zostao dobrze udokumentowane , e starszy wiek , przewleke choroby wspistniejce ( takie jak cukrzyca , przewleka obturacyjna choroba puc itp . ) i pogorszy oglne wyniki operacji pomostowania aortalno - wiecowego ( coronary artery bypass  cabg ) z jednoczesn napraw niedokrwiennej niedomykalnoci zastawki mitralnej . przeanalizowano retrospektywne dane 394 pacjentw po cabg i zaopatrzeniu zastawki mitralnej ( gwnie anuloplastyce ) . pacjentw podzielono na grupy wedug wieku , obecnoci cukrzycy oraz frakcji wyrzutowej lewej komory ( left ventricular ejection fraction  lvef ) . dane echokardiograficzne , wskaniki powika pooperacyjnych ( wstrzs kardiogenny , przedoperacyjny zawa minia sercowego , krwawienie z przewodu pokarmowego , zaburzenia poznawcze , udar , posocznica , gbokie zakaenie rany operacyjnej ) oraz wczesn pacjenci z cukrzyc nie wykazywali zmian pomidzy przed- i pooperacyjn klas nyha , a okoooperacyjna niedomykalno zastawki mitralnej wystpowaa wrd nich czciej ni u pacjentw bez cukrzycy ( odpowiednio 10,3% i 3,1% , p < 0,05 ) . we wszystkich grupach lvef niedomykalno zostaa znaczco zmniejszona , jednake przebudowa lewej komory bya wyrana jedynie u pacjentw z , , niskimi i , , umiarkowanie obnionymi  wartociami lvef . wspomniane trzy grupy nie rniy si pod wzgldem powika pooperacyjnych . starszy wiek , wspistniejca cukrzyca i obniona warto lvef nie wpywaj na wczesn i odleg miertelno , w tym na wczesne wyniki pooperacyjnej naprawy niedokrwiennej niedomykalnoci zastawki mitralnej po cabg . ischemic mitral regurgitation ( mr ) is caused by local and global myocardial ischemia , leading to altered global and regional myocardial contraction and geometry , which subsequently leads to mitral valve apparatus distortion and insufficiency . the surgical approach is expected to lead to reverse left ventricular remodeling after surgery and is associated with improved symptoms and prognosis . it is debatable whether mild mr should be repaired during the cabg surgery [ 2 , 3 ] , although most authors agree that cabg and mitral valve ( mv ) repair surgery improve the chances of survival despite the degree of mr [ 1 , 47 ] . it is obvious that early and late postoperative outcomes depend not only on the type of surgery , but also on the preoperative patient condition , including comorbidities as well . usually , patients with a coronary artery disease are older and tend to have impaired left ventricular function and the presence of chronic concomitant diseases ( such as diabetes mellitus , metabolic syndrome , obesity , chronic obstructive lung disease , etc . ) . though nowadays more and more authors claim good postoperative outcomes in the elderly , kang et al . found in their study that patients age was an independent determinant increasing postoperative mortality after cabg followed by mv repair . claim that the risk factors associated with late death include older age and insulin treated diabetes . stated in their paper   that diabetes ( diet and insulin controlled ) and lv systolic function were among the most significant factors of long - term survival in patients under the age of 65 . a recent extensive study by ranucci et al . showed that age and lvef do not increase mortality in low risk patients , but greatly increase mortality in high operative risk patients . very similar results were obtained by sadeghi et al . , who found that age , poor lv function , and neurologic disorders were risk factors associated with the overall mortality rate . our study was designed to explore the influence of older age , the presence of diabetes , and lvef on early and late postoperative outcomes in patients after cabg and mv repair surgery . during the period of 2000 - 2011 , 1385 patients underwent mitral valve repair surgery in kaunas hospital , lithuanian university of health sciences . five hundred and ninety - four of them underwent a coronary artery bypass with concomitant mv repair for ischemic mitral regurgitation ( mr ) . patients who underwent the emergency procedure and those who had complex surgery ( e.g. other heart valves were repaired or replaced and/or a carotid endarterectomy was performed ) were excluded . since the data were collected retrospectively , some of the patients , whose data were incomplete , also were excluded from the study . finally , retrospective data of 394 patients were analyzed . patients were divided into groups according to their age and the presence or absence of diabetes mellitus ( dm ) and lvef . based on their age , the patients were divided into group a ( 70 years and older ) and group b ( younger than 70 years ) . based on dm , patients were divided into those with dm ( dm ( + ) ) and without dm ( dm (  ) ) . and finally , all patients were grouped according to their lvef : group i included patients who had poor lvef ( < 30% ) , group ii included patients with lowered lvef ( 50% < lvef  30% ) , and group iii included patients with good lvef (  50% ) . operative data ( cardiopulmonary bypass time , aortic cross - clamp time , postoperative ventilation time , and intensive care unit ( icu ) stay ) were compared between the groups . left ventricular systolic and diastolic function and reverse positive remodeling were evaluated analyzing transthoracic echocardiographic ( tte ) data before and three months after the surgery and were compared in each group . the left ventricular end diastolic diameter ( lvedd ) was evaluated from the parasternal long axis , and lvef was calculated using simpson 's method . left ventricular diastolic function was evaluated by measuring the decrease of the early diastolic filling velocity  the deceleration time ( dt ) . the mr grade was evaluated from the apical four - chamber view using color flow doppler . the rate of postoperative complications ( cardiogenic shock , perioperative myocardial infarction , bleeding from gastrointestinal tract , cognitive disorders , stroke , sepsis , deep wound infection ) , as well as the early and late mortality rate were evaluated and compared between paired groups . during the surgery , standard endotracheal anesthesia was applied ( 3 gkgh fentanyl , 1 - 4 mg / h midazolam , and 1.5 - 2% minimal alveolar concentration sevoflurane , depending on the hemodynamic status ) . the cardiopulmonary bypass ( cpb ) system was filled with 1,500 ml of ringer 's acetate solution and 1,000 units of heparin . a roller pump , a membrane oxygenator ( dideco d703 , mirandola ) , and a venous reservoir were used for cpb . coronary artery bypass was performed using the standard technique via mid line sternotomy using cold ( 4c ) crystalloid antegrade cardioplegia ( st . thomas solution ) and a conventional cardiopulmonary bypass ( cpb ) using bicaval cannulation . distal anastomoses were constructed first , the proximal ones on the beating heart and a side clamp on the aorta . cardiopulmonary bypass was performed under normothermia or deliberate temperature drifting down , but no less than 32c core temperature . double semi purse 2/0 ethibond ( johnson & johnson ) suture , reinforced with teflon pledgets , was used . using annuloplasty sutures , the mv annulus was constricted to the size ( area ) of the anterior mitral valve leaflet . no patient left the operating room with a residual mr grade higher than 1 under transesophageal echocardiography ( tee ) control . after the surgery , patients were transferred to the icu . during the surgery and in the icu , mmol / l , patients received an intravenous bolus of four units of insulin every hour . if the blood glucose level increased over 10 mmol / l , a continuous infusion of insulin was administered to keep the blood glucose below 8 mmol / l . the quantitative data are presented as the mean and the standard deviation ( m  sd ) . the analyzed parameters were described using the general statistical status , distribution , and symmetry . the tests of kolmogorov - smirnov and shapiro - wilk were used to check the normal data distribution . when the statistical hypothesis was verified , the following criterion was used : p < 0.05 ( statistically significant ) . the p - value is the marginal level of statistical significance in hypothesis verification . the quantitative data are presented as the mean and the standard deviation ( m  sd ) . the analyzed parameters were described using the general statistical status , distribution , and symmetry . the tests of kolmogorov - smirnov and shapiro - wilk were used to check the normal data distribution . when the statistical hypothesis was verified , the following criterion was used : p < 0.05 ( statistically significant ) . the p - value is the marginal level of statistical significance in hypothesis verification . 71.57% ( 282 ) of the patients were women and 28.17% ( 111 ) were men . the cardiopulmonary bypass time , the aortic cross - clamp time , the artificial lung ventilation time and the duration of stay in the icu did not differ between the paired groups ( table i ) . comparison of operative data between groups ao  aorta , alv  artificial lung ventilation , cpb  cardiopulmonary bypass , dm ( + )  group with diabetes mellitus , dm (  )  group without diabetes mellitus , icu  intensive care unit , lvef  left ventricular ejection fraction , sd  standard deviation group a included 170 patients aged 70 years and over . there were significantly more women in group b than in group a ( respectively , 77.4% of women and 22.6% of men vs. 63.7% of women and 36.3% of men , p < 0.05 ) . the ratio of patients with dm did not differ significantly between the groups ( 27 [ 15.9% ] in group a and 48 [ 21.4% ] in group b , p > 0.05 ) . in relation to the ratio of patients with poor ( lvef < 30% ) , moderately lowered ( 50% < lvef  30% ) and good ( lvef  50% ) lvef , the age groups did not differ significantly ( respectively , 34.7% in group a vs. 33.9% in group b , p > 0.05 ; 55.9% in group a vs. 49.6% in group b , p > 0.05 ; 9.4% , in group a vs. 16.5% in group b , p > 0.05 ) ( table ii ) . the nyha class before the surgery did not differ significantly between the groups ( 2.9  0.6 and 2.8  0.6 , p > 0.05 ) . however , it decreased significantly in groups a and b after the surgery , when compared to that before the surgery ( table iii ) . the comparison of lvedd and mr before and after the surgery in both groups is given in table iv . when evaluating echocardiographic data , we detected that mr decreased significantly in both groups following the operation when compared to preoperative data ( from 2.8  0.5 to 0.98  0.9 in group a and from 2.7  0.6 to 1.2  0.9 in group b , p < 0.001 ) . in group b , lvedd decreased significantly ( 56.5  7.3 mm and 54.1  8.0 mm , respectively , p < 0.001 ) while in group a , lvedd showed only a tendency to decrease after the surgery ( 57.5  7.0 mm and 56.4  8.0 mm , respectively , p > 0.05 ) . comparison of preoperative data between age groups dm ( + )  group with diabetes mellitus , dm (  )  group without diabetes mellitus , lvef  left ventricular ejection fraction comparison of heart failure grade ( nyha class ) before and after surgery dm ( + )  group with diabetes mellitus , dm (  )  group without diabetes mellitus , lvef left ventricular ejection fraction , nyha  new york heart association , sd  standard deviation comparison of left ventricular end diastolic diameter and mitral regurgitation before and after surgery dm ( + )  with diabetes mellitus , dm (  )  without diabetes mellitus , lvedd left ventricular ejection fraction , mr  mitral regurgitation , sd  standard deviation in group b , a significant increase in dt was noted ( 0.17  0.05 ms vs. 0.21  0.06 ms , p < 0.001 ) after the surgery . group dm ( + ) included 75 patients and group dm (  ) included 319 patients . the dm (  ) group included significantly more men compared to the dm ( + ) group ( 75.1% men and 24.9% women vs. 57.7% men and 42.3% women , respectively ; p < 0.05 ) . the nyha class did not differ between the groups before the surgery ( 2.8  0.7 and 2.9  0.4 , p > 0.05 ) . the groups did not differ in the number of grafts performed . in the majority of patients in both groups , three grafts ( 72.1% in group dm (  ) and 75.6% in group dm ( + ) , p > 0.05 ) were performed , while two grafts were performed in 23.7% of patients in group dm (  ) and 21.8% in group dm ( + ) ( p > 0.05 ) . four grafts were performed only in 1.9% of patients in group dm (  ) and 1.3% in group dm ( + ) ( p > 0.05 ) . left ventricular end diastolic diameter and mr before and after the surgery in both groups are given in table iv . the comparison of echocardiographic data before and after the surgery revealed a significant decrease in lvedd , left ventricular end systolic diameter ( lvesd ) ( from 46.7  9.9 mm to 43.0  14.0 mm , p < 0.05 ) , and the mr grade ( 2.8  0.6 vs. 1.1  0.9 , p < 0.001 ) in group dm (  ) ( table iv ) . in group dm ( + ) , only the mr grade decreased significantly ( 2.6  0.5 vs. 1.2  0.9 , p < 0.001 ) and a tendency for a lvedd decrease was observed ( table iv ) . group i included 135 patients , group ii 206 patients , and group iii 53 patients . the groups did not differ according the number of grafts performed during the surgery . in the majority of patients , three grafts were performed ( group i  77.5% , group ii  70.5% , group iii  63.6% , p > 0.05 ) , while two grafts were performed in 18% in group i , 25.7% in group ii , and 36.4% in group iii ( p > 0.05 ) . in all three groups left ventricular end diastolic diameter and the mr grade before and after the surgery in all groups are given in table iv . the analysis of echocardiographic data indicated that in group i after the surgery , lvef increased ( from 23.6  4.3 to 29.7  9.4% , p < 0.001 ) and mr significantly decreased . in group ii , mr and lvedd decreased significantly ( table iv ) and dt increased significantly ( from 0.19  0.05 ms to 0.24  0.07 ms , p < 0.001 ) after the surgery , whereas in group iii , only the mr grade decreased significantly ( 2.9  0.5 vs. 1.4  1.0 , p < 0.001 ) 27.6% of patients required low doses of inotropic medications , 19.3% required medium doses , and 19.0% required high doses of inotropic medications . perioperative myocardial infarction was detected in 4.5% of patients , bleeding from gi tract in 2.26% of patients , postoperative cognitive dysfunction in 1.7% , and stroke in 2.5% of patients . the rate of early mortality was 16.24% , while the rate of late mortality was 2.03% . when postoperative complications were compared between paired groups , a significantly higher perioperative myocardial infarction rate was found in group dm ( + ) as compared to group dm (  ) ( 10.3% vs. 3.1% , respectively , p < 0.01 ) . moreover , in group a , a significantly higher incidence of sepsis ( 4.9% in group b vs. 0.6% in group a , p < 0.05 ) and deep wound infection ( 8.0% in group b vs. 1.8% in group a , p < 0.05 ) was observed . the rate of other complications , as well as early and late mortality , did not differ between the paired groups . there were significantly more women in group b than in group a ( respectively , 77.4% of women and 22.6% of men vs. 63.7% of women and 36.3% of men , p < 0.05 ) . the ratio of patients with dm did not differ significantly between the groups ( 27 [ 15.9% ] in group a and 48 [ 21.4% ] in group b , p > 0.05 ) . in relation to the ratio of patients with poor ( lvef < 30% ) , moderately lowered ( 50% < lvef  30% ) and good ( lvef  50% ) lvef , the age groups did not differ significantly ( respectively , 34.7% in group a vs. 33.9% in group b , p > 0.05 ; 55.9% in group a vs. 49.6% in group b , p > 0.05 ; 9.4% , in group a vs. 16.5% in group b , p > 0.05 ) ( table ii ) . the nyha class before the surgery did not differ significantly between the groups ( 2.9  0.6 and 2.8  0.6 , p > 0.05 ) . however , it decreased significantly in groups a and b after the surgery , when compared to that before the surgery ( table iii ) . the comparison of lvedd and mr before and after the surgery in both groups is given in table iv . when evaluating echocardiographic data , we detected that mr decreased significantly in both groups following the operation when compared to preoperative data ( from 2.8  0.5 to 0.98  0.9 in group a and from 2.7  0.6 to 1.2  0.9 in group b , p < 0.001 ) . in group b , lvedd decreased significantly ( 56.5  7.3 mm and 54.1  8.0 mm , respectively , p < 0.001 ) while in group a , lvedd showed only a tendency to decrease after the surgery ( 57.5  7.0 mm and 56.4  8.0 mm , respectively , p > 0.05 ) . comparison of preoperative data between age groups dm ( + )  group with diabetes mellitus , dm (  )  group without diabetes mellitus , lvef  left ventricular ejection fraction comparison of heart failure grade ( nyha class ) before and after surgery dm ( + )  group with diabetes mellitus , dm (  )  group without diabetes mellitus , lvef left ventricular ejection fraction , nyha  new york heart association , sd  standard deviation comparison of left ventricular end diastolic diameter and mitral regurgitation before and after surgery dm ( + )  with diabetes mellitus , dm (  )  without diabetes mellitus , lvedd left ventricular ejection fraction , mr  mitral regurgitation , sd  standard deviation in group b , a significant increase in dt was noted ( 0.17  0.05 ms vs. 0.21  0.06 ms , p < group dm ( + ) included 75 patients and group dm (  ) included 319 patients . the dm (  ) group included significantly more men compared to the dm ( + ) group ( 75.1% men and 24.9% women vs. 57.7% men and 42.3% women , respectively ; p < 0.05 ) . the nyha class did not differ between the groups before the surgery ( 2.8  0.7 and 2.9  0.4 , p > 0.05 ) . the groups did not differ in the number of grafts performed . in the majority of patients in both groups , three grafts ( 72.1% in group dm (  ) and 75.6% in group dm ( + ) , p > 0.05 ) were performed , while two grafts were performed in 23.7% of patients in group dm (  ) and 21.8% in group dm ( + ) ( p > 0.05 ) . four grafts were performed only in 1.9% of patients in group dm (  ) and 1.3% in group dm ( + ) ( p > 0.05 ) . the nyha class decreased significantly ( p < 0.05 ) ( table iii ) . left ventricular end diastolic diameter and mr before and after the surgery in both groups are given in table iv . the comparison of echocardiographic data before and after the surgery revealed a significant decrease in lvedd , left ventricular end systolic diameter ( lvesd ) ( from 46.7  9.9 mm to 43.0  14.0 mm , p < 0.05 ) , and the mr grade ( 2.8  0.6 vs. 1.1  0.9 , p < 0.001 ) in group dm (  ) ( table iv ) . in group dm ( + ) , only the mr grade decreased significantly ( 2.6  0.5 vs. 1.2  0.9 , p < 0.001 ) and a tendency for a lvedd decrease was observed ( table iv ) . group i included 135 patients , group ii 206 patients , and group iii 53 patients . the groups did not differ according the number of grafts performed during the surgery . in the majority of patients , three grafts were performed ( group i  77.5% , group ii  70.5% , group iii  63.6% , p > 0.05 ) , while two grafts were performed in 18% in group i , 25.7% in group ii , and 36.4% in group iii ( p > 0.05 ) . in all three groups left ventricular end diastolic diameter and the mr grade before and after the surgery in all groups are given in table iv . the analysis of echocardiographic data indicated that in group i after the surgery , lvef increased ( from 23.6  4.3 to 29.7  9.4% , p < 0.001 ) and mr significantly decreased . in group ii , mr and lvedd decreased significantly ( table iv ) and dt increased significantly ( from 0.19  0.05 ms to 0.24  0.07 ms , p < 0.001 ) after the surgery , whereas in group iii , only the mr grade decreased significantly ( 2.9  0.5 vs. 1.4  1.0 , p < 0.001 ) . 27.6% of patients required low doses of inotropic medications , 19.3% required medium doses , and 19.0% required high doses of inotropic medications . perioperative myocardial infarction was detected in 4.5% of patients , bleeding from gi tract in 2.26% of patients , postoperative cognitive dysfunction in 1.7% , and stroke in 2.5% of patients . the rate of early mortality was 16.24% , while the rate of late mortality was 2.03% . when postoperative complications were compared between paired groups , a significantly higher perioperative myocardial infarction rate was found in group dm ( + ) as compared to group dm (  ) ( 10.3% vs. 3.1% , respectively , p < 0.01 ) . moreover , in group a , a significantly higher incidence of sepsis ( 4.9% in group b vs. 0.6% in group a , p < 0.05 ) and deep wound infection ( 8.0% in group b vs. 1.8% in group a , p < 0.05 ) was observed . the rate of other complications , as well as early and late mortality , did not differ between the paired groups . some authors recommend performing cabg as a stand - alone procedure in patients with mild mr and increased perioperative risk factors , such as old age , the presence of diabetes and poor lv systolic function . they refer to the extended length of the surgery and the questionable improvement of long - term outcomes [ 1 , 2 , 7 , 11 , 12 ] . in our study , we compared the impact of high operative risk factors ( age over 70 years , presence of dm , poor lvef ) on the outcomes of cabg and mv repair . the results of our study indicate that older age , concomitant diabetes , and lowered or poor lvef did not increase early and late postoperative mortality after cabg and the mv repair surgery in patients with ischemic heart disease and ischemic mr . moreover , they did not significantly influence the time of artificial lung ventilation or the length of stay in the icu after the surgery . having compared postoperative complications in age groups , we found that infectious complications had a higher rate in the group of younger patients . the ratio of patients with dm in both groups was similar and did not differ statistically significantly . many postoperative complications after the cardiac surgery with cpb are related to the systemic inflammatory response syndrome ( sirs ) . cardiopulmonary bypass may itself provoke a systemic inflammatory response , caused by blood contact with the artificial bypass surface , cold cardiac ischemia , and hypothermia [ 13 , 14 ] . they bind to specific receptors on target cells and call into play many other cells and substances , including elements of the inflammatory response . older age is associated with a chronic low grade inflammation process , caused by significantly reduced levels of t cells , while younger age is usually associated with better reactivity of the immune system [ 15 , 16 ] . in any case after the operation , the functional capacity of the cardiovascular system ( expressed as the nyha class ) increased in both age groups . although in the group of younger patients , lvedd had only a tendency to decrease , the deceleration time increased and showed an improvement in the lv diastolic function . in the group of older patients , the reversible remodeling of lv , we found that despite good surgical results ( mr decreased significantly from grade ii - iii to grade i in both groups ) , the functional capacity of the cardiovascular system did not improve in patients with diabetes ( the nyha class did not change significantly ) . moreover , reversible remodeling of lv was not found in patients with diabetes , although a tendency of lvedd to decrease was observed . additionally , a higher incidence of perioperative mi was detected in the diabetes group of patients . diabetes causes not only vascular disorders in the heart , but also disorders in the entire body . there is another type of heart disease related to diabetes and the metabolic syndrome which is not associated with hypertension or coronary artery disease . diabetic cardiomyopathy is characterized by an impaired diastolic relaxation time ( diastolic dysfunction ) and reduced contractility ( systolic dysfunction ) . the diastolic dysfunction is the initial heart lesion and when the systolic dysfunction develops , the diastolic dysfunction is usually already significantly advanced . the underlying pathophysiological mechanisms involve interstitial and perivascular fibrosis due to necrotic and increased apoptotic myocardial cell death , impaired calcium reuptake caused by functional alterations in cellular ion channels , structural and functional changes in small coronary arteries ( atheromas are more extensive and diffuse and involve small vessels , capillary basement membranes are thickened , microaneurysms are formed ) , and cardiac autonomic neuropathy . the latter leads to parasympathetic - sympathetic nervous system imbalance , when the tone of the parasympathetic system is decreased and the sympathetic tone is relatively increasing . preexisting diabetic cardiomyopathy so , it may be supposed that diabetic cardiomyopathy determined residual lv remodeling and the remaining high nyha functional class , just as it can predispose to a higher incidence of perioperative mi in our study [ 20 , 21 ] . when patients were grouped according to lvef , it appeared that the functional cardiovascular status improved in all three groups after the surgery . echocardiographic data also showed that postoperative results improved in all three groups , although to a different degree . in patients with poor lvef , , the ejection fraction did not show such an improvement , probably because the baseline lvef was better and the change was not statistically significant . although mr decreased in all groups , reversible positive lv remodeling and an improvement of diastolic function were detected only in patients with moderately lowered lvef . we suppose that precisely this group of patients can benefit the most from cabg and mv repair surgery . the main limitation of the present study is its retrospective design . as data were analyzed retrospectively , we had to exclude patients with incomplete data , so the sample size was limited . these data reflect the experience of a single center , which may limit the study 's more general nature . elderly age and a lowered left ventricular ejection fraction did not worsen early postoperative outcomes and did not increase early and late mortality after mitral valve repair for ischemic mitral regurgitation . the presence of diabetes did not influence early and late mortality after mitral valve repair for ischemic mitral regurgitation . the presence of diabetes increased the perioperative myocardial infarction rate , while younger age was associated with an increased risk of infectious complications after mitral valve repair for ischemic mitral regurgitation . regardless of reduced mitral regurgitation , reversible remodeling of the left ventricle was observed only in the group of patients without diabetes and with a moderately lowered left ventricular ejection fraction .