Outcome of mitral valve repair or replacement for non-ischemic mitral regurgitation: a systematic review and meta-analysis

Incidence and factors associated with mitral valve reoperation in patients undergoing surgery for mitral regurgitation: A nationwide cohort study

BACKGROUND

When patients undergo surgery for mitral regurgitation, risk of reoperation is of concern.

AIMS

To examine the incidence and factors associated with mitral reoperation following surgery for mitral regurgitation according to type of surgery.

METHODS

Patients undergoing first-time surgery for mitral regurgitation, 1996-2021, were identified from nationwide registries. According to index surgery, the population was categorized into 1) mitral repair; 2) mechanical prostheses; 3) bioprostheses. Patients were followed from discharge with a maximum of 15 years of follow-up and cumulative incidence of reoperation was examined. Multivariable Cox analysis was used to examine factors associated with reoperation.

RESULTS

We identified 6958 patients: 4624 with mitral repair (72 % male, median age 66), 1250 with mechanical prosthesis (52 % male, median age 59), and 1084 with bioprosthesis (57 % male, median age 74). Cumulative incidence of reoperation was 7.3 % for repair (median 7.2 years follow-up), 6.1 % for mechanical prostheses (median 10.9 years follow-up), and 7.1 % for bioprostheses (median 4.5 years follow-up). Within first year, 22.6 % of reoperations were preceded by infective endocarditis. In long-term follow-up, bioprosthetic replacement was associated with a higher reoperation rate, while increasing age, male sex and mechanical prosthesis were associated with lower reoperation rate.

CONCLUSIONS

In patients operated for mitral regurgitation, reoperation was infrequent at approximately 7 % for all intervention types during a maximum of 15-year follow-up. In adjusted analysis, bioprosthetic replacement was associated with a higher rate of reoperation, while increasing age, male sex and mechanical prosthesis was associated with a lower rate of reoperation.

Restrictive annuloplasty or replacement on reverse remodeling for nonischemic dilated cardiomyopathy

BACKGROUND

For patients with nonischemic dilated cardiomyopathy (NIDCM), the indications for and results of mitral surgery remain controversial. We reviewed a strategy of mitral repair and replacement for clinically relevant secondary mitral regurgitation (MR) in patients with NIDCM.

METHODS

We retrospectively reviewed 65 patients with advanced NIDCM (LVEF < 40%) who underwent mitral surgery. Of them, 47 (72%) underwent mitral annuloplasty and 18 (28%) replacement for secondary MR. The primary endpoint was postoperative reduction in indexed LV end-systolic volume (LVESVI).

RESULTS

At baseline, there was no intergroup difference in LVESVI (123 ± 47 vs. 147 ± 37 ml/m2, P = 0.055), LVEF (27 ± 8% vs. 25 ± 6%, P = 0.41), incidence of severe MR (57% (27/47) vs. 72% (13/18), P = 0.40), or EuroSCORE II score (6.2% vs. 7.6%, P = 0.90). At 6 months, the annuloplasty group reduced LVESVI to a greater degree than the replacement group (P < 0.001), yielding significantly smaller postoperative LVESVI (96 ± 59 vs. 154 ± 61 ml/m2, P < 0.001) and better LVEF (P < 0.001). The rates of moderate/severe recurrent MR were 17% (8/47) and 0%, respectively. Multivariable analysis demonstrated that mitral annuloplasty (OR 6.10, 95% CI 1.14-32.8, P = 0.035) was significantly associated with postoperative LV reverse remodeling. Cumulative survival was not different between the groups (P = 0.26).

CONCLUSIONS

In patients with NIDCM, mitral annuloplasty reduced LV volume to a greater degree than did mitral replacement. These findings may assist with surgical options for secondary MR associated with NIDCM.

Clinical and echocardiographic predictors of the anterior mitral leaflet repair failure

BACKGROUND

Anterior mitral leaflet prolapse repair is a highly effective procedure, but despite excellent operative results still has an inferior long-term durability when compared to posterior leaflet repair.

METHODS

We analysed mitral repair durability in 74 consecutive patients operated for anterior leaflet prolapse between 2010 and 2021. Their pre- and postoperative clinical, echocardiographic data and repair durability as well, were compared with 74 randomly assigned posterior leaflet prolapse patients who underwent valve repair during the same period.

RESULTS

While groups were of similar age, patients with anterior leaflet prolapse had an inferior preoperative status in terms of functional reserve, atrial fibrillation, operative risk, ejection fraction and had more dilated left heart chambers as well. 1, 5, and 10-year freedom from repair failure was 87.1 ± 4.6%, 79.8 ± 6.5% and 50.7 ± 12.5% in the anterior, and 98.5 ± 1.5% respectively in the posterior leaflet group. Atrial fibrilation (hazard ratio [HR] 5.365; 95%; confidence interval [CI] 1.093-26.324 p = .038) and left ventricle end-systolic diameter (HR 1.160 95%; CI 1.037-1.299 p = .010) independently predicted anterior leaflet repair failure. Receiver Operating Curve analysis established left ventricle end-systolic diameter ≤42 mm as a cut-off value associated with improved anterior leaflet repair durability. Accordingly, 10-year repair durability in a subset of patients, with preserved left ventricle end-systolic diameter (≤42 mm) was 86.4 ± 7.8%.

CONCLUSION

Better long-term repair durability in patients with anterior mitral leaflet prolapse and preserved sinus rhytm and left-ventricle diameters justifies early reconstructive approach.

Cardiac Surgery 2021 Reviewed

PubMed displayed more than 35,000 hits for the search term "cardiac surgery AND 2021." We used the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) approach and selected relevant publications for a results-oriented summary. As in recent years, we reviewed the fields of coronary and conventional valve surgery and their overlap with their interventional alternatives. COVID reduced cardiac surgical activity around the world. In the coronary field, the FAME 3 trial dominated publications by practically repeating SYNTAX, but with modern stents and fractional flow reserve (FFR)-guided percutaneous coronary interventions (PCIs). PCI was again unable to achieve non-inferiority compared with coronary artery bypass graft surgery (CABG) in patients with triple-vessel disease. Survival advantages of CABG over PCI could be linked to a reduction in myocardial infarctions and current terminology was criticized because the term "myocardial revascularization" is not precise and does not reflect the infarct-preventing collateralization effect of CABG. In structural heart disease, new guidelines were published, providing upgrades of interventional treatments of both aortic and mitral valve disease. While for aortic stenosis, transcatheter aortic valve implantation (TAVI) received a primary recommendation in older and high-risk patients; recommendations for transcatheter mitral edge-to-edge treatment were upgraded for patients considered inappropriate for surgery. For heart team discussions it is important to know that classic aortic valve replacement currently provides strong signals (from registry and randomized evidence) for a survival advantage over TAVI after 5 years. This article summarizes publications perceived as important by us. It can neither be complete nor free of individual interpretation, but provides up-to-date information for decision-making and patient information.