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Online Appendix for the following June 5 JACC article
TITLE: Impact of Mitral Valve Anuloplasty Combined With Revascularization in
Patients With Functional Ischemic Mitral Regurgitation
AUTHORS: Tomislav Mihaljevic, MD, Department of Thoracic and Cardiovascular
Surgery, Cleveland Clinic, Cleveland, Ohio; Buu-Khanh Lam, MD, Department of
Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Jeevanantham
Rajeswaran, MSc, Department of Quantitative Health Sciences, Cleveland Clinic,
Cleveland, Ohio; Masami Takagaki, MD, Department of Thoracic and Cardiovascular
Surgery, Cleveland Clinic, Cleveland, Ohio; Michael S. Lauer, MD, Department of
Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio; A. Marc Gillinov, MD,
Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio;
Eugene H. Blackstone, MD, Department of Thoracic and Cardiovascular Surgery,
Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences,
Cleveland Clinic, Cleveland, Ohio; Bruce W. Lytle, MD, Department of Thoracic and
Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
APPENDIX
Appendix E1: Variables Used in Analyses
Preoperative
Demographic:
Age (years), gender, weight (kg), height (cm), body
surface area (m2), body mass index (kg/m2)
Symptom history:
New York Heart Association functional class
(I-IV), previous cardiac operation
Mitral valve pathophysiology:
Mitral valve regurgitation (3+ moderate to severe,
4+ severe), jet direction (central, anterior, posterior,
complex)
Ventricular function:
Degree of left ventricular dysfunction (1 = none, 2
= mild, 3 = moderate, 4 = severe), graded wallmotion abnormality (0–6): inferior/diaphragmatic,
anterior, apical, lateral, basal/infra-atrial,
septal/atrioseptal (0 = trivial/none, 1 = mild
hypokinesis/dyskinesis, 2 = mild to moderate, 3 =
moderate, 4 = moderate to severe, 5 = severe to
akinesis, 6 = aneurysm present)
Coronary artery disease:
Left main trunk disease (% stenosis), left anterior
descending coronary artery system disease
(maximum % stenosis), right coronary artery
system disease (maximum % stenosis), left
circumflex coronary artery system disease
(maximum % stenosis)
Noncardiac comorbidity:
Treated diabetes, history of peripheral vascular
disease, history of smoking, carotid disease,
peripheral vascular disease, creatinine (mg/dl1),
blood urea nitrogen (mg/dl1), hematocrit (%)
Preoperative ECG variables:
Heart rhythm: sinus bradycardia, sinus tachycardia,
sinus rhythm
Heart rate: atrial heart rate (beats/min), ventricular
heart rate (beats/min)
Atrial: P duration (ms), PR interval (ms)
Conduction: Left bundle-branch block, right
bundle-branch block, intraventricular conduction
defect
Ventricle: QRS sum (mV), QRS axis, QRS duration
(ms), QT interval (ms)
Ischemic: ST slope: lead V4, lead V5, lead V6 (mV);
ST-segment end: lead V4, lead V5, lead V6 (mV)
Myocardial infarction: Anterolateral, anterior,
anteroseptal, inferior, lateral posterior, septal
Ventricular hypertrophy: Cornell voltage (mV),
Sokolow-Lyon voltage (mV), ECG evidence of left
ventricular hypertrophy
Operative
Experience:
Date of operation (years since January 1, 1991)
Table E1. Incremental Risk Factors for Death, Including Aortic Clamp Time
Factor
Estimate ± SE
p Value
0.051 ± 0.81
>0.9
Reliability (%)*
Early Phase
CABG alone
Propensity score†
1.1 ± 0.98
Severe lateral wall-motion
abnormality‡
0 .05
71
2.0 ± 0.52
0.0001
80
0.50 ± 0.10
<0.0001
45
Earlier date of operation║
−0.54 ± 0.26
0.04
77
Longer aortic clamp time¶
2.6 ± 1.1
0.02
40
−0.43 ± 0.34
0.2
0.36 ± 0.51
0.5
Renal disease
Lower hematocrit§
1.09 ± 0.55
0.3
Late Phase
CABG alone
Propensity score†
ST slope: lead 5
87
Lower slope#
−0.13 ± 0.042
0.002
Higher slope**
20 ± 6.6
0.002
−0.30 ± 0.104
0.004
0.36 ± 0.086
<0.0001
64
−2.2 ± 1.1
0.05
48
Previous cardiac operation
0.604 ± 0.23
0.008
51
Insulin-treated diabetes
0.65 ± 0.27
0.01
54
0.0004
84
Lower slope††
Higher QRS voltage sum
‡‡
§§
Older
Higher BUN
0.024 ± 0.0068
Shorter aortic clamp time¶
−0.052 ± 0.36
>0.9
Percent of occurrences in bootstrap models. †Probability of undergoing CABG alone.
*
‡
Lateral wall-motion grades 0, 1, 2, 3, 4 versus 5, 6, a binary variable. §(40/hematocrit),
inverse transformation.
║
Ln(interval from 1/1/1991 to date of operation), logarithmic
transformation. ¶Ln(aortic clamp time+1), logarithmic transformation. #(ST slope: lead 5/3),
scaled.
slope:
**
Exp(ST slope: lead 5/500), exponential transformation.
lead
5/150)3,
cubic
transformation.
‡‡
Exp(QRS
††
(Absolute value of ST
sum/13,000),
exponential
transformation. §§(50/age), inverse transformation.
BUN = blood urea nitrogen; CABG =coronary artery bypass grafting; SE = standard
error.
Figure E1. Nomogram from multivariable equation found in Table 3. Values
otherwise held constant for each depiction are age, 66 years; hematocrit, 38%; blood
urea nitrogen, 20 mg•dL−1; no renal disease; no previous cardiac operation;
nondiabetic; lateral wall-motion grade <5; QRS sum, 13,119; ST slope, lead V5, 0;
coronary artery bypass grafting alone, date of operation, January 1, 2003, propensity
score, 0.124331.
A
B
Figure E2. Temporal trend of mitral regurgitation (MR) for propensity-matched
patients. Solid lines represent mean effect for various MR grades. Symbols represent
data grouped within time frame without regard to repeated assessment to provide a
crude verification of model fit. (A) CABG-alone group. (B) CABG+MV anuloplasty
group.
A
B
Figure E3. Temporal trend of New York Heart Association (NYHA) functional class
for propensity-matched patients. Solid lines represent mean effect for various
functional classes. Symbols represent data grouped within time frame without regard
to repeated assessment to provide a crude verification of model fit. Preop =
preoperative. (A) CABG-alone group. (B) CABG+MV anuloplasty group.
Figure E4. Nomogram from multivariable equation found in Table E1. Values
otherwise held constant for each depiction are age, 66 years; hematocrit, 38%; blood
urea nitrogen, 20 mg•dL−1; no renal disease; no previous cardiac operation;
nondiabetic; lateral wall-motion grade <5; QRS sum, 13,119; ST slope, lead V5, 0;
coronary artery bypass grafting alone; date of operation, January 1, 2003; propensity
score, 0.124331.