WASHINGTON — Mitral-valve replacement can work as well as repair in a very select group—older patients with a more complex valvular pathology—based on a review of 195 matched patients.
“We still believe that mitral-valve repair is the procedure of choice, in younger patients with posterior prolapse,” Dr. A. Marc Gillinov said at the annual meeting of the American Association for Thoracic Surgery. And “if a valve is repairable we repair it,” regardless of the patient's age, the degree of valve calcification, or the type of prolapse, said Dr. Gillinov, a cardiac surgeon and surgical director of the center for atrial fibrillation at the Cleveland Clinic. But “a good replacement is better than a bad repair,” he said.
The message from these results is that “mitral-valve repair remains the treatment of choice for about 90% of patients with defective valves. But for the approximately 10% of patients whose valve disease is complicated and who have comorbidities, mitral-valve replacement doesn't appear to compromise survival,” said Dr. Bruce W. Lytle, chairman of thoracic and cardiovascular surgery at the Cleveland Clinic.
The study began by reviewing 3,051 patients who underwent mitral valve repair and 235 who had valve replacement for isolated, degenerative mitral disease at the Cleveland Clinic from January 1985 to January 2005. The review showed that replacement surgery tended to be used on patients who were older and had left ventricular dysfunction, valve calcification, and an anterior or bileaflet prolapse. Fifteen-year survival rates were about 70% for patients who had repair compared with about 35% in patients with replaced valves.
To assess survival rates in comparable patients, Dr. Gillinov and his associates used propensity matching to identify 195 of the patients who underwent valve repair whose clinical, demographic, and valve characteristics at the time of repair closely matched a paired patient from the replacement group. The 15-year survival rate in these 195 matched pairs of patients was very similar in each of the treatment groups, about 40%, Dr. Gillinov said.