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Late Results of Mitral Valve Repair for MR Due to Leaflet Prolapse
Study Questions:
What are the late results of mitral valve (MV) repair for mitral regurgitation (MR) due to MV prolapse (MVP)?
Methods:
In a single-center, single-surgeon experience, 1,234 consecutive patients (median age, 59 years; 70.4% men) who underwent MV repair for MR due to leaflet prolapse between 1981 and 2010 were followed prospectively for a median of 13 years (interquartile range, 8-34 years). Follow-up was based on telephone calls to the patient and the referring cardiologist every 2-3 years, and included echocardiography every 2-5 years. Prolapse was recorded at the time of surgery as posterior, anterior, or bileaflet; and the degree of myxomatous degeneration as none or mild (fibroelastic deficiency or minimal myxomatous changes), moderate, or severe. There were 163 patients still at risk at 20 years. Cumulative incidences of adverse events and associated factors were examined with death as a competing outcome.
Results:
At 20 years, reoperation-free survival was 60.4% (95% confidence interval, 56.2-64.2%); the cumulative incidence of cardiac and valve-related deaths was 12%, noncardiac deaths 21.3%, reoperation on the MV 4.6%, infective endocarditis 1.1%, thromboembolism 10.3%, and bleeding 6.4%. The probability of recurrent moderate or severe MR was 12.5%, persistent or new moderate or severe tricuspid regurgitation (TR) 20.8%, and new atrial fibrillation (AF) 32.4%. Multivariable analysis identified older age, complete heart block, MV repair without an annuloplasty ring, and the degree of myxomatous degeneration of the MV to be associated with recurrent MR. The development of AF and TR was unrelated to recurrent MR. Age, left ventricular (LV) systolic dysfunction, New York Heart Association functional class, and bileaflet prolapse were associated with cardiac death.
Conclusions:
MV reoperation was uncommon after MV repair, but there was an increasing incidence of recurrent MR, TR, and new AF over time.
Perspective:
Current guidelines underscore the belief that MV repair is superior to MV replacement; recommendations for intervention among asymptomatic patients with severe MR and normal LV function are based on the belief that outcomes after MV repair are superior if intervention is performed prior to the onset of symptoms or LV dysfunction. This large, single-surgeon experience reveals good clinical outcomes following MV repair for MR due to MVP, albeit with a 12.5% incidence of recurrent moderate or severe MR at 20 years, and significant rates of new AF and new TR unrelated to recurrent MR. The finding that any degree of LV systolic dysfunction or the presence of preoperative symptoms was associated with higher cardiac mortality reinforces the role of early intervention. These data, specific to a single, high-volume surgeon, further reinforce the role for referral of patients with MVP and MR to a center of excellence.
Keywords: Atrial Fibrillation, Cardiac Surgical Procedures, Echocardiography, Endocarditis, Heart Block, Heart Failure, Heart Valve Diseases, Mitral Valve Insufficiency, Prolapse, Reoperation, Thromboembolism, Tricuspid Valve Insufficiency
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