Durability and outcome of aortic valve replacement with mitral valve repair versus double valve replacement

Department of Cardiovascular Surgery, National Cardiovascular Center, Suita, Osaka, Japan.
The Annals of Thoracic Surgery (Impact Factor: 3.63). 02/2003; 75(1):28-33; discussion 33-4. DOI: 10.1016/S0003-4975(02)04405-3
Source: PubMed

ABSTRACT The purpose of this study was to evaluate morbidity and mortality after double valve replacement (DVR) and aortic valve replacement with mitral valve repair (AVR + MVP).
From 1977 to 2000, 379 patients underwent DVR (n = 299) or AVR + MVP (n = 80). Actuarial survival and freedom from reoperation were determined by the Kaplan-Meier method. Potential predictors of mortality and reoperation were entered into a Cox multiple regression model. Propensity score was introduced for the multivariable regression modeling for adjustment of a selection bias.
Survival 15 years after surgery was similar between the groups (DVR, 81% +/- 3%; AVR + MVP, 79% +/- 7%; p = 0.44). Freedom from thromboembolic event at 15 years was similar between the groups (p = 0.25). Freedom from mitral valve reoperation at 15 years was significantly better for the DVR group (54% +/- 5%) as compared with the AVR + MVP group (15% +/- 6%; p = 0.0006), primarily due to progression of mitral valve pathology and early structural deterioration of bioprosthetic aortic valve used for patients with AVR + MVP. After AVR + MVP, freedom from mitral reoperation at 15 years was 63% +/- 16% for nonrheumatic heart diseases, and 5% +/- 5% for rheumatic disease (p = 0.04).
Although both DVR and AVR + MVP provided excellent survival, DVR with mechanical valves should be the procedure of choice for the majority of patients because of lower incidence of valve failure and similar rate of thromboembolic complications compared with AVR + MVP. MVP should not be performed in patients with rheumatic disease because of higher incidence of late failure.

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    ABSTRACT: Long-term superiority of mitral valve (MV) repair compared with replacement is well established in degenerative MV disease. In rheumatic heart disease, its advantages are unclear and it is often performed in conjunction with aortic valve (AV) replacement. Herein, we performed a systematic review and meta-analysis comparing outcomes of MV repair vs replacement in patients undergoing concomitant AV replacement. PubMed, Cochrane and Web of Science databases were searched up to 25 January 2014 for English language studies comparing outcomes of MV repair vs replacement in patients undergoing simultaneous AV replacement. Data of selected studies were extracted. Study quality, publication bias and heterogeneity were assessed. Analysis was performed using a random effects model (meta-analysis of observational studies in epidemiology recommendation). A total of 1202 abstracts/titles were screened. Of these, 20 were selected for full text review and 8 studies (3924 patients) were included in the final analysis: 1255 underwent MV repair and 2669 underwent replacement. Late outcome data were available in seven studies (cumulative follow-up: 15 654 patient-years). The early (in hospital and up to 30 days post-surgery) mortality [risk ratio (RR): 0.68, 95% confidence interval (CI): 0.53-0.87, P = 0.003] and late (>30 days post-surgery) mortality (RR: 0.76, 95% CI: 0.64-0.90 P = 0.001) were significantly lower in the MV repair group compared with the MV replacement group. The MV reoperation rate (RR: 1.89, 95% CI: 0.87-4.10, P = 0.108), thromboembolism (including valve thrombosis) (RR: 0.65, 95% CI: 0.38-1.13, P = 0.128) and major bleeding rates (RR: 0.88, 95% CI: 0.49-1.57, P = 0.659) were found to be comparable between the two groups. In a separate analysis of studies with exclusively rheumatic patients (n = 1106), the early as well as late mortality benefit of MV repair was lost (RR: 0.92, 95% CI: 0.44-1.90, P = 0.81 and RR: 0.69, 95% CI: 0.39-1.22, P = 0.199, respectively), whereas the MV reoperation rate became significantly higher (RR: 5.10, 95% CI: 1.62-16.05, P = 0.005) with MV repair. In patients undergoing concomitant mitral and AV surgery, MV repair is associated with improved early and late survival without any increased risk for mitral valve reoperation. However, in patients with rheumatic heart disease MV repair does not impart any survival advantage while the risk for MV reoperation remains significantly higher.
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    ABSTRACT: Background Concomitant aortic and mitral valve (MV) operations have more than doubled over the past decade. We utilized the Society of Thoracic Surgeons Adult Cardiac Surgery Database (ACSD) to evaluate outcomes for patients undergoing combined aortic valve replacement (AVR) and MV repair or replacement. Methods From 1993 to 2007, 23,404 patients undergoing concomitant AVR+MV surgery were identified. Patients with mitral stenosis, emergent or salvage status, and endocarditis were excluded. Outcomes were expressed as unadjusted operative mortality, adjusted odds ratio (OR) for mortality, and a composite of mortality and major complications. Results The MV repair was performed in 46.0% and replacement in 54.0% of AVR patients. The rate of MV repair increased from 22.5% in 1993 to 59.1% in 2007 (p < 0.0001). Compared with the AVR+MV replacement group, the AVR+MV repair group was older (69.7 ± 11.5 vs 67.2 ± 12.7 years, p < 0.0001), had worse ejection fraction (0.449 ± 0.153 vs 0.495 ± 0.139, p < 0.0001), and more concomitant coronary artery bypass grafting (CABG) (50.5% vs 40.9%, p < 0.0001). Unadjusted operative mortality was lower in the AVR+MV repair group (8.2% vs 11.6%, p < 0.0001). Predictors of operative mortality by multivariable analysis included the following: age (OR 1.21, p < 0.0001); concomitant CABG (OR 1.49, p < 0.0001); diabetes mellitus (OR 1.56, p < 0.0001); reoperation (OR 1.53, p < 0.0001); and renal failure with dialysis (OR 3.57, p < 0.0001). Patients undergoing MV repair had a lower independent risk of operative mortality (OR 0.61, p < 0.0001), and mortality also independently improved over time (2003 to 2007 vs 1993 to 1997, OR 0.79, p < 0.002). Conclusions When feasible, MV repair remains the most optimal method of correcting mitral regurgitation during concomitant AVR. Continued efforts to improve MV repair rates in this setting seem warranted.
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