Outcomes and quality of life in patients receiving mitral surgery for asymptomatic disease.

Objectives: We sought to characterize the demographics, outcomes, and quality of life of asymptomatic patients undergoing mitral valve surgery at our center over a 10-year period. Methods: Adults undergoing mitral surgery were retrospectively reviewed between 2010 and 2019. Patients were included if deemed asymptomatic by review of referring cardiologist and surgeon consultation. Patients were administered a telephone survey consisting of the Kansas City Cardiomyopathy Questionnaire as well as free-response regarding satisfaction surrounding their operation. Outcomes included survival, Kansas City Cardiomyopathy Questionnaire metrics, and thematic analysis of free response questions. Results: A total of 145 patients were identified who were deemed asymptomatic. Their average age was 60.3 ± 12.1 years, and 71% were male. No patients had endocarditis, and 34% had decreased ejection fraction (<60%). Repair was achieved in 95% of patients. Median length of stay was 6 (5-8) days. Ten-year survival was 91%, with no differences noted by ejection fraction. Composite Kansas City Cardiomyopathy Questionnaire score was 100 (96-100). The lowest component score was "Quality of Life," with 22% of patients reporting being "mostly satisfied" with present cardiac status. Most common themes expressed were gratitude with surgery results (58%), satisfaction with being able to stay active (23%), and happiness with early disease treatment (21%). Only 1 patient (0.7%) expressed regret with surgery choice. Conclusions: Mitral surgery for asymptomatic disease can be performed with good long-term outcomes in select patients, and the majority experience excellent quality of life and satisfaction with current health. Continued assessments of quality of life are important in evaluating outcomes of mitral surgery as indications grow.

Comparative analysis of different risk prediction tools after mitral Transcatheter edge-to-edge repair.

BACKGROUND: Transcatheter edge-to-edge repair (TEER) has become an established treatment for primary and secondary mitral regurgitation (PMR and SMR). The objective of this study was to compare the accuracy of different risk scores for predicting 1-year mortality and the composite endpoint of 1-year mortality and/or heart failure (HF) hospitalization after TEER. METHODS: We analyzed data from 206 patients treated for MR at a tertiary European center between 2011 and 2023 and compared the accuracy of different mitral and surgical risk scores: EuroSCORE II, GRASP, MITRALITY, MitraScore, TAPSE/PASP-MitraScore, and STS for predicting 1-year mortality and the composite of 1-year mortality and/or HF hospitalization in PMR and SMR. A subanalysis of SMR-only patients with the addition of COAPT Risk Score and baseline N-Terminal pro-Brain Natriuretic Peptide (NT-proBNP) list was also performed. RESULTS: MITRALITY had the best discriminative ability for 1-year mortality and the composite endpoint of 1-year mortality and/or HF hospitalization, with an area under the curve (AUC) of 0.74 and 0.74, respectively, in a composed group of PMR and SMR. In a SMR-only population, MITRALITY also presented the best AUC for 1-year mortality and the composite endpoint of 1-year mortality and/or HF hospitalization, with values of 0.72 and 0.72, respectively. CONCLUSION: MITRALITY was the best mitral TEER risk model for both 1-year mortality and the composite endpoint of 1-year mortality and/or HF hospitalization in a population of PMR and SMR patients, as well as in SMR patients only. Surgical risk scores, MitraScore, TAPSE/PASP-MitraScore and NT-proBNP alone showed poor predictive values.

Reparación percutánea de insuficiencia mitral primaria con técnica borde a borde: primer reporte de caso en Uruguay / Percutaneous edge-to-edge repair of primary mitral regurgitation: first case report in Uruguay / Correção percutânea de regurgitação mitral primária com técnica "edge-to-edge": primeiro caso reportado em Uruguai

La insuficiencia mitral (IM) es una enfermedad frecuente. La degeneración mixomatosa es la principal causa de IM primaria en los países desarrollados. Si no se corrige, conduce a la disfunción ventricular y a la insuficiencia cardíaca congestiva, con elevada morbimortalidad. La cirugía de reparación valvular es el tratamiento recomendado en la IM primaria severa y sintomática. En los pacientes con alto riesgo quirúrgico las opciones terapéuticas son limitadas. El surgimiento de la reparación percutánea borde a borde ha permitido ofrecer alternativas terapéuticas para estos pacientes, y se han demostrado buenos resultados. Se presenta el caso clínico de un paciente añoso con IM primaria severa. Por su elevado riesgo quirúrgico se optó por realizar reparación percutánea con técnica borde a borde, con excelentes resultados clínicos y ecocardiográficos. Se trata del primer reporte de caso de estas características en nuestro país.

Mitral regurgitation (MR) is a common disease. Myxomatous degeneration is the main cause of primary MR in developed countries. If not corrected, it leads to ventricular dysfunction and congestive heart failure, with high morbidity and mortality. Valve repair surgery is the recommended treatment for severe and symptomatic primary MR. In patients with high surgical risk, therapeutic options are limited. The emergence of edge-to-edge percutaneous repair has made it possible to offer therapeutic alternatives for these patients, and good results have been demonstrated. We present the clinical case of an elderly patient with severe primary MR. Due to his high surgical risk, it was decided to perform percutaneous repair with edge-to-edge technique, with excellent clinical and echocardiographic results. It is the first case report of these characteristics in our country.

A regurgitação mitral (RM) é uma doença frequente. A degeneração mixomatosa é a principal causa de RM primária em países desenvolvidos. Se não for corrigido, leva à disfunção ventricular e insuficiência cardíaca congestiva, com alta morbimortalidade. A cirurgia de reparo valvular é o tratamento recomendado na RM primária grave. Em pacientes com alto risco cirúrgico, as opções terapêuticas são limitadas. O surgimento do reparo percutâneo com plicatura dos segmentos é uma opção terapêutica alternativa, com bons resultados demonstrados. Apresentamos o caso clínico de um paciente doente por RM primária grave. Devido ao seu alto risco cirúrgico, optou-se pela correção percutânea com técnica "edge-to-edge", com excelentes resultados clínicos e ecocardiográficos. Este é o primeiro caso publicado com a técnica em Uruguai.

Percutaneous mitral and tricuspid edge-to-edge repair as a bridge therapy to heart transplantation in advanced heart failure secondary to human immunodeficiency virus: a case report.

Background: Patients with end-stage heart failure (HF) and severe pulmonary hypertension (PH) are not eligible for heart transplant due to high mortality risk. Percutaneous interventions as edge-to-edge repair of the mitral/tricuspid valves are a safe and effective therapy as a bridge for transplantation in patients who have contraindications to heart transplantations (HTs). Case summary: A 44-year-old man with a previous diagnosis of infection by human immunodeficiency virus (HIV) was admitted at the emergency room for exertional dyspnoea. He was diagnosed with a decompensated heart failure with reduced ejection fraction (HFrEF), severe mitral and tricuspid regurgitation, and high probability of PH. He presented poor response to guided medical treatment, even after implantable cardiac resynchronization therapy defibrillator (CRT-D). He was listed for a cardiac transplant, but after right catheterization, he was not an ideal candidate for transplantation, so it was decided to undergo percutaneous mitral and tricuspid edge-to-edge repair as a bridge to transplantation. The post-operative course was uneventful, with significant improvement in New York Heart Association functional class. The patient underwent a successful heart transplant 10 months after the procedure. Discussion: In patients with advanced HF due to HIV, HT is an adequate treatment option. When there are functional mitral and tricuspid regurgitation and severe PH, despite optimal treatment according to current guidelines, percutaneous mitral and tricuspid repair therapy appears to be safe and effective for control of severe PH as a bridge measure for cardiac transplantation.

Cerebrovascular Events After Transcatheter Edge-to-Edge Repair and Guideline-Directed Medical Therapy in the COAPT Trial.

BACKGROUND: Little is known regarding the risk of cerebrovascular events (CVE) in patients with heart failure and severe secondary mitral regurgitation treated with transcatheter edge-to-edge repair (TEER). OBJECTIVES: The study sought to examine the incidence, predictors, timing, and prognostic impact of CVE (stroke or transient ischemic attack) in the COAPT (Cardiovascular Outcomes Assessment of the Mitraclip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation) trial. METHODS: A total of 614 patients with heart failure and severe secondary mitral regurgitation were randomized to TEER plus guideline-directed medical therapy (GDMT) vs GDMT alone. RESULTS: At 4-year follow-up, 50 CVEs occurred in 48 (7.8%) of the 614 total patients enrolled in the COAPT trial; Kaplan-Meier event rates were 12.3% in the TEER group and 10.2 in the GDMT alone group (P = 0.91). Within 30 days of randomization, CVE occurred in 2 (0.7%) patients randomized to TEER and 0% randomized to GDMT (P = 0.15). Baseline renal dysfunction and diabetes were independently associated with increased risk of CVE, while baseline anticoagulation was associated with a reduction of CVE. A significant interaction was present between treatment group and anticoagulation such that TEER compared with GDMT alone was associated with a reduced risk of CVE among patients with anticoagulation (adjusted HR: 0.24; 95% CI: 0.08-0.73) compared with an increased risk of CVE in patients without anticoagulation (adjusted HR: 2.27; 95% CI: 1.08-4.81; Pinteraction = 0.001). CVE was an independent predictor of death within 30 days after the event (HR: 14.37; 95% CI: 7.61, 27.14; P < 0.0001). CONCLUSIONS: In the COAPT trial, the 4-year rate of CVE was similar after TEER or GDMT alone. CVE was strongly associated with mortality. Whether anticoagulation is effective at reducing CVE risk after TEER warrants further study. (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation [The COAPT Trial] and COAPT CAS [COAPT); NCT01626079).

MitraClip as bridge to mitral valve replacement in the setting of ischemic cardiogenic shock and papillary muscle rupture.

MitraClip implantation has been reported in severe mitral regurgitation following ischemic papillary muscle rupture in surgically high-risk patients with cardiogenic shock. Here we present a case of a 68-year-old female patient who suffered an ischemic papillary muscle rupture resulting in severe mitral prolapse and had a MitraClip implanted. Three months later, due to progressive symptoms, she was taken to surgery and had an elective minimally invasive mitral valve replacement. Informed consent was given and ethics board approval was obtained.

Histopathological maladaptive changes in the explanted human mitral leaflets correlate with changes in echocardiographic leaflet morphology and the severity of ischaemic mitral regurgitation.

AIMS: Several changes of the mitral valve (MV) morphology have been previously documented in ischaemic mitral regurgitation (IMR) upon macro and microscopic examination. This study aimed to correlate echocardiographic MV thickening with IMR severity and to delineate the histopathological basis of valve thickening from the explanted leaflets. METHODS AND RESULTS: Two hundred and fifty patients were included in the echo-group; of these, 48 patients (19.2%) underwent surgical mitral valve replacement (MVR), including them in the histology-group. By echocardiography, the thickness of the anterior and posterior leaflet was more extensive in moderate to severe IMR, P < 0.001. Histology-group: patients were divided into two groups based on the median thickness: those with cusp thickness <0.42 cm in Group 1, and ≥0.42 cm in Group 2. The thickness of the base and cusp was more significant in Group 2, P < 0.05 in both. Group 2 biopsies were characterized by involvement of the three leaflet segments, myxoid tissue, and fibrosis deposition. Thicker leaflets were associated with a greater degree of mitral regurgitation (MR), P < 0.0001. In the echo-group, a median leaflet thickness of 3.5 mm of the anterior and posterior MV was independently associated with moderate to severe ischaemic MR [odds ratio (OR) 2.88, P < 0.01] and (OR 10.8, P < 0.001), respectively. CONCLUSION: In ischaemic MR, the thicker the cusps, the worse the MR. Leaflet thickening was due to the myxoid and fibrosis deposition and was detected by echocardiography. Therefore, this method can be helpful in the evaluation of valve remodelling.

Transcatheter "edge-to-edge" mitral valve repair: influence of bias in randomized trials.

Functional mitral regurgitation (FMR) is the result of three-dimensional structural disruption of the mitral valve due to left ventricular dysfunction. The "edge-to-edge" surgical technique has given rise to the percutaneous transcatheter edge-to-edge repair (TEER) technique to treat FMR; however, the lack of a mitral annuloplasty ring makes TEER only partially effective, with uncertain long-term results. The MITRA-FR and COAPT trials, on which current TEER recommendations are based, show conflicting results. COAPT results possible bias has influenced current recommendations issued by clinical practice guidelines in favor of TEER in FMR.

La regurgitación valvular mitral funcional es el resultado de la desestructuración tridimensional de la válvula mitral debido a disfunción ventricular izquierda. La técnica quirúrgica de "borde a borde" ha dado lugar a la técnica transcatéter "borde a borde" percutánea (TEER) para tratar la regurgitación valvular mitral funcional; sin embargo, la falta de un anillo protésico por anuloplastia hace a la TEER solo parcialmente efectiva con resultados inciertos a largo plazo. Los estudios MITRA-FR (Multicentre Randomized Study of Percutaneous Mitral Valve Repair MitraClip Device in Patients with Severe Secondary Mitral Regurgitation) y COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation), en los cuales están basadas las recomendaciones actuales de la TEER, muestran resultados contradictorios. El posible sesgo de los resultados del COAPT ha influido en las recomendaciones actuales emitidas en las guías de práctica clínica a favor de la TEER en regurgitación valvular mitral funcional.

MitraClip as bridge to mitral valve replacement in the setting of ischemic cardiogenic shock and papillary muscle rupture.

MitraClip implantation has been reported in severe mitral regurgitation following ischemic papillary muscle rupture in surgically high-risk patients with cardiogenic shock. Here we present a case of a 68-year-old female patient who suffered an ischemic papillary muscle rupture resulting in severe mitral prolapse and had a MitraClip implanted. Three months later, due to progressive symptoms, she was taken to surgery and had an elective minimally invasive mitral valve replacement. Informed consent was given and ethics board approval was obtained.

Reparación valvular mitral transcatéter "borde a borde": influencia del sesgo en estudios aleatorizados / Transcatheter "edge-to-edge" mitral valve repair: influence of bias in randomized trials

Resumen La regurgitación valvular mitral funcional es el resultado de la desestructuración tridimensional de la válvula mitral debido a disfunción ventricular izquierda. La técnica quirúrgica de "borde a borde" ha dado lugar a la técnica transcatéter "borde a borde" percutánea (TEER) para tratar la regurgitación valvular mitral funcional; sin embargo, la falta de un anillo protésico por anuloplastia hace a la TEER solo parcialmente efectiva con resultados inciertos a largo plazo. Los estudios MITRA-FR (Multicentre Randomized Study of Percutaneous Mitral Valve Repair MitraClip Device in Patients with Severe Secondary Mitral Regurgitation) y COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation), en los cuales están basadas las recomendaciones actuales de la TEER, muestran resultados contradictorios. El posible sesgo de los resultados del COAPT ha influido en las recomendaciones actuales emitidas en las guías de práctica clínica a favor de la TEER en regurgitación valvular mitral funcional.

Abstract Functional mitral regurgitation (FMR) is the result of three-dimensional structural disruption of the mitral valve due to left ventricular dysfunction. The "edge-to-edge" surgical technique has given rise to the percutaneous transcatheter edge-to-edge repair (TEER) technique to treat FMR; however, the lack of a mitral annuloplasty ring makes TEER only partially effective, with uncertain long-term results. The MITRA-FR and COAPT trials, on which current TEER recommendations are based, show conflicting results. COAPT results possible bias has influenced current recommendations issued by clinical practice guidelines in favor of TEER in FMR.

Mitral valve repair in severe mitral regurgitation after blunt chest trauma.

Mitral valve insufficiency is a pathological condition frequently caused by etiologies such as rheumatic heart disease, ischemic cardiomyopathy, leaflets prolapse, endocarditis, rupture of a chordae tendineae, ventricular disorders or congenital heart defects among others. Nevertheless, blunt thoracic trauma, although as a rare cause, can produce valve abnormalities. We describe a case of surgical mitral valve repair of a severe insufficiency caused by blunt chest trauma in a high energy road motorbike accident.

Declaración de la Latinoamerican Association of Cardiac & Endovascular Surgery (LACES) sobre las guías de la AHA/ACC para el manejo de la enfermedad valvular 2020 / Latin American Association of Cardiac and Endovascular Surgery statement regarding the 2020 ACC/AHA guidelines for the management of valvular heart disease

Resumen Se han publicado ya las nuevas guías 2020 de recomendación clínica de la AHA/ACC para el tratamiento de pacientes con valvulopatía. Luego de un análisis profundo, con base en los más grandes estudios clínicos y en la situación en los países de Latinoamérica, la Latinoamerican Association of Cardiac & Endovascular Surgery (LACES) redactó una declaración en relación con algunas de las nuevas recomendaciones.

Abstract The new clinical guidelines of the AHA/ACC for the treatment of patients with Valvulopathy 2020 have been published. After an in-depth analysis, based on the largest clinical trials and taking into account the situation in our countries in Latin America, the Latinoamerican Association of Cardiac & Endovascular Surgery (LACES) drafting a statement on some of the new recommendations.

Quantification of mitral regurgitation after transcatheter edge-to-edge repair: Comparison of echocardiography and patient-specific in silico models.

BACKGROUND: Doppler echocardiographic (echo) assessment of residual mitral regurgitation (MR) after transcatheter edge-to-edge repair (TEER) is challenging and often subjective. This study aimed to evaluate the accuracy and feasibility of standardized quantitative echo methods for assessment of MR severity after MitraClip repair by comparing measurements against a reference MR severity obtained from patient-specific in silico models. METHODS: Post-procedure hemodynamics were simulated under five different MitraClip configurations in previously validated patient-specific in silico models for the treatment of functional MR. The residual regurgitant volume was calculated as in clinical practice using four quantitative virtual echo methods: pulsed Doppler, volumetric, proximal isovelocity surface area (PISA) and vena contracta area (VCA). Multiple permutations were performed for each method. Virtual echo MR results were evaluated against reference MR values directly extracted from the 5 patient-specific in silico models. RESULTS: The echo methods with the greatest accuracy were the three-dimensional (3D) volumetric method (r = 0.957, bias -0.8 ± 1.2 ml, p = 0.01), the 3D VCA method wherein velocity time integrals were evaluated for each jet assessed (r = 0.919, bias -1.5 ± 1.7 ml, p = 0.03), and the 3D PISA method integrating surface areas throughout systole (r = 0.98, bias -2.0 ± 0.9 ml, p = 0.003). The pulsed Doppler and 2D volumetric methods had technical limitations that may result in a high underestimation or overestimation of the MR severity after TEER. In the case of multiple regurgitant jets, a more accurate MR assessment was obtained when all significant jets were evaluated. CONCLUSIONS: Clinically, the 3D volumetric, 3D VCA and 3D PISA methods gave the most accurate MR quantification after TEER. Three-dimensional echo technologies harbor the potential of becoming the non-invasive imaging tool of choice for MR quantification after complex transcatheter mitral interventions.

Mitral valve prolapse in patients with atrial septal defect: A quantitative three-dimensional echocardiographic analysis.

INTRODUCTION AND OBJECTIVES: Mitral valve (MV) prolapse is highly prevalent in patients with atrial septal defect (ASD). Abnormal left ventricular geometry has been proposed as the main mechanism of MV prolapse in ASD, however, the changes in the morphology of the MV apparatus remain to be clarified. Our aim was to assess the MV geometry in patients with ASD and MV prolapse. METHODS: We evaluated 99 patients (73% female, median age 40 years) with ASD who underwent a three-dimensional transesophageal echocardiogram. Three-dimensional analysis of the MV was done using dedicated automated software. Transthoracic echocardiographic parameters were assessed post ASD closure in 28 patients. RESULTS: MV prolapse was found in 39% of patients. Although smaller left ventricular dimensions and greater interatrial shunt were found in patients with MV prolapse compared with those without prolapse, there was no difference in the subvalvular parameters. MV prolapse was associated with larger mitral anterior-posterior diameter, anterolateral-posteromedial diameter, anterior perimeter, posterior perimeter, total perimeter, and anterior leaflet area (all p < 0.05). Mitral regurgitation was more frequent in patients with MV prolapse (80 vs. 48%, p = 0.002). CONCLUSIONS: In patients with ASD, the main mechanism of MV prolapse is the presence of an organic primary process of the MV apparatus (excessive anterior mitral leaflet tissue and mitral annular enlargement).

Progression of Mitral Regurgitation in Rheumatic Valve Disease: Role of Left Atrial Remodeling.

Introduction: Mitral regurgitation (MR) is the most common valve abnormality in rheumatic heart disease (RHD) often associated with stenosis. Although the mechanism by which MR develops in RHD is primary, longstanding volume overload with left atrial (LA) remodeling may trigger the development of secondary MR, which can impact on the overall progression of MR. This study is aimed to assess the incidence and predictors of MR progression in patients with RHD. Methods: Consecutive RHD patients with non-severe MR associated with any degree of mitral stenosis were selected. The primary endpoint was a progression of MR, which was defined as an increase of one grade in MR severity from baseline to the last follow-up echocardiogram. The risk of MR progression was estimated accounting for competing risks. Results: The study included 539 patients, age of 46.2 ± 12 years and 83% were women. At a mean follow-up time of 4.2 years (interquartile range [IQR]: 1.2-6.9 years), 54 patients (10%) displayed MR progression with an overall incidence of 2.4 per 100 patient-years. Predictors of MR progression by the Cox model were age (adjusted hazard ratio [HR] 1.541, 95% CI 1.222-1.944), and LA volume (HR 1.137, 95% CI 1.054-1.226). By considering competing risk analysis, the direction of the association was similar for the rate (Cox model) and incidence (Fine-Gray model) of MR progression. In the model with LA volume, atrial fibrillation (AF) was no longer a predictor of MR progression. In the subgroup of patients in sinus rhythm, 59 had an onset of AF during follow-up, which was associated with progression of MR (HR 2.682; 95% CI 1.133-6.350). Conclusions: In RHD patients with a full spectrum of MR severity, progression of MR occurs over time is predicted by age and LA volume. LA enlargement may play a role in the link between primary MR and secondary MR in patients with RHD.

Coronary artery bypass on survival in patients with moderate ischemic mitral regurgitation: meta-analysis.

OBJECTIVE: The objective of the study was to systematically evaluate the effect of coronary artery bypass grafting (CABG) or CABG combined with mitral valve surgery (cMVS) on post-operative survival in patients with moderate ischemic mitral valve regurgitation. MATERIALS AND METHODS: Databases including PubMed, Web of Science, COCHRANE LIBRARY, WanFang Data, and CNKI Data were searched from inception to January 2020. According to the inclusion criterion, relevant articles were screened. After that we extracted data, assessed quality, and performed meta-analysis using RevMan 5.2. RESULTS: A total of 4 randomized controlled trial and 14 retrospective study involving 4476 patients were included in the study. The CABG group was 2278 and the cMVS group was 1698. The results of meta-analysis showed that compared with CABG group, there were no statistically significant differences in the recent mortality (odds ratio [OR] = 0.88, p = 0.62), 1-year survival (OR = 1.03, p = 0.82), 1-year survival (OR = 1.07, p = 0.62), and long-term survival (OR = 0.95, p = 0.61) of the cMVS group. CONCLUSION: Current evidence indicates that patients in the cMVS group did not benefit from CABG group in survival after surgery.

OBJETIVO: . Evaluar sistemáticamente el efecto del injerto de derivación de la arteria coronaria (CABG) o el injerto de derivación de la arteria coronaria combinados con la cirugía de la válvula mitral (cMVS) sobre la supervivencia posoperatoria en pacientes con insuficiencia valvular mitral isquémica moderada. MATERIAL Y MÉTODOS: . Se realizaron búsquedas en bases de datos que incluyen Pubmed, Web of Science, COCHRANE LIBRARY, WanFang Data y CNKI Data desde el inicio hasta enero de 2020. De acuerdo con el criterio de inclusión, se seleccionaron los artículos relevantes. Después de eso, extrajimos los datos, evaluamos la calidad y realizamos el metanálisis con RevMan 5.2. RESULTADOS: . Se incluyó un total de 4 ensayos controlados aleatorios (ECA) y 14 estudios retrospectivos con 4476 pacientes. El grupo CABG fue 2278, el grupo cMVS fue 1698. Los resultados del metanálisis mostraron que, en comparación con el grupo CABG, no hubo diferencias estadísticamente significativas en la mortalidad reciente (OR = 0.88, p = 0.62), supervivencia a 1 año (OR = 1.03, p = 0.82), supervivencia a 1 año (OR = 1.07, p = 0.62) y supervivencia a largo plazo (OR = 0.95, p = 0.61) del grupo cMVS. CONCLUSIÓN: . La evidencia actual indica que los pacientes del grupo cMVS no se beneficiaron del grupo CABG en la supervivencia después de la cirugía.