REvascularization and Valve Intervention for Ischemic Valve diseasE: REVIVE Trial

Condition(s) studied

Investigational drug(s) / intervention(s)

Percutaneous mitral valve repair: Percutaneous mitral repair will be performed using the MitraClip system.

Surgical mitral valve repair/replacement: All mitral valve surgeries will be performed either via sternotomy or right thoracotomy, and with cardioplegic arrest and cardiopulmonary bypass. Mitral valve repair may include annuloplasty and adjunctive procedures as determined by the operating surgeon. For mitral valve replacement, the choice of mitral valve prosthesis will be left at the surgeon's discretion.

Study summary

Ischemic mitral regurgitation (MR) and coronary artery disease is common and associated with significant morbidity and mortality. Ischemic MR has been traditionally treated surgically through either valve repair or replacement at the time of concomitant bypass grafting. Although patients with ischemic MR represent a heterogeneous group, outcomes for these patients over the intermediate term is poor owing to left ventricle (LV) dysfunction causing MR and the presence of coronary disease, which portends poor survival. There is an emergence of percutaneous therapies to treat MR which have been shown to be a less invasive, safe, and viable approach to treat comorbid patients.

The decision to treat ischemic MR either surgically or percutaneously is influenced by the presence of coronary disease and the ability to provide adequate revascularization. Mitral valve surgery concomitant to surgical revascularization, however, is associated with a several fold increase in mortality. In fact, the incremental risk increase is further magnified in high-risk patients. We therefore propose a novel prospective study to guide intervention for ischemic MR. Patients will be randomized to undergo surgical therapy with either mitral repair/replacement and/or concomitant coronary artery bypass grafting OR percutaneous mitral repair, followed by coronary artery bypass grafting.

Eligibility

Primary outcome measure(s)

• Mortality rate — Within 12 months of intervention
  All-cause mortality. Death from cardiovascular and non-cardiovascular causes.
• Rate of myocardial infarction — Within 12 months of intervention
  These will be defined according to the Fourth Universal Definition of Myocardial Infarction
• Rate of Stroke — Within 12 months of intervention
  1\) New, acute focal neurological deficit thought to be of vascular origin with signs or symptoms lasting \> 24 h and confirmed by a neurologist or 2) new, focal neurological deficit lasting \> 24 h with imaging evidence of cerebral infarction or intracerebral hemorrhage.
• Hospitalization rate for congestive heart failure — Within 12 months of intervention
  Admission to hospital with congestive heart failure exacerbation being the primary reason for admission. Congestive heart failure exacerbation is defined as 1) evidence of fluid overload and elevated filling pressures (for example, a central venous pressure \> 8mmHg and/or a pulmonary capillary wedge pressure \> 18mmHg) and/or 2) new decrease in cardiac output (for example, cardiac index \< 2.2 L/min/m2) and end-organ perfusion (measured by one or more of: urine output \< 20mL/hr, lactate \>= 2.0, mixed venous oxygen saturation \< 70%).

Trial sites (1)

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