Midterm Outcomes of Rheumatic Mitral Repair Versus Replacement

Abstract

SUMMARYMitral repair is feasible for patients with degenerative or ischemic heart disease, however, the appropriateness of repair for rheumatic heart disease remains controversial. We compared our outcomes for primary isolated mitral repair versus replacement in an elderly population. From November 1997 to July 2005, mitral repair (group I) was performed in 33 patients while 59 underwent replacement (group II). Survival and risk factors were evaluated by Kaplan-Meier and Cox regression analysis. Mean age at operation for groups I and II was 49.7 ± 13.2 versus 58.1 ± 11.2 (P = 0.002). No statistically significant differences with regards to demographic parameters were observed except for there being fewer percutaneous transvenous mitral commissurotomy procedures and a lower severity of pulmonary hypertension in group I. Patients with a greater Wilkins score and more valvular calcification underwent replacement more often (P < 0.001). In-hospital mortality, ICU/hospital stay, and postoperative congestive heart failure functional class did not differ significantly. Major adverse cardiac events occurred in 13 and 19 patients, respectively (P = 0.50). There were 4 versus 6 late deaths (P = 0.74). Only two from group I underwent subsequent mitral reoperation. Kaplan-Meier overall survival and event-free survival at 5 years for groups I and II were 0.81 ± 0.08 versus 0.81 ± 0.06 (P = 0.90) and 0.52 ± 0.10 versus 0.51 ± 0.10 (P = 0.21), respectively. Old age, renal insufficiency, LVEF < 40%, and a history of stroke were poor predictors of patient survival. Compared with replacement, mitral repair for rheumatic heart disease was associated with a lower surgical mortality, higher repeat-surgery rate, and good survival. Rheumatic mitral valves should be repaired in select patients with appropriate valvular pathology. (Int Heart J 2008; 49: 565-576)

Long-term outcomes after surgery for rheumatic mitral valve disease: valve repair versus mechanical valve replacement☆

“…The repair group was younger than the replacement group, consistent with the findings that use of mitral repair is inversely correlated with age [6,14,21]. Acute rheumatic mitral disease is characterised by chordal elongation, leaflet prolapse, annular dilatation and consequent predominant MR in younger individuals.…”

“…As a consequence, the number of pure MR cases declines with increasing age. This ongoing activity and complicated valvular pathology may make mitral repair more difficult, and associated with less favourable postoperative outcomes [21,24]. Age-related differences in rheumatic pathologies were observed in the present work and are commonly reported in other rheumatic mitral disease studies [21,25].…”

“…A recent study examined a homogeneous population of rheumatic mitral disease patients who underwent isolated MV surgery [21]. The cited study, involving 33 repair and 59 replacement patients, found that the groups had similar operative mortality and morbidity rates.…”

Combined Mitral and Tricuspid Valve Repair in Rheumatic Valve Disease

“…In young patients such as those in the present study, implantation of a bioprosthesis was associated with a high incidence of late reoperation; in contrast, the use of a mechanical prosthesis significantly decreased the need of reoperation even if a comparison is made with repair surgery of the mitral valve of rheumatic origin. 23,24 One of the most significant findings of this experience is, on the one hand, the relatively satisfactory immediate result with 30-day mortality of 5.9% for a group of patients with polyvalvular disease and organic involvement of the tricuspid valve. If the long study period and the fact that most patients were operated on many years ago and had polyvalvular disease are considered, this 30-day mortality rate is relatively acceptable.…”

“…Besides these data based on our experience, other studies of rheumatic heart disease have shown that patients with mitral valve repair (or open mitral commissurotomy) survived longer than those undergoing mitral valve replacement with any type of prosthesis. [23][24][25] With regard to valve-related reoperation, it is well known that it depends on the type of valve substitute used. In young patients such as those in the present study, implantation of a bioprosthesis was associated with a high incidence of late reoperation; in contrast, the use of a mechanical prosthesis significantly decreased the need of reoperation even if a comparison is made with repair surgery of the mitral valve of rheumatic origin.…”