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J Thorac Cardiovasc Surg 2000;119:53-061
© 2000 Mosby, Inc.

SURGERY FOR ACQUIRED CARDIOVASCULAR DISEASE

MITRAL VALVE REPAIR AND REPLACEMENT FOR RHEUMATIC DISEASE

From the Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.

Address for reprints: Terrence M. Yau, MD, MSc, 13EN-239, Toronto General Hospital, 200 Elizabeth St, Toronto, Ontario M5G 2C4, Canada (E-mail: terry.yau{at}utoronto.ca).

Objectives: Mitral valve repair may be technically feasible in patients with suitable anatomy, but the appropriateness of repair for rheumatic disease remains controversial. We evaluated our late outcomes after mitral repair and replacement for rheumatic disease.
Methods: Five hundred seventy-three patients underwent mitral valve surgery for rheumatic disease at our institution from 1978-1995. Follow-up was 98% complete (mean, 68 ± 46 months). Survival and morbidity were evaluated by Kaplan-Meier analysis and Cox regression, including propensity score analysis.
Results: Mean age was 54 ± 14 years, 55% of patients had congestive heart failure, 22% were undergoing redo mitral valve surgery, and 9% also underwent coronary bypass. Mitral stenosis was present in 53%, regurgitation in 15%, and both in 32%. Valve repair was performed in 25%, bioprosthetic replacement was performed in 28%, and a mechanical valve was placed in 47%. Patients undergoing repair were younger and less likely to be undergoing reoperation or to have atrial fibrillation than those undergoing replacement (P = .001). The operative mortality rate was 4.2%. Better late cardiac survival was independently predicted by valve repair rather than replacement (P = .04) after adjustment for baseline differences between patients. Freedom from reoperation was greatest (P = .005) but that from thromboembolic complications was worst (P < .0001) after mechanical valve replacement. Twenty-three patients underwent reoperation after initial repair, with no operative deaths.
Conclusions: Mechanical valves minimize reoperation but limit survival and increase thromboembolic complications. Patients undergoing valve repair had improved late cardiac survival independent of their preoperative characteristics. Rheumatic mitral valves should be repaired when technically feasible, accepting a risk of reoperation, to maximize survival and reduce morbidity.

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