Mitral-Valve Repair Versus Replacement for Severe Ischemic Mitral Regurgitation

Study Questions:

What are the relative benefits and risks of repair versus replacement, with or without coronary revascularization, in patients with severe ischemic mitral regurgitation?

Methods:

The CTSN (Cardiothoracic Surgical Trials Network) investigators 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 endpoint 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, 0.42-1.47; 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:

The authors concluded that there were no significant differences in LV reverse remodeling or survival at 12 months between patients who underwent mitral-valve repair and those who underwent mitral-valve replacement.

Perspective:

This study reported no significant difference in LV reverse remodeling, as measured by the LVESVI or survival at either 30 days or at 12 months, between patients who underwent mitral-valve repair and those who underwent mitral-valve replacement. These findings contradict much of the published nonrandomized literature on this topic, which reports several advantages to mitral-valve repair over replacement, including lower operative mortality, improved LV function, and higher rates of long-term survival, thus highlighting the importance of performing prospective randomized trials. Further patient follow-up is needed to confirm the findings of this trial, and such follow-up may also lead to the identification of predictors of recurrence of mitral regurgitation after repair to allow for a more optimal selection of patients.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Cardiac Surgery and VHD, Interventions and Structural Heart Disease, Mitral Regurgitation

Keywords: Risk, Recurrence, Follow-Up Studies, Health Resources, Quality of Life, Mitral Valve Insufficiency, Naphthalenes, Stroke Volume, Chordae Tendineae, Confidence Intervals, Risk Assessment, Cardiac Surgical Procedures


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