Mitral-Valve Repair versus Replacement for Severe Ischemic Mitral Regurgitation

Abstract

Background Ischemic mitral regurgitation is associated with a substantial risk of death. Practice guidelines recommend surgery for patients with a severe form of this condition but acknowledge that the supporting evidence for repair or replacement is limited. Methods We randomly assigned 251 patients with severe ischemic mitral regurgitation to undergo either mitral-valve repair or chordal-sparing replacement in order to evaluate efficacy and safety. The primary end point was the left ventricular end-systolic volume index (LVESVI) at 12 months, as assessed with the use of a Wilcoxon rank-sum test in which deaths were categorized below the lowest LVESVI rank. Results At 12 months, the mean LVESVI among surviving patients was 54.6±25.0 ml per square meter of body-surface area in the repair group and 60.7±31.5 ml per square meter in the replacement group (mean change from baseline, −6.6 and −6.8 ml per square meter, respectively). The rate of death was 14.3% in the repair group and 17.6% in the replacement group (hazard ratio with repair, 0.79; 95% confidence interval, 0.42 to 1.47; P = 0.45 by the log-rank test). There was no significant between-group difference in LVESVI after adjustment for death (z score, 1.33; P = 0.18). The rate of moderate or severe recurrence of mitral regurgitation at 12 months was higher in the repair group than in the replacement group (32.6% vs. 2.3%, P<0.001). There were no significant between-group differences in the rate of a composite of major adverse cardiac or cerebrovascular events, in functional status, or in quality of life at 12 months. Conclusions We observed no significant difference in left ventricular reverse remodeling or survival at 12 months between patients who underwent mitral-valve repair and those who underwent mitral-valve replacement. Replacement provided a more durable correction of mitral regurgitation, but there was no significant between-group difference in clinical outcomes. (Funded by the National Institutes of Health and the Canadian Institutes of Health; ClinicalTrials.gov number, NCT00807040.)

Is Mitral Valve Repair Superior to Mitral Valve Replacement in Elderly Patients? Comparison of Short‐ and Long‐Term Outcomes in a Propensity‐Matched Cohort

“…Fundamentally, the etiology of MV disease dictates repair feasibility and success. In a recently published, randomized controlled trial comparing MVR and MV‐repair for ischemic MV disease, there was no difference in the mortality rate between these procedures, but there was a higher incidence of recurrent MR after MV‐repair 2. The rate of recurrent MR and repeat surgery was very high in their multicenter study with only small groups of patients included from numerous institutions.…”

“…The role of MV‐repair for functional (ischemic) MV regurgitation is still under debate2, 3 and in rheumatic disease mainly MVR is performed, as MV‐repair is more complex in these patients and less durable 4. Due to the demographic changes in Western communities and a higher incidence of MV disease in the elderly population,5 the age of patients referred for MV surgery is increasing.…”

MitraClip for severe symptomatic mitral regurgitation in patients at high surgical risk

“…MVR has been advocated over MVRP, but routine sparing of the sub-valvular apparatus has resulted in reproducible reductions in operative mortality after MVRP [48]. Many patient groups do not appear to benefit from MVR over MVRP, particularly patients with a greater burden of comorbidities [49,50].…”

Treatment of mitral regurgitation

“…A large European study, the Amsterdam Center for Contemporary European Studies -A Two-Phase Observational Study of the MitraClip® System in Europe (ACCESS-EU) prospective nonrandomized trial, found 81.8% survival at 1 year and 78.9% Original Article pime pime pime pime p pi im me e EDITRICE outcomes following valve repair compared to degenerative MR [13]. Recently mitral valve replacement too has been demonstrated to have equivalent outcomes for functional MR patients in a randomized trial, even though earlier data has suggested a superior outcomes for MV repair [14]. However, an excess incidence of recurrent MR was noted at 1-year among patients undergoing MV repair [15].…”