Contemporary Outcomes of mitral valve repair for degenerative disease in the era of increased penetrance of percutaneous mitral valve technology
Brittany G. Abt1, *Michael E. Bowdish1, Ramsey S. Elsayed1, *Robbin G. Cohen1, Alexander Vorperian2, Michael Brown2, *Vaughn A. Starnes1
1Department of Surgery, Division of Cardiac Surgery, University of Southern California, Los Angeles, California, United States, 2Keck School of Medicine, Los Angeles, California, United States
Objective: Increasing application of percutaneous mitral valve (MV) technology makes it important to understand surgical outcomes of MV repair, particularly in older populations.
Methods: We retrospectively reviewed 452 consecutive patients undergoing MV repair for degenerative disease between 2010 and 2021. Survival, need for MV reoperation, and mitral regurgitation (MR) progression were compared using time-based methods between those < 60 years old (n=200, Cohort 1) and those ≥ 60 years of age (n=252, Cohort 2).
Results: Median age in years (IQR) was 52 (47-57) in Cohort 1 and 67 (63-73) in Cohort 2 (p<0.0001). Preoperative comorbidities and MV leaflet pathology were similar between groups. A right mini-thoracotomy approach was more common in the younger cohort (n=144, 72% vs n=157, 62%, p=0.03), while the older cohort required more concomitant cardiac procedures (n=20, 10% vs n=44, 17.5%, p=0.02). Among those undergoing an isolated MV repair, STS predicted risk of 30-day mortality was low (<1.0%). Median follow up was 3.6 years (IQR 1.3-6.8) and did not differ between cohorts (p=0.38). Kaplan-Meier survival at 1, 3, and 5 years was 100, 99.3, and 99.3% in Cohort 1 and 98.3, 97.2, and 94.6% in Cohort 2 (log-rank p=0.02, Figure 1A). After adjustment for sex, prior sternotomy, diabetes, atrial fibrillation, and location of leaflet repair (anterior, posterior, or bileaflet), age ≥60 years was not associated with increased mortality (HR 6.96, 95% CI 0.85-56.8, p=0.07). MV reoperation was required in 15 (3.3%) patients (3 in Cohort 1; 12 in Cohort 2, p=0.05). Cumulative incidence of need for MV reoperation with death as a competing outcome at 1, 3, and 5 years was 0.9, 1.4, 1.8% in Cohort 1 and 2.7, 4.0, 5.1% in Cohort 2 (Sub-hazard ratio, SHR, 2.95, 95% CI 0.84-10.4, p=0.09, see Figure 1B). Follow-up echocardiogram was available in 412 (91%) of patients at a median of 2.1 (0.4-5.2) years. Thirteen patients progressed to moderate to severe MR or greater (6 in Cohort 1; 7 in Cohort 2, p=0.88). Cumulative incidence of MR progression to moderate to severe or greater with death as a competing outcome at 1, 3, and 5 years was 1.4, 3.6, and 5.1% in Cohort 1 and 2.7, 3.5, and 4.7% in Cohort 2 (SHR 0.85, 95% CI 0.29-2.50, p=0.76). Similar results were found in the subgroup who underwent isolated MV repair (n=388) as age over 60 was not associated with increased mortality (adjusted HR 5.31, 95% CI 0.64-44.0, p=0.12), need for MV reoperation (SHR 4.04, 95% CI 0.89-18.4, p=0.07) or progression of MR (SHR 0.98, 95% CI 0.30-3.15, p=0.97).
Conclusions: Contemporary results with MV repair continue to be excellent, even in low-risk patients over the age of 60. These results must be carefully considered as we experience increasing pressure to enroll operative patients in percutaneous mitral repair trials.
Figure 1A: Kaplan-Meier survival in Cohort 1 vs. Cohort 2 (log-rank p=0.02)
Figure 1B: Cumulative incidence of need for MV reoperation with death as a competing outcome in Cohort 1 vs. Cohort 2 (Sub-hazard ratio, SHR, 2.95, 95% CI 0.84-10.4, p=0.09)
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