STICH Mitral Regurgitation Subanalysis

1. STICHMitral Regurgitation Subanalysis Objective • Examine the relationship of mitral regurgitation (MR) severity and survival and compare outcomes in patients with moderate–severe MR who did and did not receive mitral valve repair Background • The STICH trial, which randomly assigned 1212 patients with LVEF <35% to CABG or medical therapy alone, found no difference in all-cause mortality between these groups • CABG was associated with reductions in some secondary endpoints, including the risk of CV death and the composite endpoint of all-cause mortality or CV hospitalization • At baseline, MR was present in 64% of patients and classified as mild (46%) moderate (15%), and severe (3%); the decision to treat or not to treat MR was left to the surgeon

2. STICHMitral Regurgitation Subanalysis Results • In the medical therapy group, mortality was higher in patients with increasingly more severe MR; patients with moderate or severe MR had nearly double the risk of death from all causes as those with no or trace MR; patients with mild MR had a 60% increase in all-cause mortality • In patients with no or trace MR, CABG was not associated with decreased mortality relative to medical therapy alone; however, CABG was associated with a reduced risk of death in patients with mild MR • In the small subgroup of patients with moderate or severe MR (n=195), there was no survival advantage with CABG compared with medical therapy alone or with CABG and MV repair; however, after adjustment for baseline prognostic variables, the combination of CABG and MV repair was associated with a lower hazard of mortality compared with CABG alone and was associated with a trend toward lower mortality compared with medical therapy alone

3. STICHMitral Regurgitation Subanalysis All-Cause Mortality Estimates for 195 Patients with Moderate/Severe MR

4. STICHMitral Regurgitation Subanalysis Conclusions • In patients with moderate–severe MR, adding mitral repair to CABG tends to decrease perioperative risk and increase survival compared with CABG alone or medical therapy alone • In patients with severe LV dysfunction and mild MR, CABG alone improves survival Trial Limitations • noncore lab assessment of MR • nonrandomized treatment • important baseline differences between those with and without moderate– severe MR