When Should the Mitral Valve Be Repaired or Replaced in Patients With Ischemic Mitral Regurgitation?

BACKGROUND: Data comparing outcomes after repair versus replacement of chronic ischemic mitral regurgitation (MR) is evolving. Recent data suggest that repair is associated with recurrent MR, but not survival, when compared with replacement. However, it remains unclear when either surgical strategy should be applied based on preoperative mitral valve anatomy.

METHODS: Between 2001 and 2013, 161 patients underwent repair or replacement of chronic ischemic MR. The mean age of these patients was 68.2 ± 9.0 years, 44 (27%) were female, and concomitant coronary artery bypass grafting was performed in 126 (78%). The mean preoperative posterior leaflet angle was 27.7 ± 14.2 degrees, and the left ventricular ejection fraction was 41.2 ± 12.4%. Detailed preoperative assessments of mitral valve anatomy were determined by transesophageal echocardiography. Clinical and echocardiographic follow-up was for 4.6 ± 3.2 years and extended to 11.7 years.

RESULTS: Overall, perioperative death occurred in 6 (3.3%) patients; 2 patients died after valve repair and 4 after valve replacement. Five-year survival and freedom from recurrent MR (≥2+) rates were 74.0 ± 5.6% and 57.8 ± 8.0%, respectively, after valve repair and 69.4 ± 6.2% and 87.1 ± 7.0%, respectively, after valve replacement. Valve repair was associated with recurrent MR (≥2+) (hazard ratio [HR], 5.3 ± 3.3; p = 0.007), but not survival (HR, 0.9 ± 0.3; p = 0.8). Preoperative posterior leaflet tethering angle was associated with survival (HR, 1.09 ± 0.04; p = 0.005) and also recurrent MR (≥2+) (HR, 1.04 ± 0.02; p = 0.03) after valve repair. Based on a receiver operator curve describing the relationship between recurrent MR (≥2+) and posterior leaflet tethering angle, a threshold of 22 degrees was determined.

CONCLUSIONS: Surgical correction of chronic ischemic MR can be performed with favorable early and late results, although recurrent MR occurred more often after repair. Among patients who underwent repair of ischemic MR, a preoperative posterior leaflet tethering angle of 22 degrees or greater was associated with worse late outcomes.