Original article
Adult cardiac
A “Repair-All” Strategy for Degenerative Mitral Valve Disease Safely Minimizes Unnecessary Replacement

Presented at the Sixtieth Annual Meeting of the Southern Thoracic Surgical Association, Scottsdale, AZ, Oct 30–Nov 2, 2013.
https://doi.org/10.1016/j.athoracsur.2014.12.076Get rights and content

Background

We examined the feasibility and efficacy of a “repair-all” strategy applied in all patients with degenerative mitral regurgitation, regardless of valve complexity, risk profile, and surgical approach.

Methods

Between 2002 and 2011, 4,241 patients underwent mitral operations at our institution. Analysis was limited to 525 consecutive patients with mitral regurgitation due to leaflet prolapse (posterior, 75%; anterior, 5%; bileaflet, 20%) who underwent isolated mitral operations. A right minithoracotomy was used in 46% of procedures. Propensity scores identified 153 well-matched patient pairs for evaluation of the effect of surgical approach on valve reparability.

Results

Mitral repair was successful in 99% (520 of 525) of patients. The location of the leaflet prolapse did not significantly influence the repair rate or the need for intraoperative revision of the initial repair. The repair rate and the need for intraoperative repair revision also did not significantly differ by surgical approach. Intraoperative revision did not confer a greater risk of perioperative morbidity or longer length of stay. At 8 years, freedom from severe mitral regurgitation was 97% ± 2%. Development of residual mitral regurgitation did not differ by location of the leaflet prolapse, need for repair revision, or surgical approach. After discharge, the survival trend did not differ between patients who did and did not require intraoperative repair revision.

Conclusions

In experienced centers, a “repair-all” strategy for degenerative mitral regurgitation can be used with nearly 100% repair rates and excellent outcomes, regardless of valve complexity. When necessary, intraoperative revision of the initial repair may be performed in most patients without a significant incremental risk, thereby further enhancing repair rates.

Section snippets

Patients and Methods

The data used in this study were in part retrieved from the University of Pennsylvania’s prospective Society of Thoracic Surgeon’s registry and from each patient’s medical record. These data were approved for use in research by the University of Pennsylvania Institutional Review Board.

Results

Baseline demographics and risk profiles are summarized in Table 1. Patients with anterior or bileaflet prolapse were generally younger at the time of their operation and were more likely to be female with a smaller body mass index. Hypertension and a lower preoperative ejection fraction were significantly more prevalent in patients with anterior or bileaflet prolapse. Compared with patients who underwent mitral operations via a median sternotomy, patients selected for minithoracotomy tended to

Comment

In general, patients with degenerative MR benefit in event-free and overall survival if the MV is repaired instead of replaced. The increased morbidity and mortality associated with MV replacement is typically from higher reoperation rates due to prosthesis failure or complications of obligatory anticoagulation. Regrettably, the replacement of myxomatous MVs is not uncommon, including in developed nations 18, 19.

In an analysis of 13,614 patients in The Society of Thoracic Surgeons Adult Cardiac

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