Left Main Coronary Artery Stent Misadventure.

Coronary artery bypass grafting has long been the standard of care for patients with left main coronary artery (LMCA) disease. Lately, percutaneous coronary intervention (PCI) has become a suitable alternative for these patients, but the procedure may be challenging. We describe 2 cases of LMCA PCI failure requiring surgical intervention. (Level of Difficulty: Advanced.).

Postoperative ascending aortic gigantic pseudoaneurysm: Endovascular treatment with the use of a septal occluder plug.

A rare postoperative complication of aortic root replacement is pseudoaneurysm formation. Surgical repair may be rather challenging particularly in patients who are elder and with significant comorbidities. Endovascular approach may also be technically demanding, given the high blood velocity and the anatomical challenges of the area of the aortic root and the ascending aorta. We would like to describe a case of an 85-year-old patient with history of prosthetic graft aortic root replacement who had been developed a 7-cm pseudoaneurysm with sternotomy diastasis and extension in the subcutaneous tissue, 7 years after the initial operation. Given the comorbidities, open repair was not considered a valid option and successful endovascular repair with the use of a ventricular septal occluder plug followed. One-year follow-up confirmed satisfactory exclusion of the pseudoaneurysm with no migration of the endovascular device and no other complication. This is one of the rare cases on endovascular repair of an ascending aorta postoperative pseudoaneurysm.

Residual SYNTAX score following coronary artery bypass grafting.

Objectives: To quantify residual coronary artery disease measured using the SYNTAX score (SS) and its relation to outcomes after coronary artery bypass grafting (CABG). Methods: We conducted a retrospective analysis on a consecutive series of 1608 patients [mean age 68 years, standard deviation (SD): 7, F:M, 242:1366] undergoing first-time isolated CABG from 2004 to 2015. The baseline SS was retrospectively determined from preoperative angiograms, and the residual SS (rSS) was measured during assessment of the actual operative report for each patient after CABG. Patients were then stratified according to tercile cut points of low (rSS low 0-11, N = 537), intermediate (rSS mid >11-18.5, N = 539) and high residual SS (rSS high >18.5, N = 532). The Cox regression model was used to investigate the impact of rSS on major adverse cardiac and cerebrovascular events (MACCE) at 1 year. Results: The mean preoperative SS was 26.6 (SD: 9.4) (range 10.1-53), and the residual SS after CABG was 15.3 (SD: 8.4) (range 0-34) ( P < 0.001 versus preoperative). At 1 year, cumulative incidence of MACCE in the low rSS was 1.5% ( N = 8/537), 4.5% ( N = 24/539) in the intermediate and 8.8% ( N = 47/532) in the high rSS group. Kaplan-Meier analysis showed a statistically significant difference of MACCE-free survival between the three groups (log-rank test, P < 0.001). The estimated MACCE-free survival rate at 1 year was 98.1% [standard error (SE): 1.6] for the rSS low , 95.5% (SE: 1.9) for the rSS mid , and 90.5% (SE: 1.3) for the rSS high group, respectively. After multivariable adjustment, the rSS high group was independently associated with a higher incidence of MACCE at 1 year (hazard ratio 1.92, 95% confidence interval 1.21-3.23) compared to the rSS low group. Conclusions: These unanticipated findings suggest that a residual SS may be a useful tool for risk stratification of patients undergoing isolated first-time CABG. Our study may set the stage for further investigations addressing this important clinical question.

Unilateral Versus Bilateral Antegrade Cerebral Protection During Aortic Surgery: An Updated Meta-Analysis.

BACKGROUND: In the context of complex aortic surgery, despite the wide consensus about the use of moderate hypothermia in association with antegrade selective cerebral perfusion (ASCP), its bilateral administration is not always warranted. The aim of the present meta-analysis was to investigate outcomes of unilateral versus bilateral ASCP. METHODS: Outcomes investigated were postoperative mortality and neurologic permanent and temporary disease (PND and TND); separate analysis of heterogeneity using the Cochrane Q statistic was used to perform comparisons. Circulatory arrest (CA) time and temperature, and sample size were explored as potential causes for heterogeneity with meta-regression analysis. RESULTS: The study population consisted of 3,723 patients receiving bilateral ASCP and 3,065 patients receiving unilateral ASC. Pooled analysis showed similar rates of postoperative mortality: 9.8% (95% confidence interval [CI], 7.8% to 12.3%) for bilateral ASCP versus 7.6% (95% CI, 5.7% to 10.2%) for unilateral ASCP; p = 0.19. Postoperative PND rates as well did not differ significantly: 6.9% (95% CI, 5.0% to 9.4%) for bilateral ASCP versus 5.8% (95% CI, 3.8% to 8.7%) for unilateral ASCP; p = 0.53. Similar results yielded from TND analysis: 9.3 % (95% CI, 7.0% to 12.2%) versus 6.5% (95% CI, 4.5% to 9.5%), respectively, p = 0.14. Meta-regression analysis showed that longer CA times were associated with significantly increased mortality only among patients administered with unilateral ASCP (model Q 65.8, p < 0.0001). Furthermore, higher CA temperatures were associated with significantly reduced rates of mortality (Q 64.1, p = 0.001), PND (Q 52.3, p = 0.01), and TND (Q 62.2, p = 0.002) in both groups. CONCLUSIONS: Unilateral versus bilateral ASCP administration did not result in different mortality and neurologic morbidity rates. Nevertheless, among prolonged CA times unilateral ASCP resulted in poorer outcomes with respect to bilateral ASCP. Furthermore, moderate hypothermia was associated with best outcomes in both groups.

Hybrid treatment for thoracoabdominal aortic aneurysms in patients with Marfan syndrome.

Marfan syndrome is a heritable disorder of connective tissue leading to aortic aneurysms and other cardiovascular complications associated with reduced life expectancy. Although contemporary management of ascending aortic disease requires open surgical reconstruction, the combined retrograde visceral revascularization and endovascular exclusion (hybrid procedure) of entire thoracoabdominal aorta has been introduced for the management of descending thoracic and abdominal aortic pathology. The present experience reports 2 cases of thoracoabdominal aortic aneurysms, in Marfan patients, previously submitted to major cardiovascular surgical procedures, through a hybrid approach.

Blackish Pigmentation of the Aorta in Patient with Alkaptonuria and Heyde's Syndrome.

Alkaptonuria is an autosomal recessive trait resulting in an error of aromatic amino acids metabolism. Heyde's syndrome is a condition clustering together aortic valve stenosis and gastrointestinal bleeding from colonic angiodysplasia. At present, there is no report describing the association of the latter two syndromes in the same patient. Here we present the case of a patient with severe aortic stenosis, alkaptonuria, and Heyde's syndrome. The patient underwent aortic valve replacement by means of a valvular bioprosthesis and the histological examination of the aortic cusps revealed calcific degeneration. This was associated with stromal degeneration characterized by extra-cellular deposition of granular, brownish-pigmented material along with macrophages and multiple foci of calfication showing the same brownish pigmentation. This configuration represents the typical pattern of homogentisic acid accumulation known as ochronosis. The postoperative course was uneventful and the echocardiographic follow-up at 6 months postoperatively showed good-functioning of the aortic valve bioprosthesis.

Perioperative administration of enoximone and renal function after cardiac surgery: a propensity-matched analysis.

BACKGROUND: Perioperative administration of enoximone has been shown to improve hemodynamics, organ function, and inflammatory response. Aim of the present study is to evaluate the impact of enoximone on postoperative renal function after on-pump cardiac surgery. METHODS: A total of 3727 patients undergoing cardiac surgery at one Institution between May 2004 and November 2010 were reviewed. A propensity score was built and a 1:1 perfect matching was performed, providing two fairly comparable cohorts of 712 patients each, receiving or not enoximone after surgery. Renal function was evaluated by lower glomerular filtration rate (GFR) value reached postoperatively. RESULTS: Overall 30-day mortality rate was 4.3% (62/1424). Cumulative incidence of postoperative renal failure (RF) was 157/1424(11%), of which 99/1424(7%) needed renal replacement therapy. Mean lower postoperative GFR in patients who received or not enoximone was 63 ± 30.1 and 53.5 ± 26.1 ml/min/1.73 m(2) (p<0.0001), respectively. At multivariable analysis age (OR2.75, p=0.0004), diabetes (OR1.82, p=0.006), preoperative GFR (OR3.81, p<0.0001), preoperative cardiogenic shock (OR1.65, p=0.004), previous cardiac surgery (OR2.12, p=0.0002), type of intervention (OR1.96, p=0.005), and enoximone (OR0.38, p=0.001) were found to be independently associated with postoperative RF. Logistic regression analysis showed that the administration of enoximone (OR0.41, p=0.0001), and of no inotropes (OR0.27, p<0.0001) were protective vs. the occurrence of postoperative RF. CONCLUSION: Patients perioperatively receiving enoximone showed a statistically significant better renal function after cardiac surgery.

ß-Blockers improve survival of patients with chronic obstructive pulmonary disease after coronary artery bypass grafting.

BACKGROUND: ß-Blockers are known to improve survival of patients with cardiovascular disease, but their administration in patients with chronic obstructive pulmonary disease (COPD) remains controversial. The aim of the present study was to assess the effect of ß-blocker administration in patients with COPD undergoing coronary artery bypass grafting. METHODS: A total of 388 consecutive patients with COPD who underwent isolated coronary artery bypass grafting were studied, and clinical follow-up was completed. Diagnosis of COPD was based on preoperative forced expiration volume; exacerbation episodes were defined as a pulsed-dose prescription of prednisolone or a hospital admission for an exacerbation. Two propensity-matched cohorts of 104 patients each either receiving or not receiving ß-blockers were identified. RESULTS: At baseline, there was no significant difference among groups. After a median follow-up of 36 months, there were 8 deaths in 104 patients (7.7%) receiving ß-blockers versus 19 deaths in 104 patients (18.3%) who did not receive ß-blockers (p = 0.03). Kaplan-Meyer analysis showed a survival of 91.8% ± 2.8% for patients taking ß-blockers versus 80.6% ± 4.0% for control subjects (χ(2), 29.4; p = 0.003; hazard ratio, 0.38). In addition, ß-blocker administration did not increase rates of COPD exacerbation, which was experienced by 46 of 104 patients (44.2%) receiving ß-blockers versus 45 of 104 patients (43.3%) not receiving ß-blockers (p = 0.99). CONCLUSIONS: This study showed that in patients with COPD undergoing coronary artery bypass grafting the administration of ß-blockers is safe and significantly improves survival at mid-term follow-up. Further randomized studies are needed to confirm these findings.

Metabolic syndrome affects midterm outcome after coronary artery bypass grafting.

BACKGROUND: Metabolic syndrome (MetS) is frequently associated with coronary artery disease, but data on the impact of MetS on long-term outcome of patients undergoing coronary artery bypass grafting are still lacking. The aim of the present study was to assess the effect of MetS on mortality and morbidity late after coronary artery bypass grafting. METHODS: A total of 1,726 consecutive patients who had elective coronary artery bypass grafting were retrospectively reviewed and clinical follow-up was completed (mean follow-up time, 34.4 months; range, 6 to 79 months). The MetS was diagnosed using the modified Adult Treatment Panel III criteria, and to eliminate covariate differences, a propensity score adjustment was used. Major adverse cerebral and cardiovascular events were investigated, and C-reactive protein levels were assessed both preoperatively, postoperatively, and at follow-up. RESULTS: A total of 798 of 1,726 patients (46.2%) met the diagnostic criteria for MetS. At follow-up, all-cause mortality (7% versus 4.6%; p=0.04), cardiac arrhythmias (35.3% versus 25.2%; p<0.0001), renal failure (12% versus 8.7%; p=0.03), and major adverse cerebral and cardiovascular events (52.4% versus 39.5%; p<0.0001) showed a significantly higher incidence in MetS patients. Variables correlated with late mortality at propensity-adjusted Cox proportional-hazards regression were age (p=0.0008), preoperative left ventricular ejection fraction (p=0.001), preoperative renal failure (p=0.001), and MetS (p=0.006). Higher C-reactive protein levels were found preoperatively (8.6±2.3 versus 5.14±3.1 mg/L; p<0.0001) and both early (71.2±9 versus 49.6±8.7 mg/L; p<0.0001) and late (7.4±2.7 versus 4.8±2.5 mg/L; p<0.0001) after surgery. CONCLUSIONS: The main finding of our study was the association between MetS and mortality both early and late after coronary artery bypass grafting. Thus, MetS should be recognized as an independent preoperative variable that can lead to the identification of high-risk patients and as a risk factor to correct with lifestyle modifications and pharmacologic therapy.

On the interpretation of transport properties of sodium cholate and sodium deoxycholate in binary and ternary aqueous mixtures.

Sodium cholate (NaC) and sodium deoxycholate (NaDC) in binary and ternary aqueous mixtures were investigated by means of surface tension, electron paramagnetic resonance spectroscopy (EPR), small angle neutron scattering (SANS) and mutual diffusion coefficient analysis. Concerning the NaC-H(2)O and NaDC-H(2)O binary mixtures, the surface tension, EPR and diffusion measurements confirmed the formation of micelles above a well detectable critical concentration. The SANS data indicated for both systems, the formation of ellipsoidal micelles whose major axis increased with concentration and minor axis remained constant. The data were interpreted under the assumption that aggregate growth occurred via hydrogen bonding of small aggregates along one preferential direction. For the NaC-NaDC-H(2)O ternary mixtures, the surface tension and EPR results were in good agreement with the Clint model prediction for the ideal mixed micellization. Based on this model, the SANS data enabled a complete description of the mixed aggregates in terms of dimensions, composition and concentration. In turn, this strategy allowed for a satisfactory interpretation of the main and cross-term diffusion coefficient trends, which are quite complex.

n-3 polyunsaturated fatty acids after coronary artery bypass grafting.

BACKGROUND: Despite the robust evidence of the potential benefits of n-3 polyunsaturated fatty acid (PUFA) supplementation in patients with established coronary artery disease, the impact of this therapy on patients after coronary artery bypass grafting remains completely unknown. METHODS: Among 2,100 patients undergoing isolated coronary artery bypass grafting in one tertiary care institution, 930 (44%) were put under n-3 PUFA therapy chronically at discharge. The impact of n-3 PUFAs was assessed by means of propensity-score adjusted analysis. The primary end point was all-cause mortality. Secondary end points were repeat revascularization and the composite of death, Q-wave myocardial infarction, and cerebrovascular events. RESULTS: In a crude analysis, patients discharged on n-3 PUFAs had a lower risk for late mortality (unadjusted hazard ratio [HR], 0.51; 95% confidence interval [CI], 0.36 to 0.73; p = 0.0002), which was conformed at multivariable adjusted Cox regression analysis (HR, 0.55; 95% CI, 0.26 to 0.90; p = 0.02). Adjusted risk of repeat revascularization was significantly lower in patients receiving n-3 PUFAs than in those who did not (HR, 0.52; 95% CI, 0.28 to 0.97; p = 0.04). The adjusted risk for the composite of death, Q-wave myocardial infarction, or cerebrovascular events was lower in patients who received n-3 PUFAs compared with patients who did not (HR, 0.56; 95% CI, 0.36 to 0.81; p = 0.001). Subgroup analyses showed that mortality benefit associated with n-3 PUFAs was particularly relevant in patients with poor left ventricular function (HR, 0.36; 95% CI, 0.17 to 0.76; p = 0.007), but it was only marginal in patients with good ventricular function (HR, 0.89; 95% CI, 0.65 to 1.01; p = 0.05). CONCLUSIONS: This study showed that n-3 PUFAs after coronary artery bypass grafting were associated with a lower risk for repeat revascularization and overall mortality in patients with poor ventricular function.

How to ensure a good flow to the arm during direct axillary artery cannulation.

We herein describe a simple and safe technique to avoid compartment syndrome/arm ischemia during direct right axillary artery cannulation, especially in patients who require long-term extracorporeal membrane oxygenation support.

Diffusion in ternary aqueous systems containing human serum albumin and precipitants of different classes.

The mutual diffusion coefficients for two aqueous ternary systems, both containing a protein, human serum albumin (HSA, component 1), were measured. The first system contained a neutral polymer, polyethylene glycol (PEG, component 2), and the second an "organic solvent", 2-methyl-2,4-pentanediol (MPD, component 3). Both PEG and MPD are used as co-precipitants in HSA crystallization protocols. Measurements were performed at constant protein concentration, with increasing precipitant content. The results obtained for the two systems were discussed and compared. In both cases, the two main diffusion coefficients, relative to the motion of the protein and of the precipitant under their own concentration gradient, can be interpreted in terms of non-specific volume interactions between the solutes. Particularly, it was showed that any possible direct HSA-MPD interaction may not have a significant effect on the values of these two diffusion coefficients. Differences arise between the cross precipitant's diffusion coefficients, relative to the motion of the precipitant under the protein concentration gradient, D(i1) with i = 2, 3. In the case of PEG, the D(21) trend vs. c(2) can be simply interpreted in terms of an "exclude volume" effect. In contrast, in the case of MPD, the D(31)vs. c(3) trend seems to indicate a more complex mechanism of transport. Because the cross precipitant's diffusion coefficient plays an important role in the crystallization process, the implication of the observed difference on the crystallization procedure was also discussed.

Preoperative creatinine clearance as a predictor of short-term outcomes after cardiac surgery: a cohort study for the comparison between the Cockroft-Gault and modification of diet in renal disease formulae.

BACKGROUND: Preoperative renal function is an important risk factor in cardiac surgery for long-term and short-term outcomes. Renal function is best assessed by measuring or calculating the glomerular filtration rate (GFR). Several algorithms using the endogenous marker serum creatinine have been developed to estimate renal function. These include the Cockcroft and Gault and the modification of diet in renal disease (MDRD) formulae. The aim of this study was to compare the predictive power of the two formulae towards short-term outcomes after cardiac surgery, such as the length of intensive care unit (ICU) stay, the length of mechanical ventilation time, and the length of in-hospital stay. METHODS: One hundred and fifty patients undergoing cardiac surgery and not affected by renal failure were followed up until hospital discharge. We collected data before, during and after surgery. Before surgery data consisted of date of birth, sex, height, weight, plasma creatinine level; during surgery data consisted of type of intervention (including number of bypasses, if any), cardiopulmonary bypass time and aortic cross-clamp time; after surgery data consisted of length of ICU stay, mechanical ventilation time, length of in-hospital stay after intensive-care discharge (ward stay), incidence of acute renal failure (expressed as the need for dialysis) and mortality. The dataset was analyzed using Cox regression. RESULTS: The average mechanical ventilation time, ICU stay and ward stay were 11 h, 49 h and 10 days, respectively. After having adjusted for chronic obstructive pulmonary disease, diabetes and postsurgical dialysis, the GFR calculated with the Cockcroft and Gault formula appeared to be a predictor of ICU stay and mechanical ventilation time with very strong evidence (P = 0.002 and <0.001, respectively) and a predictor of ward stay with some evidence (P = 0.062). After an identical case-mix adjustment, the GFR calculated with the MDRD formula appeared to be a predictor of ICU stay with strong evidence (P = 0.007), a predictor of mechanical ventilation time with some evidence (P = 0.075) and it has shown no evidence of predicting ward stay (P = 0.197). CONCLUSION: There is an indication that the Cockcroft and Gault formula could be more powerful than the MDRD formula for the preoperative prediction of early postoperative clinical outcomes in cardiac surgery, in patients not affected by renal failure. Further research is needed to confirm this result.

Intraoperative continuous venovenous hemofiltration during coronary surgery.

Postoperative continuous venovenous hemofiltration decreases acute renal failure in patients with moderate renal dysfunction undergoing coronary artery bypass grafting, but it prolongs intensive care unit stay. We developed a simple method to connect a hemofiltration machine to the cardiopulmonary bypass system. To evaluate the benefit of intraoperative hemofiltration, 124 consecutive patients (mean age, 67 +/- 6 years) with moderate renal dysfunction were studied. Surgery was preformed between January 2005 and May 2007. On-pump coronary artery bypass with hemofiltration was carried out in 40 patients (group A), 44 had on-pump coronary artery bypass without hemofiltration (group B), and 40 had off-pump coronary artery bypass (group C). Postoperative acute renal failure was defined as either renal failure requiring dialysis or >or=50% decline from the baseline glomerular filtration rate but not requiring dialysis. The 3 groups had similar demographic data and preoperative renal function. After adjusting for covariates and propensity scores, multivariate analysis showed that intraoperative hemofiltration and off-pump surgery protected postoperative renal function. Independent risk factors for postoperative renal dysfunction were age >70 years, left ventricular ejection fraction <35%, and the preoperative glomerular filtration rate.

Neutrophil gelatinase-associated lipocalin levels after use of mini-cardiopulmonary bypass system.

Neutrophil gelatinase-associated lipocalin (NGAL) has been implicated as an early predictive urinary biomarker of ischemic acute kidney injury (AKI). The aim of this study was to compare the effects of miniaturized cardiopulmonary bypass system (MCPB) vs. standard cardiopulmonary bypass system (SCPB) system on kidney tissue in patients undergoing myocardial revascularization using urinary NGAL levels as an early marker for renal injury. Sixty consecutive patients who underwent myocardial revascularization were studied prospectively. An SCPB was used in 30 patients (group A) and MCPB was used in 30 patients (group B). The SCPB group but not the MCPB group showed a significant NGAL concentration increase from preoperative during the 1st postoperative day (169.0+/-163.6 ng/ml in the SCPB group vs. 94.1+/-99.4 ng/ml in the MCPB group, P<0.05, respectively). Two patients in the SCPB group developed AKI and underwent renal replacement therapy; no patient in MCPB developed AKI. The MCPB system is safe in routine clinical use. Kidney function is better protected during MCPB as demonstrated by NGAL levels. NGAL represents an early biomarker of renal failure in patients undergoing cardiac surgery and the valuation of its concentration can aid in medical decision-making.

Miniaturized cardiopulmonary bypass and acute kidney injury in coronary artery bypass graft surgery.

BACKGROUND: Acute kidney injury (AKI) is one of the most important complications after on-pump coronary artery bypass graft surgery (CABG). Miniaturized cardiopulmonary bypass (mini-CPB) systems have been developed to allow the ease of on-pump surgery but tempering the disadvantages. Whether mini-CPB reduces the incidence of AKI remains to be determined. METHODS: Using a propensity score matched analysis, we investigated the occurrence of AKI among patients undergoing CABG on mini-CPB (n = 104) versus conventional CPB (n = 601). Acute kidney injury was defined according to the recent Acute Kidney Injury Network classification. RESULTS: Overall, acute kidney injury developed in 274 of 705 patients (38.8%). A total of 27 of 705 patients (3.8%) required renal replacement therapy. The median postoperative length of intensive care unit stay in survivors with AKI was 5.4 (3.9 to 6.8) days compared with 2.0 (1.0 to 3.0) days for patients without AKI (p = 0.0002). The overall incidence of AKI for patients undergoing mini-CPB was 30 of 104 (28.8%) compared with 244 of 601 (40.5%) for patients undergoing conventional CPB (p = 0.03). In the propensity score matched-pair statistical analysis, mini-CPB was independently associated with a decreased incidence of AKI (adjusted odds ratio [OR] 0.61; 95% confidence interval [CI]: 0.38 to 0.97). Other variables independently associated with AKI were preoperative glomerular filtration rate (OR 0.988 for 1 mL.min(-1).1.73 m(-2) increase; 95% CI: 0.98 to 0.99), postoperative red blood cell transfusion (OR 1.58; 95% CI: 1.12 to 2.23); CPB time (OR 1.005 for 1-minute increase; 95% CI: 1.0 to 1.009), and postoperative low output syndrome (OR 1.72; 95% CI: 1.23 to 2.41). CONCLUSIONS: The present study showed that mini-CPB is associated with a lower incidence of AKI when compared with conventional CPB among patients undergoing CABG.

Does combined mitral valve surgery improve survival when compared to revascularization alone in patients with ischemic mitral regurgitation? A meta-analysis on 2479 patients.

OBJECTIVES: Optimal treatment of significant (>or=2+ grade) ischemic mitral regurgitation remains controversial, and the impact of mitral valve surgery (MVS) at the time of coronary artery bypass grafting (CABG) on early and late results has to be still clarified. METHODS: A systematic literature search for studies comparing CABG combined to MVS (repair or replacement) compared with CABG alone in patients with ischemic mitral regurgitation and meta-analysis for late mortality, postoperative New York Heart Association functional class and late residual mitral regurgitation grade was performed. Risk ratios and the standardized mean difference (SMD) under the fixed or random effects model were reported. RESULTS: A total of nine observational nonrandomized studies were identified including 2479 patients with ischemic mitral regurgitation who underwent CABG alone (n = 1515) and CABG combined to MVS (n = 964).Meta-analysis of the pooled study population showed that MVS did not have advantages on late mortality [risk ratio 1.02; 95% confidence interval (CI) 0.90 to 1.14; P = 0.73] compared with CABG alone.Combined MVS was significantly associated with a lower residual mitral regurgitation grade compared with CABG alone (SMD = -0.9; 95% CI -1.250 to -0.559; P < 0.0001). However, postoperative New York Heart Association class was not significantly improved in the combined MVS group (SMD = -0.26; 95% CI -0.766 to -0.24; P = 0.30). CONCLUSION: Most surgeons commonly use additional mitral valve procedure to treat moderate or severe ischemic mitral regurgitation, because it seems logical to assume that the volume overload associated with mitral regurgitation will be detrimental particularly to the patient with compromised left ventricular function. However, until definitive evidence about the superiority of this approach will be available, a tailored surgical strategy should be considered especially in mild ischemic mitral regurgitation.