Mitral Valve Replacement Is a Viable Alternative to Mitral Valve Repair for Ischemic Mitral Regurgitation: A Case-Matched Study

Division of Cardiac Surgery, University of Ottawa, Ottawa, Ontario, Canada.
The Annals of thoracic surgery (Impact Factor: 3.85). 10/2011; 92(4):1358-65; discussion 1365-6. DOI: 10.1016/j.athoracsur.2011.05.056
Source: PubMed


Comparisons of mitral valve repair with mitral valve replacement for ischemic mitral regurgitation (IMR) have been limited by differences in preoperative and operative characteristics of patients undergoing these two types of surgical treatment. We performed a propensity-based, case-matched analysis to examine whether patients who undergo mitral valve repair and those who undergo mitral valve replacement for IMR have similar long-term outcomes.
We compared 65 patients who underwent mitral valve replacement for IMR between 2001 and 2010 with 65 patients who underwent mitral repair during the same period on the basis of age, concomitant coronary bypass grafting, gender, left ventricular function, preoperative pulmonary hypertension, and urgency of operation. Mitral replacement involved preservation of the subvalvular apparatus. The mean study follow-up period was 2.5 ± 2.1 years.
Two patients who underwent mitral valve repair died at 30 days postoperatively and three patients died after valve replacement. Late survival was the same in the two groups (p = 0.4). Recurrent mitral regurgitation (MR) (grade 2+ or higher) at late follow-up was observed in 15 patients (23%) after repair; however, only 1 patient (2%) had MR with a grade of more than 2+. Mitral valve repair was more commonly associated with recurrent MR (grade 2+ or higher) than was mitral valve replacement (p = 0.04). Patients in both groups had similar freedom from valve-related complications and similar left ventricular function at follow-up (both p > 0.2).
Mitral valve replacement remains a viable option for the treatment of IMR. Although mitral valve repair effectively protects against persistent or recurrent moderate-to-severe MR, mitral valve replacement provides better freedom from mild-to-moderate MR in this population, with a low incidence of valve-related complications. Notably, there was no significant difference in left ventricular function between the valve-repair and valve-replacement groups at follow-up.

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    • "A recent publication from the Society of Thoracic Surgeons and the Center for Medicare and Medicaid Services [3] demonstrated that MV repair is a safe and sustainable long-term option for older patients. Despite these promising results, little data are available regarding the durability and long-term benefits of MV repair in elderly compared with younger patients [4] [5]. "
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    ABSTRACT: Objectives: Data regarding durability and midterm benefits of mitral valve (MV) repair in elderly patients are scarce. To evaluate the feasibility and safety of MV repair in elderly patients, we performed a retrospective data analysis. Methods: We compared clinical outcomes in younger patients (<75 years: n = 462) and older patients (≥75 years: n = 100) undergoing MV repair with or without tricuspid valve (TV) repair. The primary end-point was 30-day mortality. Results: The preoperative risk profile (EuroSCORE, NYHA class, percentage pulmonary hypertension, percentage diabetes) was higher in older patients compared with younger patients. Nevertheless, operative complications such as low cardiac output syndrome, stroke, infections, the need of haemofiltration and IABP use did not differ significantly between the two groups. The thirty-day mortality rate was 0% in older patients and 1% in younger patients (P = 0.30). In the subgroup of patients with double valve repair, the 30-day mortality rate in older patients (n = 28) and younger patients (n = 46) was 0 and 4%, respectively (P = 0.27). In older and younger patients, the 6-month mortality rate was 4 and 2%, respectively (P = 0.16), and the 1-year mortality rate was 10 and 3%, respectively (P = 0.001). The propensity score-adjusted odds ratio of 1-year mortality with the group of younger patients as a reference was 2.04 (95% confidence interval: 0.77-5.40; P = 0.15) for older patients. Freedom from 1-year reoperation did not differ significantly between age groups. Conclusions: Data demonstrate excellent postoperative mortality rates in older patients undergoing MV repair with or without TV repair. Consequently, even in older patients with numerous comorbidities, MV repair should be considered a suitable surgical method.
    Full-text · Article · Oct 2014 · Interactive Cardiovascular and Thoracic Surgery
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    • "Other adjunctive procedures, as chordal cutting, papillary muscle repositioning, augmentation of leaflets, have been proposed, but their usefulness is still not well demonstrated . The possibility to insert a MV prosthesis in selected cases, proposed by our group [2], has recently been supported by other studies [3] [4] [5] [6], which report mid and long term results similar to those of MV repair with lower grade of late MR. The failure rate of restrictive MV annuloplasty remains one of the weak points of the surgical treatment of CIMR and it is related to lower survival and worse clinical [7] and echocardiographic outcome. "
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    ABSTRACT: Objective The proper treatment of chronic ischemic mitral regurgitation (CIMR) is still under evaluation. The different role of mitral valve repair (MVr) or mitral valve prosthesis insertion (MVPI) is still not defined. Methods From May 2009 to December 2011 167 patients with ejection fraction (EF) ≤ 40% had MV surgery for CIMR, MVr in 135 (80.8%) and MVPI in 32 (19.2%). Indication to MVPI was a MV coaptation depth > 10 mm. EF was lower (26 ± 7 vs 32 ± 6, p = 0.0000) in MVPI, whereas MR grade (3.6 ± 0.8 vs 2.7 ± 0.9, p = 0.0000), left ventricle dimensions (end diastolic, LVEDD, 62 ± 7 vs 57 ± 6 mm, p = 0.0001; end systolic, LVESD, 49 ± 8 vs 44 ± 8 mm, p = 0.0018), systolic pulmonary artery pressure (51 ± 22 vs 41 ± 16 mm Hg, p = 0.0037) and NYHA Class (3.6 ± 0.5 vs 2.8 ± 0.6, p = 0.0000) were higher. Results In-hospital mortality was similar (3.1 vs 3.7%) as well as 3-year survival (86 ± 6 vs 88 ± 4) and survival in NYHA Class I/II (80 ± 5 vs 83 ± 4). One hundred thirty nine patients had an echocardiographic evaluation after a minimum of 4 months (13 ± 8). EF rose significantly in both groups (from 26 ± 7% to 30 ± 4%, p = 0.0122, and from 32 ± 6% to 35 ± 8%, p = 0.0018). LVESD reduced significantly in both groups (from 49 ± 8 to 43 ± 9 mm, p = 0.0109, and from 44 ± 8 to 41 ± 7 mm, p = 0.0033). MR grade was significantly lower in patients who had MVPI (0.1 ± 0.2 vs 0.3 ± 0.3, p = 0.0011). Conclusions With appropriate indications, MVPI is a safe procedure which provides similar results to MVr with lower MR return, even if addressed to patients with worse preoperative parameters.
    Full-text · Article · Jun 2014 · IJC Heart and Vessels
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    • "It also seems clear now that the results are mostly related to patient factors than to treatment options.71 Given such contributions, the specific issue of repair versus replacement does not seem be critical in this setting and, as a result, mitral valve replacement and repair are not so different as to refer to repair as the gold standard.72, 73 "
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    ABSTRACT: Repair of the mitral valve is the treatment of choice for mitral valve regurgitation when the anatomy is favorable. It is well known that mitral valve repair enjoys better clinical and functional results than any other type of valve substitute. This fact is beyond doubt regardless of the etiology of the valve lesion and is of particular importance in degenerative diseases. This review analyzes the most important advances in the knowledge of the anatomy, pathophysiology, and chordal function of the mitral valve as well as the different alternatives in the surgical repair and clinical results of the most prevalent diseases of the mitral valve. An attempt has been made to organize the acquired information available in a practical way.
    Full-text · Article · Aug 2012
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