Operative and long-term survival of elderly is significantly improved by mitral valve repair

doi:10.1016/j.ahj.2005.07.003

American Heart Journal

Volume 151, Issue 6, June 2006, Pages 1325-1333

https://doi.org/10.1016/j.ahj.2005.07.003 Get rights and content

Background

We review our 10-year experience of mitral valve (MV) repair in comparison with MV replacement in the elderly for floppy mitral valves/mitral valve prolapse (FMV/MVP). The use of MV repair for this entity has not been fully utilized by surgeons.

Methods

Two hundred ninety-two consecutive patients aged ≥70 years receiving mitral surgery for regurgitation due to FMV/MVP were reviewed from our prospective database between January 1, 1992, and December 31, 2002. Patients receiving concomitant coronary artery bypass grafting (CABG) were included. Two hundred eighteen patients underwent repairs and 74 replacements. Postoperative and long-term follow-up data were obtained. Mean follow-up time for survivors was 6.2 ± 2.5 years for MV repair and 6.8 ± 2.7 years for MV replacement.

Results

Patients with isolated MV repair showed lower inhospital mortality compared with MV replacement (0.7% vs 13.9%, P = .002) with reduced length of stay (8.7 ± 7.6 vs 9.6 ± 5.2 days, P = .049). There was improvement in 5-year mortality favoring repair versus replacement (81% ± 3% vs 63% ± 3%, P = .001). With concomitant CABG, there was minimal difference in survival up to 5 years. Freedom from valve replacement was 93.9% ± 1.3% for MV repair and 98.2% ± 0.4% for MV repair with CABG at 10 years. Mitral valve repair was an independent protector of long-term mortality within multivariate correlates (hazard ratio 0.43, 95% CI 0.19-0.97, P = .041).

Conclusions

In elderly patients, MV repair reduced inhospital mortality and length of stay and increased long-term survival. With concomitant CABG, survival was similar to replacement. The preferred option for elderly patients with FMV/MVP is MV repair, especially in those without coronary artery disease.

Section snippets

Patient population

Approval for this study was obtained from the Institutional Review Board. From January 1, 1992, to December 31, 2002, 292 patients aged ≥70 years with MR caused by FMV/MVP underwent first-time MV surgery. Patients underwent MV replacement if there was extensive calcification of the MV not amenable to repair. The diagnosis of FMV/MVP was based on echocardiographic, surgical, and pathological findings. Exclusion criteria included patients with MR known to be due to rheumatic, endocarditic, or

Patient demographics

Isolated valve surgery. There was a statistical difference between isolated MV repair and replacement within the proportion of patients undergoing tricuspid repair only (8.2% MV repair, 27.8% MV replacement, P = .003) (Table II). There was no significant difference between age, proportion of female patients, hypertension, diabetes, coronary artery disease, cerebrovascular disease, previous myocardial infarction, hypercholesterolemia, chronic renal insufficiency, preoperative atrial

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Cited by (39)

Mitral Valve Repair for Anterior/Bi-leaflet Versus Posterior Leaflet Degenerative Mitral Valve Disease: A Systematic Review and Meta-analysis
2022, Current Problems in Cardiology
Citation Excerpt :
When comparing various mitral valve pathologies, studies show that degenerative disease of the mitral valve is the most amenable to repair.18 Gogbashian et al. demonstrated that isolated MVr was an independent factor for improving long-term survival outcomes among elderly patients.19 Our analysis delineated similar findings with no significant difference in the long-term survival between anterior/bi-leaflet and isolated posterior MVr group.
Mitral valve repair (MVr) secondary to degenerative anterior/bi-leaflet mitral valve disease is more challenging than posterior leaflet repair. However, conclusive evidence is needed to make decisions based on the outcomes rather than technical difficulties. This meta-analysis compares anterior/bi-leaflet MVr with isolated posterior leaflet repair in patients with mitral regurgitation (MR) due to degenerative mitral valve disease. The outcomes of interest were long-term (≥ 5 years) survival and freedom from re-operation and moderate-to-severe MR. Meta-analysis of 10 studies showed that there was no significant difference in long-term survival (risk ratio, RR: 1.00; 95% confidence interval, 95% CI 0.96-1.04), freedom from moderate-to-severe MR (RR: 0.95; 95% CI 0.87-1.03), and freedom from re-operation (RR: 0.96; 95% CI 0.90-1.02) between anterior/bi-leaflet MVr and posterior leaflet repair. As outcomes of anterior/bilateral repair were comparable with those of isolated posterior leaflet repair, our findings do not support the inclination towards replacement over repair for MR caused by anterior/bilateral degenerative mitral disease.
Meta-Analysis Comparing Mitral Valve Repair Versus Replacement for Degenerative Mitral Regurgitation Across All Ages
2019, American Journal of Cardiology
Citation Excerpt :
The other study10 showed results in a subgroup of patients with degenerative MR (139 of 322 overall study patients). Three studies10,14,18 enrolled only elderly patients, although the cut-off age of elderly was different in the studies (70, 80, and 75, respectively). One study20 separately presented results in subgroups of elderly patients (between 65 to 74 and ≥75).
Although current guidelines recommend mitral valve repair (MVr) over mitral valve replacement (MVR) for patients with mitral regurgitation (MR), it is unclear if it should be also recommended in elderly patients with limited life expectancy. This study was conducted to compare the results of MVr with those of MVR to determine the optimal treatment option for patients with degenerative MR, particularly according to the patient's age. A literature search of 5 electronic databases was performed. The primary outcome was all-cause mortality. The secondary outcomes included early mortality and freedom from reoperation. A metaregression analysis and subgroup analysis were performed according to the mean age of the study population. Twelve retrospective studies (2,950 and 1,252 patients in the MVr and MVR groups, respectively) were selected. Pooled analyses demonstrated that the risk of all-cause mortality was significantly higher in the MVR group than in the MVr group both in all studies and in studies presenting adjusted results (hazard ratio[95% confidence interval] = 1.57[1.39 to 1.77] and 1.53[1.34 to 1.74], respectively). This benefit was similar across all ages when the metaregression analysis and the subgroup analysis were performed (p = 0.879 and 0.123, respectively). Early mortality and risk of reoperation were also higher in the MVR group than in the MVr group (risk ratio[95% confidence interval] = 4.51[3.12 to 6.51] and hazard ratio[95% confidence interval] = 1.47[1.09 to 1.98], respectively). In conclusion, this study indicates that MVr is beneficial compared with MVR in patients with degenerative MR regardless of patients’ age in terms of all-cause mortality.
Predictors of survival in octogenarians after mitral valve surgery for degenerative disease: The Mitral Surgery in Octogenarians study
2018, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
Initially, MVr was considered to be an unnecessary procedure in elderly subjects; moreover, there were concerns that fragile tissues and valvular calcification were more likely to preclude satisfactory valve repair in older patients.14 However, with increasing skill and understanding of mitral disease, the repair rate, especially in expert hands in high-volume centers, has continued to grow in the last few years.12-26 Our study confirms this trend, with an increasing ratio of MVr to MVR over time in octogenarians without significant cardiopulmonary bypass time difference between the 2 techniques.
An increasing number of octogenarians are referred to undergo mitral valve surgery for degenerative disease, and percutaneous approaches are being increasingly used in this subgroup of patients. We sought to determine the survival and its predictors after Mitral Valve Surgery in Octogenarians (MiSO) in a multicenter UK study of high-volume specialized centers.
Pooled data from 3 centers were collected retrospectively. To identify the predictors of short-term composite outcome of 30 days mortality, acute kidney injury, and cerebrovascular accident, a multivariable logistic regression model was developed. Multiple Cox regression analysis was performed for late mortality. Kaplan–Meier curves were generated for long-term survival in various subsets of patients. Receiver operating characteristic analysis was done to determine the predictive power of the logistic European System for Cardiac Operative Risk Evaluation.
A total of 247 patients were included in the study. The median follow-up was 2.9 years (minimum 0, maximum 14 years). A total of 150 patients (60.7%) underwent mitral valve repair, and 97 patients (39.3%) underwent mitral valve replacement. Apart from redo cardiac surgery (mitral valve repair 6 [4%] vs mitral valve replacement 11 [11.3%], P = .04) and preoperative atrial fibrillation (mitral valve repair 79 [52.6%] vs mitral valve replacement 34 [35.1%], P < .01), there was no significant difference in terms of any other preoperative characteristics between the 2 groups. Patient operative risk, as estimated by logistic European System for Cardiac Operative Risk Evaluation, was lower in the mitral valve repair group (10.2 ± 11.8 vs 13.7 ± 15.2 in mitral valve replacement; P = .07). No difference was found between groups for duration of cardiopulmonary bypass and aortic crossclamp times. The 30-day mortality for the whole cohort was 13.8% (mitral valve repair 4.7% vs mitral valve replacement 18.6%; P < .01). No differences were found in terms of postoperative cerebrovascular accident (2% vs 3.1%; P = .9), acute kidney injury requiring dialysis (6.7% vs 13.4%; P = .12), and superficial or deep sternal wound infection (10% vs 16.5%, P = .17; 2% vs 3.1%, P = .67, respectively). The final multiple regression model for short-term composite outcome included previous cardiac surgery (odds ratio [OR], 4.47; 95% confidence interval [CI], 1.37-17.46; P = .02), intra-aortic balloon pump use (OR, 4.77; 95% CI, 1.67-15.79; P < .01), and mitral valve replacement (OR, 7.7; 95% CI, 4.04-14.9; P < .01). Overall survival for the entire cohort at 1, 5, and 10 years was 82.4%, 63.7%, and 45.5% (mitral valve repair vs mitral valve replacement: 89.9% vs 70.7% at 1 year, 69.6% vs 54% at 5 years, and 51.8% vs 35.5% at 10 years; P = .0005). Cox proportional hazard model results showed mitral valve replacement (hazard ratio, 1.88; 95% CI, 1.22-2.89; P < .01) and intra-aortic balloon pump use (hazard ratio, 2.54; 95% CI, 1.26-5.13; P < .01) to be independent predictor factors affecting long-term survival. Logistic European System for Cardiac Operative Risk Evaluation did not perform well in predicting early mortality (area under the curve, 0.57%).
In octogenarians, mitral valve repair for degenerative disease is associated with good survival and remains the gold standard, whereas mitral valve replacement is still associated with significant mortality. Logistic European System for Cardiac Operative Risk Evaluation was unable to predict early mortality in our cohort of patients. Larger international multicenter registries are required to optimize the decision-making process in such a high-risk subgroup.
Mitral valve repair versus replacement in the elderly: Short-term and long-term outcomes
2014, Journal of Thoracic and Cardiovascular Surgery
To compare the short-term and long-term outcomes of mitral valve repair (MVP) versus mitral valve replacement (MVR) in elderly patients.
All patients, age 70 years or greater, with mitral regurgitation who underwent MVP or MVR with or without coronary artery bypass graft (CABG), tricuspid valve surgery, or a maze procedure between 2002 and 2011 were retrospectively identified. Patients with a rheumatic cause or who underwent concomitant aortic valve or ventricular-assist device procedures were excluded.
Overall, 556 patients underwent MVP and 102 patients underwent MVR. The mean age of the patients in the MVR group was 78 years versus 77 years for those in the MVP group (P < .02). The patients in the MVR group had a better mean left ventricular ejection fraction than those in the MVP group (60% vs 55%, P = .04). The incidence of concomitant CABG, tricuspid valve operations, and atrial fibrillation ablation procedures was similar in both groups, but perfusion time was significantly longer for the MVR group (median 177 minutes vs 146 minutes for MVP, P = .001). Postoperatively, patients in the MVR group had a higher incidence of stroke (6% vs 2%, P < .10) and significantly longer intensive care unit stay (median 86 hours vs 55 hours, P = .001) and hospital stay (9 days vs 8 days, P < .01). Operative mortality of patients was significantly higher for the MVR group (8.8% vs 3.6%, P = .03) and remained significant long-term on Kaplan-Meier analysis. Cox regression analysis of all 658 patients and propensity-matched analysis of 96 patients also confirmed these results.
Elderly patients with mitral regurgitation who undergo MVP have better postoperative outcomes, lower operative mortality, and improved long-term survival than those undergoing MVR. MVP is a safe and more effective option for the elderly with mitral regurgitation.
Geriatric cardiac surgery: Chronology vs. biology
2014, Heart Lung and Circulation
Cardiac surgery is increasingly performed in elderly patients, and whilst the incidence of common risk factors associated with poorer outcome increases with age, recent studies suggest that outcomes in this population may be better than is widely appreciated. As such, in this review we have examined the current evidence for common cardiac surgical procedures in patients aged over 70 years.
Coronary artery bypass grafting (CABG) in the elderly has similar early safety to percutaneous intervention, though repeat revascularisation is lower. Totally avoiding instrumentation of the ascending aorta with off-pump techniques may also reduce the incidence of neurological injury.
Aortic valve replacement (AVR) significantly improves quality of life and provides excellent short- and long-term outcomes. Combined AVR and CABG carries higher risk but late survival is still excellent. Mini-sternotomy AVR in the elderly can provide comparable survival to full-sternotomy AVR. More accurate risk stratification systems are needed to appropriately select patients for transcatheter aortic valve implantation.
Mitral valve repair is superior to replacement in the elderly, although choosing the most effective method is important for achieving maximal quality of life. Minimally-invasive mitral valve surgery in the elderly has similar postoperative outcomes to sternotomy-based surgery, but reduces hospital length of stay and return to activity. In operative candidates, surgical repair is superior to percutaneous repair.
Current evidence indicates that advanced age alone is not a predictor of mortality or morbidity in cardiac surgery. Thus surgery should not be overlooked or denied to the elderly solely on the basis of their “chronological age”, without considering the patient's true “biological age”.
Early and late mortality after repair or replacement in mitral valve prolapse and functional ischemic mitral regurgitation: A systematic review and meta-analysis of observational studies
2014, International Journal of Cardiology

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Valvular and Congenital Heart DiseaseOperative and long-term survival of elderly is significantly improved by mitral valve repair

Background

Methods

Results

Conclusions

Section snippets

Patient population

Patient demographics

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Prog Cardiovasc Dis

Am Heart J

J Am Coll Cardiol

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Am Coll Cardiol

Reconstructive valvuloplasty. A new technique of mitral valvuloplasty

Presse Med

Very long-term results (more than 20 years) of valve repair with Carpentier's techniques in nonrheumatic mitral valve insufficiency

Circulation

Valve repair improves the outcome of surgery for mitral regurgitation. A multivariate analysis

Circulation

Very long-term survival and durability of mitral valve repair for mitral valve prolapse

Circulation

Valvular and Congenital Heart Disease
Operative and long-term survival of elderly is significantly improved by mitral valve repair