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Address for reprints: Alexander A. Brescia, MD, MSc, Department of Cardiac Surgery, University of Michigan, Frankel Cardiovascular Center, 1500 E. Medical Center Dr, Ann Arbor, MI 48109.
Mitral valve repair is superior to replacement for degenerative disease, but long-term outcomes of anterior versus posterior leaflet repair remain poorly defined. We propensity matched anterior and posterior repairs to compare long-term outcomes.
Methods
Patients undergoing first-time degenerative mitral repair between 1992 and 2018 were identified. Primary outcome was overall survival. Secondary outcomes were postprocedural residual mitral regurgitation and reoperation. From 1025 patients, 1:1 propensity score matching was performed, yielding 309 anterior (isolated anterior = 85, bileaflet = 224) and 309 isolated posterior repairs.
Results
Age was 58 ± 15 years, ejection fraction was 57% ± 10%, and matched groups were well balanced. Anterior repairs had longer bypass (122 ± 53 vs 109 ± 43 minutes, P = .001) and crossclamp (94 ± 44 vs 85 ± 62 minutes, P = .033) times. Mean residual mitral regurgitation grade was 0.44 (95% confidence interval, 0.24-0.65) for anterior repair and 0.30 (95% confidence interval, 0.13-0.47) for posterior repair (P = .31). Overall, 92% (569/618) of matched patients had no residual mitral regurgitation, with no differences in mitral regurgitation grade between groups (P = .77). Survival did not differ between anterior (10 years: 72% ± 7%; 15 years: 63% ± 7%) and posterior (10 years: 74% ± 7%; 15 years: 60% ± 8%) groups (log-rank P = .93). Linearized incidence of reoperation was 0.62% per patient-year, including 0.74% for anterior and 0.48% for posterior repairs. Cumulative incidence of reoperation at 15 years was 7.5% after anterior repair and 4.9% after posterior repair (Gray's test P = .26).
Conclusions
No long-term survival or reoperation difference was found between posterior and anterior repair. On the basis of these findings, surgeons at centers of excellence should aim for repair of both anterior and posterior leaflet pathology with the same decision-making threshold over valve replacement for degenerative mitral disease.
Surgeons should aim to repair both anterior and posterior leaflet pathology with the same decision-making threshold compared with valve replacement for degenerative mitral disease.
Even at mitral valve centers of excellence, repair rates for anterior degenerative disease have been lower than for posterior disease. With a well-performed degenerative repair, surgeons should not fear worse outcomes after anterior repair, and all repair types including isolated anterior, bileaflet, and isolated posterior should be aggressively pursued over replacement for degenerative mitral disease.
See Commentaries on pages 1097 and 1098.
Mitral regurgitation (MR) is the most common valve disease in the United States, affecting 0.5% to 9.3% of adults, depending on age.
Hospital volume, mitral repair rates, and mortality in mitral valve surgery in the elderly: an analysis of US hospitals treating Medicare fee-for-service patients.
Long-term results of mitral valve surgery for degenerative anterior leaflet or bileaflet prolapse: analysis of negative factors for repair, early and late failures, and survival.
patients undergoing repair enjoy a life expectancy restored to that of the general population. Although average rates of MVr for degenerative disease are still only 75% nationally and vary by hospital,
The Society of Thoracic surgeons mitral repair/replacement composite score: a report of the Society of Thoracic surgeons quality measurement Task force.
These findings have prompted many surgeons to approach anterior leaflet degenerative disease with a lower threshold for replacement over repair. Even at valve centers of excellence, repair rates for anterior degenerative disease have been substantially lower than for posterior disease.
repair has also been reported in more contemporary series, although others have found improved freedom from reoperation and survival after both isolated anterior
Very long-term durability of the edge-to-edge repair for isolated anterior mitral leaflet prolapse: up to 21 years of clinical and echocardiographic results.
repair. Despite these apparent improvements in performing anterior leaflet repair, a bias within the specialty potentially persists that anterior repair has worse outcomes because of the increased technical challenges of performing anterior leaflet repair
Mitral-valve repair without annuloplasty rings: results after repair of anterior leaflet versus posterior-leaflet defects using polytetrafluoroethylene sutures for chordal replacement.
and less familiarity with anterior repair due to the lower incidence of anterior leaflet pathology. This may also be due to a tolerance of postprocedure residual MR in prior series,
Very long-term durability of the edge-to-edge repair for isolated anterior mitral leaflet prolapse: up to 21 years of clinical and echocardiographic results.
In the context of poor outcomes in past series, contemporary series reporting long-term outcomes after anterior repair remain limited.
To address this knowledge gap, we performed a retrospective, propensity-matched analysis of 3 decades of MVr for degenerative disease to compare long-term outcomes of anterior versus posterior leaflet repair.
Materials and Methods
Data
Our data were obtained from the institutional component of the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database and supplemented through individual chart review. Data were compiled and entered into the University of Michigan Research Database, which is prospectively maintained, with standard STS data points supplemented by clinical, echocardiographic, and reoperative data obtained during clinical in-person or telephone follow-up. This study was deemed “not regulated” by the University of Michigan Institutional Review Board (HUM00148119). Although 11 surgeons performed the mitral repairs in this study population, the majority (874/1025, 85.3%) of operations were performed by a single surgeon.
Patient Population
Our study population included patients undergoing first-time MVr for degenerative MR between July 1992 and March 2018. Patients who underwent concomitant aortic procedures, myectomy, or percutaneous neochord repair, as well as those with rheumatic disease, active or treated endocarditis, or missing data were excluded. Patients who underwent intervention on the anterior leaflet only (isolated anterior) or both anterior and posterior leaflets (bileaflet) were collectively defined as anterior repairs for the primary analysis, whereas patients only undergoing intervention on the posterior leaflet were characterized as posterior repairs. Video 1 shows a complex bileaflet repair including formation of 2 polyetrafluoroethyelene (Gore-Tex; WL Gore & Associates Inc, Newark, Del) anterior leaflet neochords, posterior cleft closure and commissural advancement, and annuloplasty banding (Video 1). Figure 1 shows the overall study population.
Propensity scores were estimated through logistic regression for each patient's propensity of having anterior repair using the following preoperative variables: age, sex, ejection fraction, body mass index, preoperative dialysis, race (white, black, other, unknown), operative status (elective, urgent, emergency), and history of diabetes, dyslipidemia, cerebrovascular disease, previous cardiovascular intervention, hypertension, peripheral vascular disease, family history of early-onset coronary artery disease, and liver disease. Patients were matched 1:1 with 0.2 standard deviation calipers using 1-to-1 matching without replacement in the “psmatch2” statistical package in Stata.
PSMATCH2: Stata module to perform full Mahalanobis and propensity score matching, common support graphing, and covariate imbalance testing. Version 4.0.12.
Matching yielded 309 patients in each group. The average effect of treatment on the treated is reported from this propensity score–matched sample. Covariate balance was assessed by standardized mean differences, with less than 10% considered acceptable for each covariate after matching was performed. Propensity score distribution and overlapping were displayed with a mirrored histogram (Figure E1), and a Love plot (Figure E2) showed changes in standardized mean differences before and after matching.
Outcomes
Primary outcome was overall survival. Patients were confirmed as dead through at least 1 of 3 methods: institution electronic health records, STS database file, or the National Death Index, which was used to confirm death but not to confirm alive status. Secondary outcomes included postprocedure residual MR, postoperative length of stay, and mitral-related reoperation. Residual MR was reported as a categoric variable in MR grades 0 to 4 (none, mild, moderate, moderate-to-severe, and severe) for descriptive data and divided as follows for Cox regression analyses: less than mild MR (<1+), mild or greater MR (≥1+), or missing (n = 32/815, 3.9%). Residual MR grade for each patient was collected from operative and echocardiogram reports and reflects the intraoperative postprocedure amount of MR while under anesthesia. Mitral reoperation was defined as any subsequent intervention on the mitral valve and was collected through review of clinical follow-up recorded in the University of Michigan Research Database, which includes individual paper and electronic institutional paper charts, as well as a regional, shared electronic records system spanning most hospitals in the states of Michigan and Ohio. Follow-up for patients who did not experience an event (death or reoperation) was defined by date of surgery to latest clinical follow-up and was 100% complete.
Multiple sensitivity analyses were performed. For the primary outcome, the unmatched population was analyzed with Kaplan–Meier unadjusted survival analysis, as well as multivariable Cox regression proportional hazards modeling including every covariate used in the primary propensity score–matching analysis, as well as mild or greater postprocedure MR and cardiopulmonary bypass time. In addition, a second sensitivity analysis was performed by repeating the analysis after excluding patients who underwent concomitant coronary artery bypass grafting (CABG) or aortic valve replacement from the unmatched population.
Statistical Analysis
Bivariate comparisons used paired, 2-tailed t tests and McNemar's chi-square testing. Time-to-event analyses for survival was performed using the log-rank test and Kaplan–Meier estimates. Cox proportional hazard regressions were performed for mortality, with data reported in hazard ratios and 95% confidence intervals (CIs). Cox models were created using risk adjustment for the unmatched population and the treatment variable (repair type) alone for the matched population. Both global and covariate-specific proportional hazards assumptions were evaluated using Schoenfeld residuals with chi-square P value less than .05 indicating assumptions were not met for individual variables or the global model. Linearized rates of reoperation were calculated by incidence of reoperation divided by total patient-years of follow-up and reported both for the overall cohort and each repair group. Cumulative risk of reoperation was assessed using a competing risks regression to determine the cumulative incidence function of reoperation for each group, with death as a competing risk. Gray's test was used to determine differences in cumulative incidence between groups. A 2-year landmark competing risks regression was also performed to capture the cumulative incidence function of reoperation beyond the period of time (2 years) during which repair failures requiring reoperation would be expected to be due to technical error. All data construction and analyses were performed in Stata 16.0 (StataCorp LLC, College Station, Tex).
Results
Among 1025 overall patients, 716 (69.9%) underwent isolated posterior repair, 224 (21.9%) underwent bileaflet repair, and 85 (8.3%) underwent isolated anterior repair (Table E1). Matching yielded 309 posterior and 309 anterior leaflet repairs (Figure 1). Age was 58 ± 15 years, 36% were female, and left ventricular ejection fraction was 57% ± 10%. Matched groups were well balanced with standardized mean differences less than 10% for each covariate (Table 1 and Figures E1 and E2). Within the matched anterior repair group, 85 (28%) underwent isolated anterior repair and 224 (72%) underwent bileaflet repair, whereas 309 underwent isolated posterior repair. The most common technique for both isolated anterior and bileaflet anterior repair was neochord formation (isolated: 58/85 [68%]; bileaflet: 101/224 [45%], Table 2). Anterior repairs underwent fewer concomitant CABG operations compared with posterior repairs (39/309 [13%] vs 59/309 [19%], P = .025), whereas concomitant aortic valve replacement (anterior: 10/309 [3%] vs posterior: 8/309 [3%], P = .81) and tricuspid valve repair (anterior: 46/309 [15%] vs posterior: 35/309 [11%], P = .10) did not differ between groups. Anterior repairs had longer cardiopulmonary bypass (122 ± 53 minutes vs 109 ± 43 minutes, P = .001) and crossclamp (94 ± 44 minutes vs 85 ± 62 minutes, P = .033) times. Overall mean postoperative length of stay was 6.4 ± 7.4 days and did not differ between groups (anterior: 6.4 ± 6.4 days vs posterior: 6.4 ± 8.3 days, P = .97). Mean follow-up was 7.3 (95% CI, 6.9-7.8) years and did not differ between groups. Mean residual MR grade was 0.44 (95% CI, 0.24-0.65) for anterior repair and 0.30 (95% CI, 0.13-0.47) for posterior repair (P = .31). Overall, 92% (569/618) of patients had no MR on postprocedure echocardiogram, with no differences in proportions of postprocedure residual MR grade between matched groups (P = .77, Table 3). In-hospital mortality was 1% (6/618) and not different between anterior (3/309: 1%) and posterior (3/309: 1%) repairs (P = 1.00). Ten-year survival of the unmatched population was 72% ± 7% after anterior repair and 72% ± 4% after posterior repair (P = .08, Figure 2, A). After propensity matching, long-term survival did not differ between the anterior (5 years: 90% ± 4%; 10 years: 72% ± 7%; 15 years: 63% ± 7%) and posterior (5 years: 88%% ± 5%; 10 years: 74% ± 7%; 15 years: 60% ± 8%) groups (P = .93, Figure 2, B). Neither isolated anterior leaflet nor bileaflet repairs were associated with overall mortality in the matched and unmatched population analyses (Table 4). Independent risk factors for mortality within the unmatched population included older age, lower left ventricular ejection fraction, black race, and cardiopulmonary bypass time.
Table 1Patient characteristics for overall unmatched and matched populations
Variable
Unmatched
Matched
Total n = 1025
Posterior n = 716
Anterior n = 309
Standardized mean difference
Total n = 618
Posterior n = 309
Anterior n = 309
Standardized mean difference
Age, mean ± SD y
60 ± 14
61 ± 13
58 ± 15
0.214
58 ± 15
58 ± 14
58 ± 15
−0.001
Female sex, n (%)
325 (32)
210 (29)
115 (37)
−0.168
221 (36)
106 (34)
115 (37)
−0.061
LVEF, mean ± SD %
56 ± 10
56 ± 10
57 ± 9
−0.109
57 ± 10
57 ± 10
57 ± 9
−0.024
Diabetes mellitus, n (%)
78 (8)
48 (7)
30 (10)
−0.110
56 (9)
26 (8)
30 (10)
−0.045
Dyslipidemia, n (%)
184 (18)
111 (16)
73 (24)
−0.206
144 (23)
71 (23)
73 (24)
−0.015
Cerebrovascular disease, n (%)
58 (6)
32 (4)
26 (8)
−0.161
50 (8)
24 (8)
26 (8)
−0.024
Previous CV intervention, n (%)
97 (9)
54 (8)
43 (14)
−0.207
84 (14)
41 (13)
43 (14)
−0.019
Liver disease, n (%)
4 (0)
2 (0)
2 (1)
−0.054
4 (1)
2 (1)
2 (1)
0.000
BMI, mean ± SD kg/m2
26.2 ± 4.7
26.3 ± 4.6
26.1 ± 4.9
0.028
26.2 ± 4.7
26.3 ± 4.5
26.1 ± 4.9
0.043
Hypertension, n (%)
418 (41)
295 (41)
123 (40)
0.028
257 (42)
134 (43)
123 (40)
0.072
Peripheral vascular disease, n (%)
35 (3)
21 (3)
14 (5)
−0.084
24 (4)
10 (3)
14 (5)
−0.067
Family history of CAD, n (%)
262 (26)
188 (26)
74 (24)
0.053
152 (25)
78 (25)
74 (25)
0.030
Preoperative dialysis, n (%)
8 (1)
5 (1)
3 (1)
−0.030
6 (1)
3 (1)
3 (1)
0.000
Race, n (%)
0.162
0.032
White
907 (88)
635 (89)
272 (88)
545 (88)
273 (88)
272 (88)
Black
39 (4)
21 (3)
18 (6)
37 (6)
19 (6)
18 (6)
Other
24 (2)
18 (3)
6 (2)
11 (2)
5 (2)
6 (2)
Unknown
55 (5)
42 (6)
13 (4)
25 (4)
12 (4)
13 (4)
Operative status, n (%)
0.094
0.000
Elective
941 (92)
653 (91)
288 (93)
576 (93)
288 (93)
288 (93)
Urgent
76 (7)
58 (8)
18 (6)
36 (6)
18 (6)
18 (6)
Emergency
8 (1)
5 (1)
3 (1)
6 (1)
3 (1)
3 (1)
SD, Standard deviation; LVEF, left ventricular ejection fraction; CV, cardiovascular; BMI, body mass index; CAD, coronary artery disease.
Table 4Cox proportional hazards regression for all-cause mortality, with multivariable adjustment for the unmatched population (n = 1025) and inclusion of the treatment variable only for the propensity-matched population (n = 609)
Variable
Unmatched (n = 1025)
Matched (n = 609)
HR (95% CI)
P value
HR (95% CI)
P value
Repair type
Isolated anterior leaflet vs isolated posterior
1.29 (0.78-2.14)
.32
1.49 (0.91-2.44)
.11
Bileaflet vs isolated posterior
1.00 (0.74-1.36)
1.00
0.87 (0.61-1.25)
.45
Age, per 5 y
1.48 (1.39-1.57)
<.001
Female sex
0.90 (0.69-1.18)
.46
Ejection fraction, per 5%
0.92 (0.87-0.97)
.003
Diabetes mellitus
1.13 (0.76-1.68)
.55
Dyslipidemia
0.77 (0.44-1.34)
.35
Cerebrovascular disease
1.29 (0.82-2.03)
.28
Previous cardiovascular intervention
0.92 (0.62-1.36)
.68
Liver disease
6.39 (0.82-49.6)
.08
Body mass index
0.97 (0.94-1.00)
.05
Hypertension
1.10 (0.85-1.43)
.48
Peripheral vascular disease
0.90 (0.51-1.58)
.72
Family history of early-onset coronary artery disease
1.02 (0.79-1.33)
.86
Preoperative dialysis
0.94 (0.29-3.10)
.92
Race (reference: white)
Black
2.45 (1.31-4.60)
.005
Other
1.54 (0.61-3.89)
.36
Operative status (reference: elective)
Urgent
1.40 (0.97-2.02)
.07
Emergency
0.66 (0.23-1.92)
.44
Mild or greater (≥1+) postprocedure MR
1.08 (0.66-1.79)
.75
Cardiopulmonary bypass time, per 20 min
1.06 (1.01-1.12)
.016
Statistically significant predictors of all-cause mortality are italicized. HR, Hazard ratio; CI, confidence interval; MR, mitral regurgitation.
Linearized rate of reoperation was 0.62% per patient-year overall, including 0.74% per patient-year for anterior repairs and 0.48% per patient-year for posterior repairs. Cumulative incidence of reoperation at 15 years with death as a competing risk was 7.5% in the anterior group and 4.9% in the posterior group (Gray's test P = .26), whereas cumulative incidence of reoperation in 2-year landmark analysis was 2.8% in the anterior group and 3.0% in the posterior group out to 15 years (Gray's test P = .91) (Figure 3). Sensitivity analysis excluded all patients who underwent concomitant CABG (n = 183/1025 [18%]) or aortic valve replacement (n = 26/1025 [3%]) from the original, unmatched population. Primary (overall survival) and secondary (reoperation and residual MR) outcomes in the sensitivity analysis changed quantitatively from the primary analysis, but were qualitatively unchanged. For the primary outcome, 10-year survival estimates in unmatched (anterior: 77% ± 7% vs posterior: 78% ± 5%, P = .18) and matched (anterior: 77 ± 7% vs posterior: 79 ± 7%, P = .80) sensitivity analyses (Figure E3) were similar to results of the primary survival analysis (Figure 2).
Figure 3Cumulative incidence of reoperation with death as a competing risk after anterior versus posterior MVr. A, Cumulative incidence of reoperation among propensity-matched patients. B, Two-year landmarked analysis of cumulative incidence of reoperation among propensity-matched patients. SHR, Subhazard ratio; CI, confidence interval.
Figure 4Visual abstract of manuscript methods, results, and implications including comparison of overall survival and cumulative incidence of reoperation between propensity-matched groups. MR, Mitral regurgitation; MVr, mitral valve repair.
In this retrospective, propensity-matched analysis, long-term survival and reoperation rates of patients undergoing anterior and posterior leaflet mitral repair for degenerative disease did not differ. Cumulative incidence of reoperation was exceedingly low for both groups, including an overall linearized annual rate of reoperation less than 1% for both anterior and posterior leaflet repairs. Importantly, 92% of patients were left with no residual postprocedure MR, with a mean MR grade less than trace and no difference between groups. Collectively, these findings suggest that long-term survival among isolated anterior, bileaflet, and isolated posterior repair do not differ and that both anterior and posterior leaflet repairs for degenerative disease are durable with low cumulative incidence of reoperation when performed well with minimal to no residual MR.
Prior studies have reported mixed outcomes after anterior versus posterior MVr for degenerative disease. Multiple major series established that anterior repair conferred a higher risk of reoperation and recurrent MR.
Long-term results of mitral valve surgery for degenerative anterior leaflet or bileaflet prolapse: analysis of negative factors for repair, early and late failures, and survival.
repair, but have not compared them directly with isolated posterior repair. Unlike prior studies, the current series used propensity matching to isolate groups with comparable risk profiles to more reliably compare long-term survival. Although in concordance with prior analyses, isolated anterior leaflet repair was found to be associated with a slightly higher rate of recurrence and reoperation,
Long-term results of mitral valve surgery for degenerative anterior leaflet or bileaflet prolapse: analysis of negative factors for repair, early and late failures, and survival.
Furthermore, cumulative incidence of reoperation after anterior repairs (15 years: 7.5%) compared with posterior repairs (15 years: 4.9%) did not statistically differ in our series (Gray's test P = .26), and linearized rates of reoperation for both anterior (0.74% per patient-year) and posterior (0.48% per patient-year) repairs were both low.
Although existing data comparing reoperation and recurrent MR among anterior versus posterior subsets are mixed, both this analysis and prior work have not found a difference in short-, mid-, or long-term survival between groups.
Long-term results of mitral valve surgery for degenerative anterior leaflet or bileaflet prolapse: analysis of negative factors for repair, early and late failures, and survival.
The current analysis spans 3 decades and through propensity matching demonstrates no difference in short- or long-term survival between anterior and posterior repairs across the entire study period (log-rank P = .93, Figure 2, B). Importantly, our findings in conjunction with prior work reiterate the excellent survival and durability of all MVr for degenerative disease and its superiority over replacement,
Hospital volume, mitral repair rates, and mortality in mitral valve surgery in the elderly: an analysis of US hospitals treating Medicare fee-for-service patients.
Long-term results of mitral valve surgery for degenerative anterior leaflet or bileaflet prolapse: analysis of negative factors for repair, early and late failures, and survival.
Despite these established and reiterated benefits of anterior and posterior mitral repair over replacement, the average repair rate for degenerative disease remains approximately 75% in North America
The Society of Thoracic surgeons mitral repair/replacement composite score: a report of the Society of Thoracic surgeons quality measurement Task force.
These repair rates may be low because of the technical difficulty of performing anterior repair and relatively lower incidence of anterior compared with posterior leaflet disease. Prior analyses have reported techniques such as chordal transposition,
Very long-term durability of the edge-to-edge repair for isolated anterior mitral leaflet prolapse: up to 21 years of clinical and echocardiographic results.
Mitral-valve repair without annuloplasty rings: results after repair of anterior leaflet versus posterior-leaflet defects using polytetrafluoroethylene sutures for chordal replacement.
The patients in our series almost uniformly underwent chordal replacement with at least 2 polytetrafluoroethylene (Gore-Tex) neochords for anterior repair. We have found the use of neochords in conjunction with semi-rigid partial ring annuloplasty to be a durable solution for nonrheumatic anterior leaflet degenerative mitral valve disease.
Study Limitations
This study has several limitations. First, our analysis is retrospective in nature at a single center, but is one of the largest available. Additionally, mitral repairs performed within the same practice help to limit heterogeneity and confounding inevitable with retrospective studies. Second, we do not have universal long-term echocardiographic follow-up for all patients, because performing routine echocardiograms on asymptomatic patients is not indicated by the American Heart Association/American College of Cardiology guidelines. However, we do have postprocedure echocardiographic results to demonstrate the importance of avoiding residual MR and complete long-term survival data. Furthermore, patients requiring reoperation routinely return to our center, and we have extensive long-term clinical follow-up for this study population through institutional records and a shared electronic records data source within our state. Third, our study period spans parts of 3 decades, during which practice patterns evolved. Although this makes conclusions more challenging, the breadth of experience in mitral repair over this period provides an opportunity to evaluate time-related trends and report long-term outcomes across our institutional experience, and any changes or improvements over time in our practice should be equally reflected in outcomes after both anterior and posterior repair.
Conclusions
A propensity-matched analysis of this large cohort showed no long-term survival difference between posterior and anterior leaflet MVr. Furthermore, both anterior and posterior repair had an exceedingly low cumulative incidence of reoperation over multiple decades, with a linearized annual rate of less than 1% and no difference between anterior and posterior groups. As expected, older age, lower ejection fraction, black race, and cardiopulmonary bypass time were independent risk factors for mortality in the unmatched population, whereas repair type (isolated anterior, bileaflet, or isolated posterior) was not. Importantly, this may be due to the fact that a mean of less than trace MR was left for both groups after surgery, including greater than 90% of patients with no residual MR and no differences in residual MR between anterior and posterior repairs. In accordance with multiple prior analyses,
Long-term results of mitral valve surgery for degenerative anterior leaflet or bileaflet prolapse: analysis of negative factors for repair, early and late failures, and survival.
we have again demonstrated no difference in survival by repair type. These findings are summarized in Figure 4. In contrast, numerous studies have shown superior survival after all types of degenerative mitral repair compared with replacement.
Hospital volume, mitral repair rates, and mortality in mitral valve surgery in the elderly: an analysis of US hospitals treating Medicare fee-for-service patients.
Long-term results of mitral valve surgery for degenerative anterior leaflet or bileaflet prolapse: analysis of negative factors for repair, early and late failures, and survival.
Therefore, with a well-performed degenerative repair, surgeons should not fear worse outcomes after anterior repair, and all types of repair including isolated anterior, bileaflet, and isolated posterior should be aggressively pursued over replacement for degenerative mitral disease.
Authors have nothing to disclose with regard to commercial support.
The authors acknowledge members of the Section of Health Services Research and Quality for their contributions to data used for this project. Team members include Mary Barry, Lauren Conlin, Brett Cross, Amy Geltz, Mary Ryzak, David Sturmer, and Jeremy Wolverton.
Figure E1Mirrored histogram showing the propensity score distribution and overlapping in unmatched (gray) and matched (green) samples in the treatment (anterior repair, top) and the control (posterior repair, bottom) groups.
Figure E2Love plot showing changes in standardized mean differences before (solid dots) and after (X) matching. CV, Cardiovascular; CVD, cerebrovascular disease; PVD, peripheral vascular disease; BMI, body mass index; Hx, history; CAD, coronary artery disease.
Figure E3Overall survival Kaplan–Meier estimates of anterior versus posterior leaflet MVr after excluding patients undergoing concomitant CABG or aortic valve repair (resultant n = 819). A, Overall unmatched population (n = 819) of anterior (n = 261) versus posterior (n = 558) mitral repair (log-rank P = .18). B, Propensity-matched population of anterior (n = 259) versus posterior (n = 259) mitral repair (log-rank P = .80). CI, Confidence interval.
Hospital volume, mitral repair rates, and mortality in mitral valve surgery in the elderly: an analysis of US hospitals treating Medicare fee-for-service patients.
Long-term results of mitral valve surgery for degenerative anterior leaflet or bileaflet prolapse: analysis of negative factors for repair, early and late failures, and survival.
The Society of Thoracic surgeons mitral repair/replacement composite score: a report of the Society of Thoracic surgeons quality measurement Task force.
Very long-term durability of the edge-to-edge repair for isolated anterior mitral leaflet prolapse: up to 21 years of clinical and echocardiographic results.
Mitral-valve repair without annuloplasty rings: results after repair of anterior leaflet versus posterior-leaflet defects using polytetrafluoroethylene sutures for chordal replacement.
PSMATCH2: Stata module to perform full Mahalanobis and propensity score matching, common support graphing, and covariate imbalance testing. Version 4.0.12.
I support the important findings of Brescia and colleagues1 regarding the feasibility of routinely achieving successful repair of degenerative anterior mitral leaflet (AML) disease. They compared 309 patients with AML disease, and 309 with posterior leaflet (PL) disease. AMLs were repaired with polytetrafluoroethylene (PTFE) neochords (51%), chordal transposition (33%), leaflet resection (24%), and a semirigid partial ring annuloplasty. They found no significant differences in outcomes up to 15 years after surgery.
Mitral valve repair is superior to mitral valve replacement in patients with degenerative mitral valve disease. Available data comparing repair with replacement support this statement, and few would disagree.1,2 Because the majority of patients with degenerative disease have posterior leaflet prolapse, most of the data supporting the benefits of mitral valve repair are based on the results of posterior leaflet/chordal repair. In this issue of the Journal, Brescia and colleagues3 from the University of Michigan present data to support mitral valve repair in those with anterior (or bileaflet) prolapse, as well.
With the rapid advancement of transcatheter alternatives to surgical approaches, the surgical community bears the responsibility of optimizing surgical outcomes to provide a fair benchmark against which novel, less-invasive approaches can be compared. Mitral valve repair is one of such operations that has a significant margin for advancement, both via system-level strategies for volume regionalization1 and technical-level improvement to optimize the outcomes inherent to the operation itself.
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