively. PCI + TEER had shorter hospital stays (17.3 days) than CABG + MVR (22.4 days). Hospital/30-day intra-aortic balloon pump rate was lower in CABG + MVR (7.9%) than PCI + TEER (24.1%). 30-day/in-hospital complications included cerebrovascular events (CABG + MVR: 4.1%, PCI: 0.7%), atrial fibrillation (CABG + MVR: 22.9%), and LCOS (CABG + MVR: 19.6%). One-year readmission and 10-year reoperation rates post-CABG + MVR were 7.4% and 31.1%, respectively.

CONCLUSIONS

CABG + MVR demonstrated superior long-term survival and lower cardiovascular mortality than PCI but carried higher perioperative risks and complication rates. PCI + TEER showed shorter hospital stays but insufficient data to assess long-term efficacy. Treatment selection requires balancing comorbidities, surgical risk, and MR severity through multidisciplinary decision-making. Robust comparative trials are needed to optimize IMR management.