Mitral Repair versus Replacement for Ischemic Mitral Regurgitation

Abstract

Background-When compared to mitral valve replacement (MVR), mitral valve repair (MVRp) is associated with better survival in patients with organic mitral regurgitation (MR). However, there is an important controversy about the type of surgical treatment that should be used in patients with ischemic MR. The objective of this study was to compare the postoperative outcome of MVRp versus MVR in patients with ischemic MR. Methods and Results-Preoperative and operative data of 370 patients with ischemic MR who underwent mitral valve surgery were prospectively collected and retrospectively analyzed. MVRp was performed in 50% of patients (nϭ186) and MVR in 50% (nϭ184). Although operative mortality was significantly lower after MVRp compared to MVR (9.7% versus 17.4%; Pϭ0.03), overall 6-year survival was not statistically different between procedures (73Ϯ4% versus 67Ϯ4%; Pϭ0.17). After adjusting for other risk factors and propensity score, the type of procedure (MVRp versus MVR) did not come out as an independent predictor of either operative (OR, 1.5; 95% CI, 0.7-2.9; Pϭ0.34) or overall mortality (HR, 1.2; 95% CI, 0.7-1.9; Pϭ0.52). Conclusion-As opposed to what has been reported in patients with organic MR, the results of this study suggest thatMVRp is not superior to MVR with regard to operative and overall mortality in patients with ischemic MR. These findings provide support for the realization of a randomized trial comparing these 2 treatment modalities. (Circulation. 2009;120[suppl 1]:S104-S111.)

Echo-Guided Mitral Repair

“…These early results compare favorably with other contemporary publications. 6,7,[41][42][43][44] Echo guidance was also associated with durable long-term results. The linearized recurrent regurgitation rate for degenerative disease was 0.6% per year, which compares favorably with 1.6% to 3.7% per year in other large degenerative series.…”

“…28 It is unreasonable to conclude that replacement is equivalent to repair for all patients with myopathic regurgitation. 7 Replacing the valve for simple ischemic annular dilation unnecessarily disrupts the subvalvular apparatus even if the chords are spared. It is equally inappropriate to attempt repair using only reductive ring annuloplasty when the tenting area is >2.0 cm 2 because regurgitation will almost certainly recur.…”

“…3,4 Mitral repair is potentially curative and often provides excellent long-term event-free survival. [5][6][7] When compared with repair, valve replacement increases operative mortality and, in the absence of maintenance anticoagulation or reintervention, eventually results in death from prosthetic failure. 8 Even minor improvements in diagnosis and management of mitral disease would be expected to significantly reduce morbidity and mortality, especially for the medically underserved.…”

Primary mitral valve regurgitation: Update and review

“…Management of Type IIIb regurgitation involves the use of an isolated annuloplasty, which accomplishes the immediate goal of repair, but without long-term durability, as the ventricular dysfunction and remodeling are not addressed with the annuloplasty. 98,99 Studies show a more reliable reduction in mitral regurgitation with valve replacement, 100 with no difference in major outcomes between repair and replacement. 99,101 D. Watchful waiting versus early surgical intervention in asymptomatic patients with severe mitral regurgitation High volume centers of excellence are moving toward a more aggressive surgical approach and they recommend mitral valve repair in asymptomatic patients with severe mitral regurgitation in the absence of left ventricular dysfunction, atrial fibrillation and pulmonary hypertension.…”

When to use stress echocardiography in the evaluation of patients with valvular heart disease

“…(61,62) Surgery solely for mitral regurgitation in patients with ischaemic mitral regurgitation and impaired left ventricular systolic function does not seem to offer survival benefit, (63)(64)(65) but may be considered for relief of symptoms in those with associated heart failure refractory to medical therapy. (66) In some patients, mild to moderate ischaemic mitral regurgitation may become severe with exercise and these patients are at higher risk of heart failure or death.…”