Original article
Adult cardiac
Valve Repair Is Superior to Replacement in Most Patients With Coexisting Degenerative Mitral Valve and Coronary Artery Diseases

Presented at the Fifty-second Annual Meeting of The Society of Thoracic Surgeons, Phoenix, AZ, Jan 23–27, 2016.
https://doi.org/10.1016/j.athoracsur.2016.08.076Get rights and content

Background

For mitral regurgitation (MR) from degenerative mitral disease in patients with coexisting coronary artery disease, the appropriate surgical strategy remains controversial.

Methods

From 1985 to 2011, 1,071 adults (age 70 ± 9.3 years, 77% men) underwent combined coronary artery bypass grafting and either mitral valve repair (n = 872, 81%) or replacement (n=199, 19%) for degenerative MR. Propensity matching (177 patient pairs, 89% of possible matches) was used to compare early outcomes and time-related recurrence of MR after mitral valve repair, mitral valve reoperation, and mortality. Risk factors for death were identified with multivariable, multiphase hazard-function analysis.

Results

Patients undergoing valve replacement were older, with more valve calcification and a higher prevalence of preoperative atrial fibrillation and heart failure (all p < .0001). Among matched pairs, mitral replacement versus repair was associated with higher hospital mortality (5.0% vs 1.0%, p = .0001) and more postoperative renal failure (7.0% vs 3.2%, p = .01), reexplorations for bleeding (6.0% vs 3.1%, p = .05), and respiratory failure (14% vs 4.7%, p < .0001). Of matched patients undergoing repair, 18% had MR above 3+ by 5 years. Mitral valve durability was similar between matched groups, but survival at 15 years was 18% after replacement versus 52% after repair. Nomograms from the multivariable equation revealed that in 94% of cases, 10-year survival was calculated to be higher after repair than after replacement.

Conclusions

In patients with coexisting degenerative mitral valve and coronary artery diseases, mitral valve repair is expected to confer a long-term survival advantage over replacement despite some recurrence of MR. When feasible, it is the procedure of choice for these patients.

Section snippets

Patients

Classification of degenerative structural mitral valve disease was based on standard criteria [8], particular attention being paid to differentiating these patients from those having functional ischemic MR. From January 1, 1985, to January 1, 2011, 1,071 patients underwent primary mitral valve repair (n = 872, 81%) or replacement (n = 199, 19%) and CABG for combined degenerative mitral valve and coronary artery diseases (Tables 1 and 2). Patients undergoing concomitant tricuspid valve repair

Choice of Mitral Valve Procedure

Mitral valve repair rather than replacement increased over time (Fig 1), stabilizing at approximately 80%. Preoperatively, patients undergoing valve replacement rather than repair were more likely to be older and more symptomatic (Table 1 and Supplemental eTable 1). Their mitral valve pathology was less likely to be a flail leaflet, but rather prolapse with valve calcification, often including areas of leaflet restriction. Their concomitant coronary grafts were similar, but in the mitral

Key Findings

At our institution, mitral valve repair is preferred for patients with combined degenerative mitral valve and coronary artery diseases; those undergoing valve replacement were older and sicker, with more complex valve pathology including leaflet and annular calcification and leaflet restriction or fibrosis, which present particular challenges for repair. Mitral valve repair was associated with fewer postoperative adverse events, similar risk of reoperation albeit for different indications, and

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    The logistic regression model analysis did not identify DMV+CABG surgery as an independent predictor of mortality, while it confirmed that replacing the MV instead of repairing it is associated with worse health outcome. Others have already underlined this concept by showing that MV repair is the preferred option in these patients7 with a reduced incidence of complications and mortality rate.24 This study has some limitations.

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