Mitral Valve Reconstruction
annuloplasty, for stabilization of the repair and annular remodeling.
Deloche and Carpentier reported similar results in patients followed for up to 20 years, demonstrating a 15-year freedom from thromboembolism of 94%, a 15-year freedom from reoperation of 93% in patients with degenerative disease, and 76% in patients with rheumatic disease.(1,2)
Yun and Miller reviewed more than 10 large series comparing mitral valve repair with replacement, concluding from cumulative data that patients having valve repair had a better freedom from late valve-related morbidity than patients having valve replacement.(10) Similarly, in a large comparative trial of NYU patients having mitral valve repair and replacement reported by Grossi et al, late results demonstrated improved survival in 224 patients with degenerative disease who underwent mitral valve repair, compared with similar patients who had valve replacement.(6) Also, patients having valve repair had a better late freedom from thromoboemboli, endocarditis and anticoagulant related complications than patients having valve replacement. Thus, it is becoming increasingly clear that both survival and late freedom from valve-related morbidity may be better after valve repair than after valve replacement.
In summary, over the last 20 years, surgeons have learned that mitral valve reconstruction for patients with mitral valve insufficiency is extremely durable and is associated with less valve-related complications than valve replacement surgery. Survival may also be increased in certain subgroups of patients. This experience has influenced the decision-making analysis for patient selection and patients are now frequently referred for surgery early based on echocardiographic findings of progressive left ventricular volume overload or early left ventricular systolic dysfunction. In most cases, surgery is now recommended prior to the development of clinical symptoms. These findings have changed the standards of care and have improved outcomes and enhanced quality of life.
| Nearly two decades of clinical experience with mitral valve reconstruction reported from multiple centers suggest that repair offers substantial advantages over replacement.(1,2,6,8,9) The data uniformly suggest that patients undergoing valve repair not only showed a lower risk of valve-related complications, but possibly had improved survival compared to patients undergoing replacement surgery. In the NYU experience, summarized by Spencer, data have been accumulated since 1979 from more than 1,000 patients followed prospectively after undergoing mitral valve reconstruction. In this series, the operative risk was 2.5% for isolated valve repair, and the 10-year freedom from thromboembolism and anticoagulant-related complications was 90% and 96%, respectively. Thus, in patients operated on by experienced valve repair surgeons, both the durability of valve repair and the freedom from valve-related complications have been excellent. Prospective follow-up approaching 100% in this series provides valuable information about the durability of repair and demonstrates a 10-year freedom from reoperation for 88% of patients with any non-rheumatic etiology. We also speculate that the excellent durability of valve repair is in part due to the near-routine use of ring |
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Deloche and Carpentier reported similar results in patients followed for up to 20 years, demonstrating a 15-year freedom from thromboembolism of 94%, a 15-year freedom from reoperation of 93% in patients with degenerative disease, and 76% in patients with rheumatic disease.(1,2)
Yun and Miller reviewed more than 10 large series comparing mitral valve repair with replacement, concluding from cumulative data that patients having valve repair had a better freedom from late valve-related morbidity than patients having valve replacement.(10) Similarly, in a large comparative trial of NYU patients having mitral valve repair and replacement reported by Grossi et al, late results demonstrated improved survival in 224 patients with degenerative disease who underwent mitral valve repair, compared with similar patients who had valve replacement.(6) Also, patients having valve repair had a better late freedom from thromoboemboli, endocarditis and anticoagulant related complications than patients having valve replacement. Thus, it is becoming increasingly clear that both survival and late freedom from valve-related morbidity may be better after valve repair than after valve replacement.
In summary, over the last 20 years, surgeons have learned that mitral valve reconstruction for patients with mitral valve insufficiency is extremely durable and is associated with less valve-related complications than valve replacement surgery. Survival may also be increased in certain subgroups of patients. This experience has influenced the decision-making analysis for patient selection and patients are now frequently referred for surgery early based on echocardiographic findings of progressive left ventricular volume overload or early left ventricular systolic dysfunction. In most cases, surgery is now recommended prior to the development of clinical symptoms. These findings have changed the standards of care and have improved outcomes and enhanced quality of life.