Valve repair versus valve replacement
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.
Overview
Mitral valve surgery is indicated when the mitral regurgitation is severe or when the patient is symptomatic. Valve repair or replacement are the two types of surgeries available to treat these conditions. Decision between valve repair or valve replacement is made based on the type and severity of damage to mitral valve.
Indications
Mitral valve repair is recommended in following:
- Limited damage to certain areas of the mitral valve leaflets or chordae tendineae[1]
- Limited calcification of the leaflets or annulus
- Prolapse of less than one-third of either leaflet
- Pure annular dilatation
- Valvular perforations
- Incomplete papillary muscle rupture
Mitral valve replacement is recommended in following:
- Extensive calcification or degeneration of a leaflet or annulus
- Prolapse of more than one-third of the leaflet tissue
- Extensive chordal fusion, calcification, or papillary muscle rupture
- Extensive damage of mitral valve secondary to endocarditis
Clinical trial data
- Multiple studies have shown that there are better outcomes in terms of left ventricular function and survival with mitral valve repair compared to valve replacement.[2][3][4][5]
- In a 6 year follow-up study[6] of 45 patients with isolated non-ischemic mitral regurgitation and EF ≤50%, who underwent either valve repair(27 patients) or replacement(18 patients) following results were observed:
- 5 patients and 6 patients died in repair group and replacement group respectively.
- 2 patients underwent valve replacement due to failure of valve repair while 1 patient in valve replacement group underwent re-operation due to prosthetic valve endocarditis.
- Incidence of atrial fibrillation was similar between both groups.
- Left ventricular end diastolic dimension(LVEDD), velocity time integral and ejection fraction(EF) improved with valve repair while LVEDD and EF worsened in valve replacement patients.
- In another study, lower operative mortality (2.6% vs 10.3%), greater increase in left ventricular EF and higher 10 years survival rate (68% vs 52%) were observed among patients who underwent valve repair compared to valve replacement.[7]
- A survival benefit with valve repair may not be seen in high risk patients with ischemic MR.[8][9]
- Long term rates of re-operation appear to be similar in both valve repair and replacement.[10] However, among patients who underwent mitral valve surgeries between 1984 and 1997, 10 year rates of re-operation was shown to be lower with valve repair.[11]
Advantages of Mitral valve repair
- Improves left ventricular EF and function.
- Preserves native heart valve.
- Avoids long term use of anticoagulants.
- Lower risk for endocarditis.
- Has good overall outcome with good survival rates.
ACC/AHA Guidelines
Based on the above, ACC/AHA 2008 guidelines[12] recommend mitral valve repair rather than mitral valve replacement if the anatomy is appropriate, including patients with rheumatic mitral valve disease[4] and mitral valve prolapse[13] (Grade 1C). The procedure should be performed at experienced surgical centers.
References
- ↑ Gillinov AM, Faber C, Houghtaling PL, Blackstone EH, Lam BK, Diaz R; et al. (2003). "Repair versus replacement for degenerative mitral valve disease with coexisting ischemic heart disease". J Thorac Cardiovasc Surg. 125 (6): 1350–62. PMID 12830055.
- ↑ Krayenbuehl HP (1986). "Surgery for mitral regurgitation. Repair versus valve replacement". Eur Heart J. 7 (8): 638–43. PMID 3769948.
- ↑ Enriquez-Sarano M, Schaff HV, Orszulak TA, Tajik AJ, Bailey KR, Frye RL (1995). "Valve repair improves the outcome of surgery for mitral regurgitation. A multivariate analysis". Circulation. 91 (4): 1022–8. PMID 7850937.
- ↑ 4.0 4.1 Yau TM, El-Ghoneimi YA, Armstrong S, Ivanov J, David TE (2000). "Mitral valve repair and replacement for rheumatic disease". J Thorac Cardiovasc Surg. 119 (1): 53–60. PMID 10612761.
- ↑ Tribouilloy CM, Enriquez-Sarano M, Schaff HV, Orszulak TA, Bailey KR, Tajik AJ; et al. (1999). "Impact of preoperative symptoms on survival after surgical correction of organic mitral regurgitation: rationale for optimizing surgical indications". Circulation. 99 (3): 400–5. PMID 9918527.
- ↑ Kouris N, Ikonomidis I, Kontogianni D, Smith P, Nihoyannopoulos P (2005). "Mitral valve repair versus replacement for isolated non-ischemic mitral regurgitation in patients with preoperative left ventricular dysfunction. A long-term follow-up echocardiography study". Eur J Echocardiogr. 6 (6): 435–42. doi:10.1016/j.euje.2005.01.003. PMID 16293530.
- ↑ Ling LH, Enriquez-Sarano M, Seward JB, Orszulak TA, Schaff HV, Bailey KR; et al. (1997). "Early surgery in patients with mitral regurgitation due to flail leaflets: a long-term outcome study". Circulation. 96 (6): 1819–25. PMID 9323067.
- ↑ Gillinov AM, Wierup PN, Blackstone EH, Bishay ES, Cosgrove DM, White J; et al. (2001). "Is repair preferable to replacement for ischemic mitral regurgitation?". J Thorac Cardiovasc Surg. 122 (6): 1125–41. doi:10.1067/mtc.2001.116557. PMID 11726887.
- ↑ Grossi EA, Goldberg JD, LaPietra A, Ye X, Zakow P, Sussman M; et al. (2001). "Ischemic mitral valve reconstruction and replacement: comparison of long-term survival and complications". J Thorac Cardiovasc Surg. 122 (6): 1107–24. doi:10.1067/mtc.2001.116945. PMID 11726886.
- ↑ Suri RM, Schaff HV, Dearani JA, Sundt TM, Daly RC, Mullany CJ; et al. (2006). "Survival advantage and improved durability of mitral repair for leaflet prolapse subsets in the current era". Ann Thorac Surg. 82 (3): 819–26. doi:10.1016/j.athoracsur.2006.03.091. PMID 16928491.
- ↑ Thourani VH, Weintraub WS, Guyton RA, Jones EL, Williams WH, Elkabbani S; et al. (2003). "Outcomes and long-term survival for patients undergoing mitral valve repair versus replacement: effect of age and concomitant coronary artery bypass grafting". Circulation. 108 (3): 298–304. doi:10.1161/01.CIR.0000079169.15862.13. PMID 12835220.
- ↑ Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD; et al. (2008). "2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". J Am Coll Cardiol. 52 (13): e1–142. doi:10.1016/j.jacc.2008.05.007. PMID 18848134.
- ↑ Mohty D, Orszulak TA, Schaff HV, Avierinos JF, Tajik JA, Enriquez-Sarano M (2001). "Very long-term survival and durability of mitral valve repair for mitral valve prolapse". Circulation. 104 (12 Suppl 1): I1–I7. PMID 11568020.