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Recurrent Mitral Regurgitation Following Degenerative Mitral Valve Repair
Study Questions:
What are the rates, predictors, and consequences of developing recurrent mitral regurgitation (MR) following degenerative mitral valve repair?
Methods:
Consecutive patients who underwent isolated primary mitral valve repair for pure degenerative MR (mitral valve prolapse [MVP]) at Mayo Clinic from 1990 to 2000 were studied (including patients with concomitant tricuspid valve repair, maze procedure, or coronary bypass surgery). Follow-up was by review of clinically indicated transthoracic echocardiography reports and clinic visits at and remote from Mayo Clinic.
Results:
A total of 1,218 patients met study criteria (864 [71%] men, mean age 64 ± 13 years, mean left ventricular ejection fraction 63 ± 9%). Prolapse was posterior in 62%, bileaflet in 26%, and anterior in 12%. Median follow-up duration was 11.5 years (interquartile range 9.2-13.6 years). The 15-year incidence of recurrent ≥2+ (moderate) MR was 13.3%, mitral re-operation was 6.9%, and overall mortality was 44.0%. Independent determinants of recurrent MR were residual mild MR in the operating room (hazard ratio [HR], 4.23; 95% confidence interval [CI], 1.86-8.32), anterior leaflet prolapse (HR, 2.57; 95% CI, 1.54-4.22), bileaflet prolapse (HR, 2.00; HR, 1.33-2.99), repair prior to 1996 (HR, 1.52; 95% CI, 1.06-2.19), perfusion time >90 minutes (HR, 1.73; 95% CI, 1.19-2.50), and age (HR, 1.02; 95% CI, 1.01-1.03); use of a ring annuloplasty predicted less likely recurrent MR (HR, 0.33; 95% CI, 0.18-0.63). Recurrence of ≥2+ MR was associated with adverse left ventricular remodeling and increased likelihood of death (HR, 1.72; 95% CI, 1.24-2.39). Among patients undergoing repair after 1996, the rate of MR recurrence was 1.5%/patient-year (95% CI, 0.6-2.5%) during the first year after repair, decreasing to 0.9%/patient-year (95% CI, 0.6-1.1%) thereafter.
Conclusions:
The authors concluded that recurrent MR after degenerative mitral valve repair is rare and decreases after the first year (1.5% in the first year, and then 0.9% per year thereafter), and associated with adverse left ventricular remodeling and late death. The authors suggest that a transparent discussion regarding recurrent MR risk should take place when referring patients with complex MVP.
Perspective:
This large, observational, retrospective, single-center study reflects what might be the best-case scenario for long-term outcomes after repair of degenerative MR (MVP). Individual surgeons and institutions should know and make publicly available their own results. Recurrent MR was more common following repair of bileaflet or anterior leaflet MVP, and referral to a center of excellence seems appropriate. However, with 5-year rates of recurrent MR in excess of 5% even at this high-volume tertiary referral center, care should be taken (based on current guideline recommendations) in recommending ‘prophylactic’ mitral valve repair among patients with anything other than isolated posterior leaflet MVP.
Keywords: Cardiovascular Surgical Procedures, Coronary Artery Bypass, Echocardiography, Heart Valve Diseases, Mitral Valve Insufficiency, Mitral Valve Prolapse, Prolapse, Reoperation, Ventricular Remodeling, Tricuspid Valve
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