Mitral-Valve Repair Versus Replacement for Severe Ischemic Mitral Regurgitation
What are the relative benefits and risks of repair versus replacement, with or without coronary revascularization, in patients with severe ischemic mitral regurgitation?
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.
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.
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.
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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