Elsevier

The Annals of Thoracic Surgery

Volume 88, Issue 6, December 2009, Pages 1828-1837
The Annals of Thoracic Surgery

Original article
Adult cardiac
Mitral Valve Repair for Degenerative Disease: A 20-Year Experience

Presented at the Poster Session of the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009.
This paper is dedicated to Dr David C. Sabiston, Jr (1924–2009) whose vision established the Duke Cardiac Surgery Databank in 1982.
https://doi.org/10.1016/j.athoracsur.2009.08.008Get rights and content

Background

Recent advances in surgical technique allow repair of most mitral valves with degenerative disease. However, few long-term data exist to support the superiority of repair versus prosthetic valve replacement, and repair could be limited by late durability or other problems. This study was designed to compare survival characteristics of mitral valve repair versus prosthetic replacement for degenerative disorders during a 20-year period.

Methods

From 1986 to 2006, 2,580 patients underwent isolated mitral valve procedures (with or without coronary artery bypass grafting), with 989 classified as having degenerative origin. Of these, 705 received valve repair, and 284 had prosthetic valve replacement. Differences in baseline characteristics between groups were assessed, and unadjusted survival estimates were generated using Kaplan-Meier methods. Survival curves were examined after adjustment for differences in baseline profiles using a Cox model, and average adjusted survival differences were quantified by area under the curve methodology. Survival differences during 15 years of follow-up also were assessed with propensity matching.

Results

Baseline characteristics were similar, except for (variable: repair, replacement) age: 62 years, 68 years; concomitant coronary artery bypass grafting: 24%, 32%; ejection fraction: 0.51, 0.55; congestive heart failure: 68%, 43%; and preoperative arrhythmia: 11%, 7% (all p < 0.05). Long-term survival was significantly better in the repair group, both for unadjusted data (p < 0.001) and for risk-adjusted results (p = 0.040). Patient survival in the course of 15 years averaged 7.3% better with repair, and increased with time of follow-up: 0.7% better for 0 to 5 years, 4.9% better for 5 to 10 years, and 21.3% better for 10 to 15 years. Treatment interaction between repair or replacement and age was negative (p = 0.66). In the propensity analysis, survival advantages of repair versus replacement were similar in magnitude with a p value of 0.046.

Conclusions

As compared with prosthetic valve replacement, mitral repair is associated with better survival in patients with degenerative disease, especially after 10 to 15 years. This finding supports the current trend of increasing repair rates for degenerative disorders of the mitral valve.

Section snippets

Material and Methods

This study was performed with approval from the Duke Institutional Review Board and under a waiver of informed consent, but approval was not afforded for new late patient contact, unless the patient was already being followed under existing protocols. Therefore, only all-cause mortality data were available consistently. In the Duke Databank for Cardiovascular Disease, 2,580 patients with isolated mitral valve disease who underwent cardiac surgery from January 1, 1986, through December 31, 2006,

Results

The application of mitral valve repair versus replacement for degenerative disease increased steadily during the 20 years (Fig 1). Baseline characteristics for the total series of 989 patients subdivided into group 1 (repair) and group 2 (replacement) are shown in Table 1. Specifically worse risk factors for group 2 versus group 1 included greater age (68 years versus 62 years), more CABG surgery (32% versus 24%), and more nonelective surgery (34% versus 25%), whereas group 1 had worse

Comment

Many patients in this series may have received valve replacement because of surgeon choice, but it is also likely that most of the replacement patients had anatomy that was difficult to repair, such as Barlow's valves or bileaflet prolapse. Because these details of valve anatomy were not captured in the databank, one might argue that group comparisons in this paper are not strictly quantitative. However, significant changes in techniques of repair have occurred recently [29, 30], and now most

References (40)

Cited by (68)

  • Mitral Valve Repair Versus Replacement in The Elderly

    2023, Seminars in Thoracic and Cardiovascular Surgery
    Citation Excerpt :

    Mitral valve repair is the preferred surgical strategy for mitral valve regurgitation in the current guidelines.1,2 In specialized centers, repair rate of degenerative disease ranges from 71 – 100% with excellent short- and long-term results.3–5 These results are explained by the absence of prosthesis related complications (e.g. thromboembolic events, bleeding from anticoagulation and endocarditis) and positive left ventricular remodeling due to preservation of sub valvular apparatus.6,7

View all citing articles on Scopus
View full text