Mitral Gradients and Frequency of Recurrence of
Mitral Regurgitation After Ring Annuloplasty for
Ischemic Mitral Regurgitation
Matthew L. Williams, MD, Mani A. Daneshmand, MD, James G. Jollis, MD,
John R. Horton, MS, Linda K. Shaw, MS, Madhav Swaminathan, MD, Robert D. Davis, MD,
Donald D. Glower, MD, Peter K. Smith, MD, and Carmelo A. Milano, MD
Divisions of Cardiothoracic Surgery and Cardiovascular Medicine, Duke University Medical Center, and Duke Clinical Research
Institute, Durham, North Carolina
Background. Undersized ring annuloplasty and surgi-
cal revascularization are commonly used to correct ischemic
mitral regurgitation (MR), but published series have failed
to demonstrate a benefit compared with revascularization
alone. We hypothesized that surgical revascularization
and annuloplasty lead to a durable repair, but may also
lead to increased mitral gradients that could limit the
benefit of the repair technique.
Methods. Data were collected for 222 consecutive
patients who underwent combined revascularization
and repair for ischemic MR between 1999 and 2006.
The most recent transthoracic echocardiogram avail-
able for each patient (namely, the study that occurred
at the latest date after surgery) was reviewed to define
the fate of ischemic MR. When present, the mean
gradient across the mitral valve was measured. Cox
regression modeling was then performed to determine
whether increasing gradients were associated with
decreased long-term survival or increased hospitaliza-
tion for heart failure.
T he presence of mitral regurgitation (MR) has been
shown to adversely impact outcomes in patients who
undergo coronary artery bypass grafting [1]. The technique
of undersized annuloplasty for the treatment of functional
MR in patients with cardiomyopathy was popularized by
Bolling and associates [2]. Currently, undersized ring annu-
loplasty and coronary artery bypass grafting (CABG) are
frequently applied to patients with ischemic MR, but pub-
lished series to date have thus far failed to show a benefit
relative to revascularization alone [3, 4]. Furthermore, it has
been demonstrated in some surgical series that recurrent
MR occurs in one third of patients when echocardiographic
follow-up is available [5, 6]. Some authors have argued that
to avoid recurrent mitral regurgitation, undersized, com-
Accepted for publication June 1, 2009.
Presented at the Poster Session of the Forty-fifth Annual Meeting of The
Society of Thoracic Surgeons, San Francisco, CA, Jan 26 –28, 2009.
Address correspondence to Dr Williams, University of Louisville Health
Sciences, Division of Cardiovascular and Thoracic Surgery, 201 Abraham
Flexner Way, Suite 1200, Louisville, KY 40202; e-mail: mwilliams@
ucsamd.com.
© 2009 by The Society of Thoracic Surgeons
Published by Elsevier Inc
ADULT CARDIAC
Results. For the group of 222 patients, echocardio-
graphic follow-up was available for 68% (149 patients).
At follow-up, 1.3% had severe MR and 9.4% had moder-
ate MR; 54% of patients (66 of 123) were found to have
gradients of 5 mm or greater across the mitral valve, with
11% demonstrating gradients of 8 mm or more. Cox
proportional hazards models failed to show adverse
effects of increasing mitral gradient on outcomes ana-
lyzed: survival hazard ratio ⴝ 0.95 (95% confidence inter-
val: 0.82 to 1.11, p ⴝ 0.527) and survival/heart failure
hospitalization hazard ratio ⴝ 1.04 (95% confidence in-
terval: 0.93 to 1.17, p ⴝ 0.488).
Conclusions. Undersized ring annuloplasty and revas-
cularization can provide a durable correction of ischemic
mitral regurgitation. This technique frequently increases
the gradient across the mitral valve, but increasing mitral
gradient does not appear to adversely impact survival or
heart failure hospitalization.
(Ann Thorac Surg 2009;88:1197–201)
© 2009 by The Society of Thoracic Surgeons
plete rigid annuloplasty rings should be utilized, and have
shown a decrease in need for reoperation as evidence that
this technique provides a more durable correction for
ischemic MR [7]. It would appear that a more durable
correction of ischemic MR performed concurrently with
CABG would yield greater benefits for patients, although at
the risk of creating iatrogenic mitral stenosis.
Concerns have previously been raised that an aggres-
sively undersized annuloplasty ring may lead to in-
creased gradients across the mitral valve, which could
have a deleterious effect on outcome [8]. Clearly, moder-
ately increased gradients have been described in patients
with rheumatic mitral stenosis that were well tolerated
for long periods of time with few deleterious effects [9,
10]. However, it is unknown what the effect of increased
gradient is after repair of ischemic MR. The population of
ischemic MR patients would certainly be expected to
have a higher left ventricular end-diastolic pressure than
rheumatic patients and would therefore be at higher risk
of heart failure symptoms after the creation of moderate
stenosis by undersized annuloplasty.
0003-4975/09/$36.00
doi:10.1016/j.athoracsur.2009.06.022
 1198 WILLIAMS ET AL Ann Thorac Surg
RECURRENCE OF MR AFTER RING ANNULOPLASTY 2009;88:1197–201

In surgical patients with ischemic MR, the dominant Table 1. Patient Characteristics
(although not uniform) strategy at our institution has
Patients with Paired
been to undersize the valve with a complete, nonflexible All Patients Echocardiographic
annuloplasty ring. We hypothesized that this, along with Characteristic (n ⫽ 222) Data (n ⫽ 83)
revascularization, would lead to a durable repair and
ADULT CARDIAC

Age, median years (IQR) 67 (59, 74) 65 (58, 73)

would reduce left ventricular diameters. We sought to
Male (%) 101 (46) 39 (47)
determine if this strategy led to increased gradients
Black (%) 48 (22) 23 (28)
across the repaired valve, and if this had any measurable
Preoperative ejection 30 (20, 40) 30 (20, 40)
impact on fatal or nonfatal outcomes. fraction, median (IQR)
Renal failure (%) 16 (7) 9 (11)
Material and Methods Diabetes mellitus (%) 86 (39) 33 (40)
COPD (%) 46 (21) 22 (27)
All data collection and analysis was performed with History of CABG (%) 18 (8) 8 (10)
waiver of consent with Institutional Review Board History of myocardial 106 (48) 43 (52)
approval. infarction (%)
Between February 1999 and August 2006, we identified History of stroke (%) 17 (8) 7 (8)
222 consecutive patients who underwent CABG and Class III or IV heart failure 99 (45) 40 (48)
annuloplasty for ischemic mitral regurgitation. Preoper- (%)
ative clinical characteristics as well as longitudinal data Number of diseased vessels 2.6 (⫾ 0.1) 2.6 (⫾ 0.6)
for survival and heart failure hospitalization were col- (SD)
lected as part of the Duke Cardiovascular Databank and Cerebrovascular disease (%) 23 (10) 10 (12)
were 98% complete. The most recent transthoracic echo- Peripheral vascular disease 37 (17) 18 (18)
(%)
cardiogram available for each patient (namely, the echo-
Smoking (%) 117 (53) 42 (51)
cardiogram that occurred at the latest date after surgery)
Hypertension (%) 159 (72) 59 (71)
was reviewed to determine the extent of MR in patients
Hypercholesterolemia (%) 126 (57) 51 (61)
who underwent surgical repair and revascularization for
Preoperative inotropes (%) 5 (2) 2 (3)
ischemic MR. If moderate or severe MR was identified,
Emergency status (%) 32 (14) 15 (18)
an attempt was made to determine the cause from the
echocardiogram. If available, left ventricular diameters Preoperative IABP (%) 18 (8) 6 (7)
were compared using a sign-rank test. In addition, if Redo operation (%) 22 (10) 9 (10)
measured, the mean gradient across the mitral valve was CABG ⫽ coronary artery bypass graft surgery; COPD ⫽ chronic
recorded. obstructive pulmonary disease; IABP ⫽ intra-aortic balloon pump;
IQR ⫽ interquartile range.
Two endpoints were examined in time-to-event anal-
yses: all-cause mortality and a composite of death or
heart failure hospitalization. Unadjusted Kaplan-Meier Results
plots were generated and stratified by low mitral gradi-
ent (gradient 5 or less) versus high mitral gradient For the group of 222 patients, preoperative data can be
(gradient more than 5). Kaplan-Meier methods were also seen in Table 1. The intraoperative transesophageal
used to examine survival differences for patients with echocardiogram demonstrated moderate MR in 138 of
follow-up echocardiogram versus no follow-up echocar- 222 (62%) and severe MR in 78 of 222 patients (35%). Six
diogram. Unadjusted Cox-proportional hazards were ex- patients (3%) had mild MR. Median follow-up time for all
surviving patients was 2.20 years with an interquartile
amined to assess relationships with outcomes. Multiva-
range (IQR) of 1.04 years to 4.42 years, and 2.22 years with
riable Cox proportional hazards models were used to
an IQR of 1.1 to 4.26 years for surviving patients with a
assess relationships between clinical characteristics and
follow-up echocardiograph. This is a very high risk group
both endpoints. The following covariates were examined
of patients: 30-day mortality was 6.3% (14 of 222). A
in the unadjusted and adjusted models: mitral gradient,
nonflexible ring was utilized in 98% of patients, with an
history of diabetes, renal disease, male, chronic obstruc- average ring size of 24.8 mm (⫾ 1.3 mm). A complete ring
tive pulmonary disease, baseline ejection fraction, pul- was used in 91% of patients, and the average number of
monary gradient, surgery redo, preoperative balloon bypass grafts was 2.8 (⫾ 0.9). A preoperative chest wall
bump, age, prior CABG, history of myocardial infarction, echocardiogram was available for 134 patients. Average
and number of grafts, number of disease vessels, on- preoperative left ventricular end-diastolic diameter for
pump, race, and New York Heart Association (NYHA) this group was 5.4 cm (⫾ 0.8 cm), and left ventricular
class. Mean mitral gradient was assessed in an adjusted end-systolic diameter was 4.3 cm (⫾ 1.0 cm). Echocardio-
model with all significant components to determine if graphic follow-up was available for 149 of 222 patients
increasing gradients were associated with decreased sur- (68%). Median time to latest echocardiographic follow-up
vival or increased hospitalization for heart failure. All was 321 days; the IQR was 17 to 918 days. At the time of
analyses were performed utilizing SAS version 8.1 or follow-up echocardiograph, 1.3% (2 of 149 patients) had
higher (SAS Institute, Cary, NC). severe MR and 9.4% (14 of 149) had moderate MR. Upon
Ann Thorac Surg WILLIAMS ET AL 1199
2009;88:1197–201 RECURRENCE OF MR AFTER RING ANNULOPLASTY

Table 2. Left Ventricular (LV) Diameters (n ⫽ 83) Possible explanations for this finding include differences
in patient population or the incomplete echocardio-
Diameter
graphic follow-up. More likely, though, this finding rep-
Preoperative LV end-diastolic diameter 5.5 cm (⫾ 0.8) resents a true decrease in recurrent MR secondary to the
Postoperative LV end-diastolic diameter 5.1 cm (⫾ 1.0) strategy of aggressive undersizing and the utilization of

ADULT CARDIAC
Delta ⫽ ⫺0.4 cm, p ⬍ 0.001 complete, rigid annuloplasty rings. It appears that this
Preoperative LV end-systolic diameter 4.3 cm (⫾ 1.0) technique does reduce the rate of recurrent MR, but at
Postoperative LV end-systolic diameter 4.2 cm (⫾ 1.2) the price of increased mitral gradients, as the majority of
Delta ⫽ ⫺0.1 cm, p ⫽ 0.08 those patients in whom it was measured demonstrated a
mean transmitral gradient of 5 mm Hg or more. This is a
higher proportion than has usually been reported in
series of repairs of ischemic MR or functional MR, even
review of the echocardiograms, 81% (13 of 16 patients) after aggressive undersizing [11], although one other group
with moderate or severe MR were determined to have has reported a mean mitral gradient of greater than 5 mm
progressive posterior leaflet tethering as the etiology for Hg afater restrictive annuloplasty for functional MR[12]. In
failure of repair. No patients underwent reoperation for addition, left ventricular diameters were decreased after
mitral regurgitation; 2 patients did go on to receive cardiac surgical revascularization and mitral annuloplasty. The
transplantation. modest decrease in left ventricular diameter may not be
Paired preoperative and postoperative transthoracic clinically significant, but increasing chamber size is as-
echocardiograms were available for 37% of patients (83 of sociated with worse outcome in patients with heart
222). Left ventricular end-diastolic diameter was signifi- failure and after myocardial infarction [13, 14].
cantly decreased relative to preoperative transthoracic Using proportional hazards models, we were unable to
echocardiogram; left ventricular end-systolic diameter demonstrate any adverse relationship between mitral
was decreased but did not reach statistical significance gradient and survival or the composite of survival and
(Table 2). Measurement of the transmitral gradient was hospitalization for heart failure. Although the number of
available for 123 patients; 54% of patients were found to patients analyzed was low (123 patients), this is a cohort
have mean gradients of 5 mm Hg or greater across the of patients with high event rates, and there appeared to
mitral valve, with 13% demonstrating gradients of 8 mm be no trend toward an adverse effect. This finding runs
Hg or more (average 5.0 ⫾ 2.2 mm Hg). Diabetes mellitus, counter to recent descriptions of the adverse effect of
preoperative intra-aortic balloon pump, increased age, patient-prosthesis mismatch at the mitral position [15, 16].
history of myocardial infarction, number of grafts, and
higher NHYA class were found to be significantly asso- Table 3. Adjusted Proportional Hazards Survival Survival/
ciated with increased mortality (p values ⬍ 0.05) in the Hospitalization for Heart Failure
multivariable proportional hazards model, following Wald Hazard Ratio p
stepwise selection of all candidate variables. Diabetes, Variable ␹2 (95% CI) Value
male, chronic obstructive pulmonary disease, baseline
Adjusted proportional
ejection fraction, and preoperative intra-aortic balloon
hazards survival
pump were found be associated with increased risk for (n ⫽ 123)
the composite of death or heart failure rehospitalization. Mitral gradient 0.400 0.95 (0.82–1.11) 0.527
When mitral gradient was forced into these models, there Diabetes mellitus 10.047 3.10 (1.54–6.24) 0.002
was no indication of an association with either endpoint Preoperative IABP 6.408 3.56 (1.33–9.51) 0.011
(p values ⫽ 0.527 and 0.488, respectively; Table 3). No
Age 4.764 1.05 (1.10–1.09) 0.029
difference in these endpoints was observed when com-
History of myocardial 9.646 3.74 (1.63–8.59) 0.002
paring patients with follow-up echocardiogram to pa- infarction
tients without follow-up echocardiogram (Fig 1A, B). No Number of grafts 3.257 1.43 (0.97–2.12) 0.071
differences in the unadjusted plots were observed for NYHA class CHF 8.119 1.60 (1.16–2.20) 0.004
patients with a mitral gradient of 5 mm Hg compared
Adjusted proportional
with patients having a gradient of 5 mm Hg or less hazards
(death, p ⫽ 0.274; death/rehospitalization, p ⫽ 0.560; survival/hospitalization
Fig 2A, B). Actuarial survival of the entire cohort was 72% for heart failure
at 2 years and 55% at 5 years. (n ⫽ 123)
Mitral gradient 0.481 1.042 (0.93–1.17) 0.488
Diabetes mellitus 5.639 1.90 (1.12–3.21) 0.018
Comment Male 4.576 1.78 (1.05–3.02) 0.032
In this series of patients who underwent undersized ring COPD 3.541 1.73 (0.98–3.07) 0.060
annuloplasty and surgical revascularization for treatment Ejection fraction 6.990 0.97 (0.94–0.99) 0.008
of ischemic MR, a durable correction of the ischemic MR Preoperative IABP 22.057 5.81 (2.79–12.12) ⬍0.0001
was achieved. The rate of recurrent MR in this cohort of
CHF ⫽ congestive heart failure; CI ⫽ confidence interval; COPD ⫽
patients was less than that reported in other series with chronic obstructive pulmonary disease; IABP ⫽ intra-aortic balloon
comparable rates of echocardiographic follow-up [5, 6]. pump; NYHA ⫽ New York Heart Association.
 1200 WILLIAMS ET AL Ann Thorac Surg
RECURRENCE OF MR AFTER RING ANNULOPLASTY 2009;88:1197–201

It could be that mitral gradients more commonly found

in this series (between 5 mm and 8 mm Hg) are simply
well tolerated, and gradients at this level are a good trade
for lower rates of MR recurrence. Other interpretations
are possible. Mitral gradient measurement with echocar-
ADULT CARDIAC

diography relies on a number of assumptions, and the

lack of an apparent effect of increased gradients could
simply reflect a lack of accuracy using this technique. In
addition, increasing cardiac output—all other factors
being equal—would tend to increase the mitral gradient.
The finding of increased gradient alone then could reflect
increased cardiac output relative to other patients, rather
than greater restriction at the level of the mitral valve.
Despite the low rate of MR recurrence and the appar-
ently benign nature of the increased gradients, survival
of this very ill group of patients remained poor, with only
about half expected to survive 5 years after operation.
Weaknesses of this study are the drawbacks of retrospec-
tive analysis, including the absence of a significant group of

Fig 2. Mitral gradients: (A) survival probability; (B) freedom from

death or hospitalization for heart failure. (Solid line ⫽ gradient
more than 5; broken line ⫽ gradient 5 or less.)

patients who received flexible or larger rings. In addition,

echocardiographic follow-up is not available for the entire
cohort and is based on a variable time interval from oper-
ation, which weakens conclusions drawn from those data. It
is reassuring to note, however, that there does not appear to
be any significant difference with respect to long-term
outcomes between patients who did or did not undergo
follow-up echocardiography (Figs 1A and B).
In conclusion, undersized ring annuloplasty and sur-
gical revascularization provide a durable correction of
ischemic MR that reduces left ventricular diameters. This
technique frequently increases the gradient across the
mitral valve as measured by echocardiography, but in-
creasing mitral gradient does not appear to adversely
impact survival or heart failure hospitalization (Table 3).
Fig 1. Echocardiographic follow-up: (A) survival probability;
(B) freedom from death or hospitalization for heart failure. (Solid
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The Society of Thoracic Surgeons Policy Action Center
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© 2009 by The Society of Thoracic Surgeons
Published by Elsevier Inc
WILLIAMS ET AL 1201
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prosthesis mismatch on late outcomes after mitral valve
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16. Li M, Dumesnil JG, Mathieu P, et al. Impact of valve
prosthesis/patient mismatch on pulmonary arterial pressure
after mitral valve replacement. J Am Coll Cardiol 2005;45:
1034 – 40.
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