Mitral valve repair versus replacement for moderate-to-severe mitral regurgitation in patients undergoing concomitant aortic valve replacement

Effect of concurrent mitral valve surgery for secondary mitral regurgitation upon mortality after aortic valve replacement or coronary artery bypass surgery

Objectives

It is uncertain whether concurrent mitral valve repair or replacement for moderate or greater secondary mitral regurgitation at the time of coronary artery bypass graft or aortic valve replacement surgery improves long-term survival.

Methods

Patients undergoing coronary artery bypass graft and/or aortic valve replacement surgery with moderate or greater secondary mitral regurgitation were reviewed. The effect of concurrent mitral valve repair or replacement upon long-term mortality was assessed while accounting for patient and operative characteristics and mitral regurgitation severity.

Results

Of 1,515 patients, 938 underwent coronary artery bypass graft or aortic valve replacement surgery alone and 577 underwent concurrent mitral valve repair or replacement. Concurrent mitral valve repair or replacement did not alter the risk of postoperative mortality for patients with moderate mitral regurgitation (hazard ratio = 0.93; 0.75-1.17) or more-than-moderate mitral regurgitation (hazard ratio = 1.09; 0.74-1.60) in multivariable regression. Patients with more-than-moderate mitral regurgitation undergoing coronary artery bypass graft-only surgery had a survival advantage from concurrent mitral valve repair or replacement in the first two postoperative years (P = 0.028) that did not persist beyond that time. Patients who underwent concurrent mitral valve repair or replacement had a higher rate of later mitral valve operation or reoperation over the five subsequent years (1.9% vs. 0.2%; P = 0.0014) than those who did not.

Conclusions

These observations suggest that mitral valve repair or replacement for more-than-moderate mitral regurgitation at the time of coronary artery bypass grafting may be reasonable in a suitably selected coronary artery bypass graft population but not for aortic valve replacement, with or without coronary artery bypass grafting. Our findings are supportive of 2021 European guidelines that severe secondary mitral regurgitation "should" or be "reasonabl[y]" intervened upon at the time of coronary artery bypass grafting but do not support 2020 American guidelines for performing mitral valve repair or replacement concurrent with aortic valve replacement, with or without coronary artery bypass grafting.

Treatment of Moderate Functional Mitral Regurgitation during Aortic Valve Replacement: A Cohort Study

Background

Treatment of moderate functional mitral regurgitation (FMR) during aortic valve replacement (AVR) is controversial. This study aimed to evaluate the effect of different surgical strategies in patients with moderate FMR undergoing AVR.

Methods

A total of 468 patients with moderate FMR undergoing AVR from January 2010 to December 2019 were retrospectively studied comparing 3 different surgical strategies, namely isolated AVR, AVR + mitral valve repair (MVr) and AVR + mitral valve replacement (MVR). Survival was estimated using the Kaplan-Meier method and compared with the log-rank test, followed by inverse probability treatment weighting (IPTW) analysis to adjust the between-group imbalances. The primary outcome was overall mortality.

Results

Patients underwent isolated AVR (35.3%), AVR + MVr (30.3%), or AVR + MVR (34.4%). The median follow-up was 27.1 months. AVR + MVR was associated with better improvement of FMR during the early and follow-up period compared to isolated AVR and AVR + MVr (p < 0.001). Compared to isolated AVR, AVR + MVR increased the risk of mid-term mortality (hazard ratio [HR]: 2.13, 95% confidence interval [CI]: 1.01-4.48, p = 0.046), which was sustained in the IPTW analysis (HR: 4.15, 95% CI: 1.69-10.15, p = 0.002). In contrast, AVR + MVr showed only a tendency to increase the risk of follow-up mortality (HR: 1.63, 95% CI: 0.72-3.67, p = 0.239), which was more apparent in the IPTW analysis (HR: 2.54, 95% CI: 0.98-6.56, p = 0.054).

Conclusions

In patients with severe aortic valve disease and moderate FMR, isolated AVR might be more reasonable than AVR + MVr or AVR + MVR.

Valve-in-valve transcatheter aortic valve replacement versus redo aortic valve replacement: which procedure for which patient?

INTRODUCTION

Bioprosthetic aortic valves are increasingly being utilized in a younger population due to improved durability and possibility for future valve-in-valve replacement. This has resulted in a larger population of patients with bioprosthetic aortic valve degeneration requiring re-intervention. Despite no head-to-head comparisons between redo surgical aortic valve replacement (SAVR) and valve-in-valve transcatheter aortic valve replacement (ViV TAVR), observational studies suggest a comparable long-term risk between which led to the incorporation of ViV TAVR to current guidelines.

AREAS COVERED

This article summarizes the comparative performance of redo SAVR versus ViV TAVR in patients with bioprosthetic valve dysfunction and provides a guide to better understand which procedure is best for which patient.

EXPERT OPINION

With the rising use of TAVR, we will be confronted with more bioprosthetic aortic valve degeneration requiring re-intervention. Based on the available evidence and expert consensus, we propose that patients with bioprosthetic aortic valve degeneration be treated with ViV TAVR if they have a history of radiation heart disease, prohibitive surgical risk, and multiple sternotomies; while patients with small prostheses, history of infective endocarditis, those at high risk for coronary obstruction, and those with need for other cardiac surgery will be managed with redo SAVR.

Fate of moderate secondary mitral regurgitation in patients undergoing aortic valve replacement for severe aortic regurgitation

OBJECTIVES

Moderate secondary mitral regurgitation is common in patients with severe aortic regurgitation, but whether it has to be addressed at the time of aortic valve surgery remains unclear. With this study, we evaluated the long-term fate of moderate secondary mitral regurgitation in this specific scenario.

METHODS

Between January 2004 and January 2018, in 154 patients admitted to our institution for treatment of severe aortic regurgitation, a moderate secondary mitral regurgitation was diagnosed. Ninety-four patients underwent isolated aortic valve replacement (group 1) and 60 patients underwent also concomitant mitral valve annuloplasty (group 2).

RESULTS

One death (1.1%) occurred in group 1, whereas two deaths (3.3%) occurred in group 2 (p = .561). At 11 years, the cumulative incidence function of cardiac death, with noncardiac death as a competing risk was 11.5 ± 5.11% in group 1 and 8.3 ± 5.15% in group 2 (p = .731). The cumulative incidence function of mitral valve reintervention, with death as a competing risk, was 3.7 ± 2.61% in group 1 and 4.5 ± 4.35% in group 2 (p = .620) at 11 years. Secondary mitral regurgitation improved to ≤mild in 66% and 76% of the survivors of group 1 and group 2, respectively (p = .67).

CONCLUSIONS

In our experience, in patients with moderate secondary mitral regurgitation undergoing aortic valve replacement for severe aortic regurgitation, concomitant mitral valve annuloplasty did not improve the long-term survival, the incidence of cardiac death and mitral valve reoperation or the evolution of the mitral valve disease.

Mitral Regurgitation in Patients With Coexisting Chronic Aortic Regurgitation: An Evidence-Based Narrative Review

Chronic aortic regurgitation (AR) frequently leads to significant downstream changes to the left ventricle and pulmonary vasculature; these structural and physiologic changes result in lower- than expected patient survival. Progressive, uncorrected AR can lead to left ventricle dilation and subsequent mitral valve leaflet tethering, as well as mitral annular dilation, resulting in secondary mitral regurgitation (MR) in up to 45% of patients. Surgical aortic valve replacement (AVR) improves secondary MR in most patients, but survival is significantly lower in those patients who do not show improvement in MR after AVR. Thus, there is considerable debate on whether the mitral valve should be intervened upon at the time of the AVR. In this review, the authors address the long-term outlook for patients with chronic AR and concurrent MR. The authors also review the available evidence on concomitant mitral valve surgery in patients undergoing AVR for AR. Lastly, this narrative review examines the recent advances in transcatheter mitral valve repair and replacement, and explores the potential role of transcatheter mitral therapies in patients with secondary MR due to AR.

Survival and long-term outcomes after concomitant mitral and aortic valve replacement in patients with rheumatic heart disease

Introduction

Double valve replacement (DVR) with a mechanical prosthesis is associated with a higher risk of mortality. We planned to study the survival rate, early and late mortality and major adverse cardiac and cerebrovascular events (MACCE) in patients undergoing DVR for rheumatic heart disease, with various generations of prosthetic valves ranging from ball in cage to bileaflet prosthesis and tilting disc valves.

Materials and methodology

We followed up 277 patients with rheumatic heart disease who underwent DVR between August 1999 and November 2009, retrospectively, at Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram. Two hundred and fifty-nine patients were followed up for a minimum period of 10 years, and the follow-up period varied between 10 and 20 years. Eighteen patients were lost to follow-up after the surgery and could not be contacted. Their data was included till the time they appeared for follow-up last, for survival analysis. Survival analysis was carried out using the life table method to calculate the freedom from reoperation, survival rates and freedom from MACCE at 1 year, 5 years and 10 years post-DVR.

Results

The median duration of hospital stay was 8 days. The number of patients with stroke was 11 (4.26%), 21 (8.7%) and 29 (12%) at the end of 1 year, 5 years, and 10 years, respectively. A total of 5 (2%) patients underwent reoperation by the end of 10 years. Seven patients died either in hospital or in the first 30 days following operation, making the early mortality 2.5%. At the end of 1 year, a total of 16 patients (5.8%) died. The mortality at the end of 5 years was 6.8% (19 patients), and at the end of 10 years, it was 7.2% (20 patients). The survival rate of the study population was 94.9%, 93.02% and 93.02% at the completion of 1 year, 5 years and 10 years, respectively. The freedom from MACCE was 93.8%, 88.6% and 85% at 1 year, 5 years and 10 years, respectively. The freedom from re-operation was 98% at 10 years. Kaplan-Meier analysis showed an overall survival time of 226.3 months in the entire study population. The mean survival time in males was 227.5 months and in females was 206.3 months, with no statistically significant difference between the two. Univariate logistic regression analysis revealed an association with mortality when DVR was combined with concomitant tricuspid valve repair procedures, with an odds ratio of 4.5 (p value 0.005). Multivariate logistic regression analysis also showed an association with mortality when tricuspid valve procedures were combined with DVR with an odds ratio of 5.25 (p value 0.003).

Conclusion

The operative mortality and morbidity for DVR have been significantly reduced with advancements in operative techniques, myocardial preservation and postoperative care. Patients can have an improved functional status following surgery, with good rates of freedom from re-operation and MACCE.

Transaortic repair of concomitant mitral insufficiency in patients with critical aortic stenosis undergoing aortic valvular replacement

Background

In this study, we present operation technique and outcomes of transaortic mitral valve repair in high-risk patients undergoing aortic valve replacement due to severe aortic stenosis.

Methods

Between January 2005 and March 2016, a total of 11 patients (7 females, 4 males; mean age 71.2±4.1 years; range, 65 to 77 years) with severe aortic valve stenosis (aortic valve area <1 cm2 or aortic valve area index <0.6 cm2/m2) and concomitant moderate or severe mitral regurgitation (non-ischemic, regurgitant jet origin between A2-P2 portions) secondary to left ventricular dysfunction (EuroSCORE logistic score >5%, left ventricular ejection fraction <30%) who were operated were retrospectively analyzed. Aortic valve replacement and transaortic mitral edge-to-edge repair was applied to all patients. Operations were performed through sternotomy, cardiopulmonary bypass, and bicaval venous return. Transesophageal echocardiography was used to evaluate mitral valve before surgery and valve functions after surgery. Postoperative course of all patients was monitored, and postoperative complications were recorded.

Results

The mean preoperative ejection fraction was 24.5±4.1% and the mean transaortic pressure gradient was 35.8±4.8 mmHg. The mean aortic cross-clamp time was 62.09±10.1 (range, 43 to 76) min and the median cardiopulmonary bypass time was 90.1±11.9 (range, 66 to 114) min. No hospital mortality was observed. In the postoperative period, two patients experienced renal insufficiency. Hemofiltration was initiated in these patients and no dialysis was required at two weeks. One patient had postoperative atrial fibrillation and one patient had pericardial effusion leading to cardiac tamponade and this patient underwent reoperation. The patients were followed up for a mean of four years and control echocardiography didn"t detect increase in mitral regurgitation degree.

Conclusion

Transaortic edge-to-edge mitral valve repair can be used in high-risk patients undergoing aortic valve replacement. This technique is feasible with shorter cross-clamp time and can reduce mortality and morbidity in selected high-risk patients.

Outcomes of mitral valve surgery during concomitant aortic valve replacement

BACKGROUND

This study evaluates outcomes of mitral valve surgery (MVS), replacement (MVR), and repair (MVr), during concomitant aortic valve replacement (AVR).

METHODS

Patients undergoing MVS with concomitant AVR between 2011 and 2017 at a single center were reviewed. Patients were stratified into MVR versus MVr with concomitant AVR. Outcomes included early and midterm mortality, hospital re-admissions, re-operations, and complications. Multivariable Cox regression analysis was used for risk-adjustment.

RESULTS

Four hundred twenty-four patients underwent MVS with concomitant AVR: 247 (58.3%) MVr and 177 (41.7%) MVR. In unadjusted analysis, there was a non-significant increase in 30-day mortality with MVR, with no differences in 1- and 5-year mortality (30-day: 5.6% vs 10.1%, P = 0.081; 1-year: 14% vs 18.2%, P = 0.181; 5-year: 35.1% vs 37.8%, P = 0.232). Freedom from re-admission and mitral reoperation were comparable. Freedom from at least moderate mitral regurgitation at 5 years was 78% in MVr patients. Those undergoing MVR had increased postoperative blood transfusions, acute renal failure, and pleural effusions requiring drainage (P each <0.05).

CONCLUSIONS

MVr can be performed during concomitant AVR without an adverse impact on longer-term outcomes, including mortality, re-admissions, and mitral reoperations. The majority of patients have durable repairs at 5 years although durability is less than that reported in isolated MVS.

Aortic and mitral valve repair for anterior mitral leaflet perforation caused by severe aortic regurgitation

A 23-year-old man presented with acute onset of dyspnea on exert. Preoperative echocardiography showed a severe regurgitation of the bicuspid aortic valve (due to prolapse of the fused cusp) creating a jet directed through the defect in the anterior leaflet of the mitral valve. Both valves were repaired. Endocarditis was excluded with cultures and polymerase chain reaction (PCR). Postoperative course was uneventful.

Surgery for mitral regurgitation in patients with aortic root aneurysm: Transaortic or transseptal approach?

OBJECTIVE

Mitral regurgitation is common in patients with aortic root aneurysm. Mitral valve repair (MVP) or replacement (MVR) can be performed for these patients through either a transverse aortotomy (TA) or transseptal approach (TS). This study sought to compare the early outcomes of mitral valve surgery through the TA and TS approaches and decide which is optimal for this subset of patients.

METHODS

Between March 2013 and April 2015, we operated on 99 patients (81 males, 81.8%) with aortic root aneurysm who developed mitral regurgitation. Mean age was 47.8±16.5years. MVR was performed in 66 patients (TAR=27; TSR=39) and MVP in 33 (TAP=8; TSP=25). The baseline and operative outcomes data were compared between patients with MVR and MVP through the TA vs TS approaches.

RESULTS

Preoperatively, the mitral regurgitation area was significantly larger in the MVR than MVP groups (8.9±2.0 vs 7.8±3.8 cm², p=0.0009), and in the TSP vs TAP groups (8.5±4.1 vs 5.6±1.3cm², p=0.0049), but no significant difference was found between the TAR and TSR groups (8.7±2.2 vs 9.0±1.8cm², p=0.4681); the aortic sinus size was significantly larger in the TAR than TSR group (66.7±15.8 vs 52.1±8.8mm, p=0.0061). Subvalvular structure was preserved in 12 MVR patients (18.2%). In MVP patients, Kay annuloplasty was used in 11 (33.3%) and annuloplastic ring in 22 (66.7%). The times of cardiopulmonary bypass (CPB) and cross-clamp in patients with TA approach were significantly shorter compared to those with the TS approach (139±34 vs 176±38min, p=0.0001; 101±26 vs 129±31min, p=0.0002). No cases of mortality, stroke and renal failure occurred in the whole series. The amount of transfusion, lengths of ICU and hospital stay did not differ between patients with MVR and MVP, and between the TA and TS approaches.

CONCLUSIONS

Both the TA and TS approaches achieved good early outcomes in MV surgery for patients with root aneurysm. The transverse aortotomy was associated with shorter CPB and cross-clamp times. Surgical approaches should be selected according to the underlying mitral valve etiology and the size of the aortic root.

Outcomes of patients undergoing concomitant mitral and aortic valve surgery: results from an Italian regional cardiac surgery registry

OBJECTIVES

There are limited reliable data on the long-term survival of patients operated upon with double-valve surgery (DVS) in the literature. In this study, in-hospital mortality and 5-year survival were determined and the potential risk factors for increased mortality were identified and discussed.

METHODS

This is a report of an observational retrospective study of 1167 patients undergoing concomitant aortic and mitral valve surgery from 2002 to 2011. Data were prospectively collected in a regional database from Emilia-Romagna (Italy).

RESULTS

The overall in-hospital mortality rate for DVS was 6.9%. Both in-hospital and 1-year mortality were statistically significant between age groups. In-hospital mortality was significantly higher for patients with a smaller body mass index (BMI), for those who had concomitant coronary artery bypass grafting (CABG) and those who received mitral valve replacement (MVR) instead of plasty (MVP). In-hospital and 1-year mortality were highest in patients ≥70 who had implantation of mitral and aortic mechanical valves. There were significant differences in 5-year follow-up survival according to age, BMI and concomitant CABG. The choice of MVR and MVP did not affect 5-year survival. Multivariable analysis showed that patient-related factors appear to be the major determinant of late survival, irrespective of the type of operation or other intraoperative variables.

CONCLUSIONS

Advanced age, smaller BMI and concomitant CABG are significant risk factors for mortality in DVS. MVP provided comparable 5-year outcomes with MVR. Multivariable analysis demonstrates that preoperative and clinical patient-related factors are the real burden in the successful treatment of patients undergoing double-valve procedures.