Comparison of Repair vs Replacement in Calcific and Rheumatic Mitral Disease

Mitral valve repair versus bioprosthetic replacement outcomes in patients with rheumatic disease over 60: Propensity score-matching results

BACKGROUND

Rheumatic mitral valve disease remains a significant health issue in developing countries, especially among elderly patients with severe valvular abnormalities. The optimal surgical intervention-mitral valve repair versus bioprosthetic mitral valve replacement-for patients aged more than 60 years is debated because of limited studies in this age group. We aimed to compare mid- to long-term outcomes of mitral valve repair and bioprosthetic mitral valve replacement in elderly patients with rheumatic mitral valve disease.

METHODS

We retrospectively analyzed patients aged 60 years or more who underwent mitral valve repair or bioprosthetic mitral valve replacement at Anzhen Hospital from January 2011 to June 2023. Propensity score matching was used to balance the groups. Kaplan-Meier survival analysis assessed mid- to long-term survival and reoperation rates. Subsequently, the hazard ratio for late mortality and the subdistribution hazard ratio for reoperation, considering death as a competing risk, were calculated.

RESULTS

The study included 981 patients, with 317 in the mitral valve repair group and 664 in the bioprosthetic mitral valve replacement group. After propensity score matching, 254 patients from each group were included. After propensity score matching, patients had a median age of 64 years (interquartile range, 6 years). The mitral valve repair group had significantly shorter operative times, less need for blood transfusions, and lower perioperative reoperation rates. At a median follow-up of 4.8 years, patients undergoing mitral valve repair had comparable late mortality compared with bioprosthetic mitral valve replacement (hazard ratio, 0.637; 95% CI, 0.355-1.143; P = .130). Valve-related reoperation rates and adverse events, except for severe mitral regurgitation, were similar between groups.

CONCLUSIONS

Among patients aged more than 60 years with rheumatic mitral valve disease, valve repair is associated with comparable mid- to long-term survival and perioperative mortality when compared with bioprosthetic valve replacement. Mitral valve repair is regarded as an optional surgical intervention for patients aged more than 60 years who have experienced rheumatic mitral valve disease.

Comparison of Mitral Valve Repair Versus Percutaneous Mitral Balloon Commissurotomy for Patients With Rheumatic Heart Disease: A Single-Centre Study

BACKGROUND

Percutaneous mitral balloon commissurotomy (PMBC) is the standard treatment option for patients with rheumatic mitral stenosis (MS), according to current guidelines. This study aimed to compare the outcomes of rheumatic mitral valve repair (rMVR) and PMBC in this patient population.

METHODS

Baseline, clinical, and follow-up data from 703 patients with rheumatic heart disease who underwent PMBC or rMVR at the current centre were collected and analysed. A 1:1 propensity score (PS) matching method was used to balance the differences in baseline characteristics between the two groups. The primary outcome was mitral valve reoperation, and the secondary outcome was all-cause mortality.

RESULTS

Propensity score matching generated 101 patient pairs for comparison. In the matched population, there were no significant differences in the early clinical outcomes between the groups. The median follow-up time was 40.9 months. Overall, patients in the rMVR group had a statistically significantly lower risk of mitral valve reoperation than those in the PMBC group (HR 0.186; 95% CI 0.041-0.835; p=0.028). Regarding all-cause mortality, no statistically significant differences were observed between the rMVR and PMBC groups (HR 4.065; 95% CI 0.454-36.374; p=0.210).

CONCLUSIONS

Compared with PMBC, rMVR has more advantages for the correction of valve lesions; therefore, it may offer a better prognosis than PMBC in select patients with rheumatic MS. However, this finding needs to be verified in future studies with larger sample sizes and longer follow-up periods.

Valvular heart disease: from mechanisms to management

Valvular heart disease is common and its prevalence is rapidly increasing worldwide. Effective medical therapies are insufficient and treatment was historically limited to the surgical techniques of valve repair or replacement, resulting in systematic underprovision of care to older patients and those with substantial comorbidities, frailty, or left ventricular dysfunction. Advances in imaging and surgical techniques over the past 20 years have transformed the management of valvular heart disease. Better understanding of the mechanisms and causes of disease and an increasingly extensive and robust evidence base provide a platform for the delivery of individualised treatment by multidisciplinary heart teams working within networks of diagnostic facilities and specialist heart valve centres. In this Series paper, we aim to provide an overview of the current and future management of valvular heart disease and propose treatment approaches based on an understanding of the underlying pathophysiology and the application of multidisciplinary treatment strategies to individual patients.