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Severe Functional Ischemic Mitral Regurgitation: Repair or Replace the Valve?

Summary and Comment |
November 18, 2013

Severe Functional Ischemic Mitral Regurgitation: Repair or Replace the Valve?

  1. Howard C. Herrmann, MD

Outcomes of both procedures were similar at 1 year.

  1. Howard C. Herrmann, MD

Functional mitral regurgitation (MR), usually resulting from ischemic heart disease, is associated with increased mortality, either from the MR itself or from the underlying cardiac disease. Most patients with severe symptoms undergo valve surgery, but whether repair is better than replacement is unclear. In this multicenter, randomized trial, investigators assigned 251 patients with severe ischemic MR (effective orifice area >0.4 cm2; average ejection fraction, about 40%) to either valve replacement with complete preservation of the chords and subvalvular apparatus or repair with a downsized annuloplasty ring. In both groups, three quarters of the patients underwent concomitant coronary artery bypass grafting.

At 12 months, the primary endpoint, left ventricular end-systolic volume index (LVESVI), was 55 mL/m2 in the repair group and 61 mL/m2 in the replacement group, a nonsignificant difference. Mortality did not differ significantly between the replacement and repair groups at 30 days (4.0% and 1.6%) or at 1 year (18% and 14%). The rate of recurrent moderate or severe MR at 1 year was 33% in repair patients versus 2% in replacement patients; in the repair group, recurrence was associated with increased LVESVI. Mean postoperative hospital stay was 12 days in both groups, and between-group differences in subsequent rates of heart failure, arrhythmias, infection, respiratory failure, and readmission were nonsignificant. Improvements in quality of life and functional status were similar in both groups.

Comment

Mitral valve repair has proven advantages over replacement in degenerative disease, but this is the first randomized comparison of repair and replacement — importantly, with full chordal preservation — in functional MR. Outcomes were similar in both groups, which conflicts with results of observational studies suggesting higher mortality with replacement; in those studies, however, the sickest patients tended to undergo replacement, and the findings may be attributable to either the lack of full subvalvular preservation or the difficulty in fully adjusting for differences between the groups. Two-year follow-up will enable comparison of the late effects of residual MR after repair with possible longer-term adverse effects of prosthetic valves.

  • Disclosures for Howard C. Herrmann, MD at time of publication Consultant / Advisory board Gerson Lehrman Group; Siemens; St. Jude Medical Speaker's bureau American College of Cardiology Foundation; Cardiovascular Institute; Cardiovascular Research Foundation; Christiana Medical Center; Coastal Cardiovascular Society; Crozer-Chester Hospital; Mayo Clinic; New York Cardiology Society Equity Micro-Interventional Devices, Inc. Grant / research support Abbott Vascular; Edwards Lifesciences; Gore; Medtronic; St. Jude Medical Editorial boards Catheterization and Cardiovascular Interventions; Circulation-Cardiovascular Interventions; Journal of Interventional Cardiology; Journal of Invasive Cardiology

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