Mitral valve repair versus replacement in severe ischemic mitral regurgitation systematic review and meta‐analysis

Abstract

Background and Aim Ischemic mitral regurgitation (IMR) is a serious consequence of coronary artery disease. The choice of the optimal surgical strategy remains debatable. The aim of the present meta‐analysis is to compare the outcomes of mitral valve repair (RPR) versus replacement (RPL) regarding perioperative mortality, overall mortality, reoperation, recurrence of MR, and reverse remodeling after surgery. Methods Electronic searches were performed using the searchable databases of Google Scholar, Pubmed, and Embase, and the search terms mitral valve, IMR, RPR, RPL, and coronary artery bypass grafting. The main outcomes of interest are perioperative mortality, overall mortality, reoperation, recurrence of MR, and reverse remodeling after surgery. Perioperative mortality was defined as death during the surgery or within 30 days after the operation. Results There was a trend towards better perioperative survival in the RPR arm. However, the difference fell short of statistical significance [odds ratio (OR) (95% confidence interval [CI]): 0.66 (0.41–1.07), p = 0.09]. Patients submitted to RPR experienced a significantly higher MR recurrence rate when compared with their counterparts submitted to RPL [OR (95% CI): 16.8 (5.07–55.7, p = 0.00001)]. Conclusion There is a trend towards lower perioperative mortality in RPR in comparison to RPL. On the other hand, RPL was associated with significantly lower recurrence rates.

Mitral valve repair or replacement. How long is this feud to last?

“…We believe it is time to end this feud between repair and replacement (Figure 1). It is now obvious that they are both worthwhile surgical approaches, and this is also confirmed by the meta‐analysis by Gamal et al 6 …”

“…10 We believe it is time to end this feud between repair and replacement (Figure 1). It is now obvious that they are both worthwhile surgical approaches, and this is also confirmed by the meta-analysis by Gamal et al 6 Already at the beginning of the 2000s, we proposed a simple echocardiographic parameter, the coaptation depth, to choose between the two techniques, reserving replacement for patients with worse LV remodeling, going against the dogma according to which MV repair should be the predominant choice to be adopted. 11 Today we know that isolated annuloplasty may not be enough to reach a long-term stability and competence of the valve and, in these cases, we can choose between a more complex MV repair procedure that includes also a valvular and subvalvular procedure, or valve replacement.…”

“…In this confusing scenario, the meta‐analysis of Gamal and coworkers 6 tries to thin out at least somewhat the fog. Among 2987 records initially identified, the authors report pooled results of 14 studies including only one randomized trial 7 .…”

Proof of Concept: Development of a Mitral Annuloplasty Ring With Crosshatch Net

“…4 There is a preponderance of evidence that mitral valve repair is associated with improved outcomes over valve replacement, including decreased risk of mortality and device infection, and no requirement for postoperative anticoagulation. 5,6 Despite the overwhelming evidence in favor of repair for primary mitral disease, a significant variability in repair rates among surgeons and hospitals remains. [7][8][9] Analysis of practice patterns in New York revealed that repair rates varied from 48% to 77% and were directly related to annual surgeon volume.…”

“…4 There is a preponderance of evidence that mitral valve repair is associated with improved outcomes over valve replacement, including decreased risk of mortality and device infection, and no requirement for postoperative anticoagulation. 5,6…”