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Late Outcomes of Mitral Valve Repair for Mitral Regurgitation Due to Degenerative Disease
Study Questions:
What are the long-term outcomes of mitral valve (MV) repair performed for degenerative mitral regurgitation (MR)?
Methods:
All 840 patients who underwent MV repair for MR due to degenerative diseases from 1985 to 2004 at a single large center were prospectively followed with clinical and echocardiographic evaluations at biennial intervals up to 26 years (median of 10.4 years). Clinical, hemodynamic, and pathological variables were evaluated for their association with outcomes.
Results:
In multivariable analysis, age, left ventricular (LV) ejection fraction, and functional class were predictors of late cardiac- and valve-related deaths. MV repair failed to restore life span to normal in patients with functional class IV symptoms prior to intervention. A total of 38 patients had repeat MV surgery, with a probability of reoperation of 5.9% at 20 years. During the follow-up interval, recurrent severe MR developed in 37 patients, and moderate MR developed in 61. Age, isolated prolapse of the anterior leaflet, the degree of myxomatous changes of the MV, lack of mitral annuloplasty, and duration of cardiopulmonary bypass were associated with increased risk of recurrent MR. At 20 years, the freedom from recurrent severe MR was 90.7%, and the freedom from moderate or severe MR was 69.2%.
Conclusions:
MV repair for degenerative MR restored life span to normal except in patients with preoperative functional class IV symptoms and impaired LV function. Advanced age and complex MV pathologies increased the risk of late recurrent MR.
Perspective:
This study is remarkable not only for the number of patients operated on and the duration of follow-up, but in that all patients underwent biennial echocardiography during follow-up; not only were clinical events assessed, but freedom from MR (in a potentially asymptomatic patient) also can be reported. The results represent the work of a single highly skilled surgeon, and repair techniques notably evolved over the duration of the study. Results of current interventions are presumably at least as good as those in this historical report, although surgeon experience and skill certainly also play a role. Inasmuch as these results should not be extrapolated to all surgical interventions (regardless of the surgeon), this report provides data suggesting that, when performed in the right hands, MV repair for degenerative MR is a durable procedure. The study further reinforces recommendations that intervention ideally should occur before the onset of advanced symptoms or LV systolic dysfunction.
Keywords: Reoperation, Mitral Valve Prolapse, Mitral Valve Insufficiency, Cardiology, Cardiomyopathies, Cardiovascular Diseases, Cardiopulmonary Bypass, Heart Valve Prosthesis Implantation, Mitral Valve Annuloplasty, Cardiac Surgical Procedures, Hemodynamics
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