Author + information
- Received August 6, 2015
- Revision received October 16, 2015
- Accepted October 27, 2015
- Published online February 9, 2016.
- Rakesh M. Suri, MD, DPhila,∗ (, )
- Marie-Annick Clavel, DVM, PhDb,c,
- Hartzell V. Schaff, MDa,
- Hector I. Michelena, MDb,
- Marianne Huebner, PhDd,
- Rick A. Nishimura, MDb and
- Maurice Enriquez-Sarano, MDd
- aDivision of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
- bDivision of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota
- cInstitut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec City, Québec, Canada
- dDepartment of Statistics and Probability, Michigan State University, East Lansing, Michigan
- ↵∗Reprint requests and correspondence:
Dr. Rakesh M. Suri, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, J4-1, Cleveland, Ohio 44195.
Background The risk for and consequences of recurrent mitral regurgitation (MR) following degenerative mitral valve repair are poorly understood.
Objectives This study sought to examine recurrent MR risk along with reoperation and survival rates.
Methods We evaluated patients undergoing primary mitral repair for isolated degenerative MR over 1 decade. Median follow-up was 11.5 years (interquartile range: 9.2 to 13.6 years) and was 99% complete. Multivariate analysis of post-repair MR recurrence employed Cox proportional hazards and multistate modeling.
Results A total of 1,218 patients met the study criteria; the mean age was 64 ± 13 years, mean ejection fraction was 63 ± 9%, and 864 (71%) patients were men. Prolapse was posterior in 62%, bileaflet in 26%, and anterior in 12%. The 15-year incidence of recurrent MR (i.e., MR ≥2) was 13.3%, incidence of mitral reoperation was 6.9%, and overall mortality was 44.0%. Repair before 1996 independently predicted MR recurrence (hazard ratio: 1.52). Additional determinants were: age, mild intraoperative residual MR, anterior leaflet prolapse, bileaflet prolapse, perfusion time >90 min, and lack of annuloplasty. Recurrence of moderate or greater MR was associated with adverse left ventricular remodeling and increased likelihood of death (hazard ratio: 1.72). Among those undergoing repair after 1996, MR recurrence rate was 1.5 per 100 patient-years during the first year post-repair, decreasing markedly to 0.9 thereafter.
Conclusions Our study demonstrated that recurrent MR following degenerative mitral valve repair is associated with adverse left ventricular remodeling and late death. The incidence of MR recurrence decreases markedly following the first year after intervention. A transparent discussion of recurrent MR risk has pressing relevance when referring patients with complex mitral valve prolapse.
Early surgical correction of severe mitral regurgitation (MR) caused by prolapse due to flail leaflets improves long-term survival and diminishes late heart failure risk (1,2), particularly when performed by valve repair specialists within a center of excellence (3–5). Mitral valve (MV) repair is safe and preferred over replacement in correcting MR caused by degenerative valve disease (6,7). Current consensus statements mandate “rescue” MR correction in the presence of left ventricular (LV) dysfunction or symptoms (8). In the absence of these Class I triggers, early “restorative” surgery is advocated to improve patient prognosis to normal in the presence of atrial fibrillation (AF) or pulmonary hypertension, or when performed at centers where the procedural risk of mortality is <1% and the MV repair rate is >95% (9). Prior to taking the step to generalize the recommendation for early MR correction in the presence of Class IIa indications, however, it is critically important to understand recurrent MR rates following MV repair, along with the consequences and predictors of this occurrence.
Although prior series have demonstrated that reoperation rate following degenerative MV repair is approximately 0.5% to 1% per year (7,10), assessing durability on the basis of reintervention alone likely underestimates the long-term patient risk. While expert single surgeon series (3–5) have suggested that it is possible to repair degenerative mitral prolapse with near 100% certainty (3,11) and infrequent reversion to replacement in the current era (4), MR recurrence (not merely reoperation) rates from multisurgeon practices must be better understood to formulate guidelines applicable to community cardiology practices worldwide. Additionally, although mechanisms of and therapeutic approaches to address recurrent MR following prior repair have been described (12,13), the effects on LV remodeling and long-term life expectancy remain poorly defined. A final important limitation of prior work has been the inability to account for the attrition of patients during follow-up due to late death. The true incidence of recurrent MR and its determinants may therefore not be fully appreciated (13–15).
We hypothesized that the use of multistate modeling to account for the competing risk of death would alter prior findings of the long-term outcomes of degenerative MV repair. We thus analyzed outcomes from a multisurgeon, “center of excellence” heart valve practice to determine mortality-adjusted, post–degenerative valve repair recurrent MR rates, determinants, and consequences.
We studied consecutive patients who underwent degenerative MV repair between January 1, 1990, and December 31, 2000, at Mayo Clinic in Rochester, Minnesota. Eligible patients were those who underwent primary, isolated MV repair for pure MR (no stenosis), and who had degenerative disease with surgically verified MV prolapse as cause of regurgitation.
We excluded patients who had: mitral stenosis by hemodynamic assessment or surgical evaluation of the lesions; concomitant aortic valve replacement or repair; tricuspid valve replacement; previous mitral, aortic, or tricuspid valve repair or replacement; concomitant congenital (other than closure of patent foramen ovale), pericardial, or myocardial (particularly with dilated or hypertrophic cardiomyopathy) disease; ischemic MR with or without papillary muscle rupture; or organic, nondegenerative MR, such as rheumatic heart disease, endocarditis, or miscellaneous causes. We did not exclude patients who required tricuspid valve repair for functional tricuspid regurgitation, Cox-Maze operation for AF, or coronary bypass for obstructive coronary disease.
The study was approved by our institutional review board, and informed consent was obtained from study participants.
Transthoracic echocardiograms were performed within routine clinical practice using standard methods. LV assessment employed parasternal long-axis views by 2-dimensional direct measurements or guided M-mode at end-diastole and -systole and measurement of left ventricular ejection fraction (LVEF) as well as LV mass (16,17). Left atrial diameter was measured using parasternal views. MR severity was assessed on a scale from 1 to 4 by Doppler echocardiography using comprehensive MR assessment on the basis of systematic collection of specific and supportive signs with MR quantitation (18) as judged feasible by the responsible physician. Immediate post-repair echocardiographic findings were confirmed by a second post-operative echocardiography performed within 1 month post-repair in 1,215 (>99%) patients. MR that was mild or greater in hospital was considered “residual MR.” Subsequent echocardiographic follow-up was performed in >85% of alive patients for each time point between 0 to 10 years and 80% between 10 to 15 years (Figure 1). Echocardiographic data were used as collected without subsequent modification.
Patients were followed by their personal physicians at a Mayo Clinic facility or at the patient’s home institution. Information on follow-up events was obtained from medical examination or direct patient interview by the research team or use of repeated follow-up letters and questionnaires. Follow-up echocardiographic reports from all sources were obtained after authorization. Documentation of testing and surgical reports were reviewed and validated by the investigators. In the present series, 99% of patients were followed from diagnosis until death or at least 5 years post-operatively. In patients who died during follow-up, cause of death was adjudicated by review of death certificates, physician/hospital notes, and autopsy certificate if available. All patients underwent post-operative echocardiography at our Institution or at the facility of their personal physician (Figure 1). These results were all included in the follow-up; the first Doppler echocardiographic study demonstrating MR of moderate or severe degree was considered “MR recurrence.” No patients left the operating room with moderate or severe MR, but mild MR was noted in a subset of patients and considered insignificant by the surgeon during intraoperative echocardiography. These patients were considered to have “residual MR,” which was a variable incorporated within the operative characteristics during statistical analysis.
Continuous variables were summarized as mean ± SD or median and quartiles as appropriate. Categorical variables were described as frequencies and percentages. Groups were compared using the Student t test or chi-square test. The main endpoint of the study was first diagnosis of recurrent MR post-repair with secondary endpoints of reoperation and post-operative death. Rates of endpoints were calculated using the Kaplan-Meier method and expressed as mean ± SE. Recurrence and death are not independent endpoints, as post-operative death may prevent later MR recurrence. Hence, multivariate analysis of post-repair MR recurrence was conducted not only using Cox proportional hazards but also as a competing risk to death using a multistate model to estimate the hazard ratio (HR) of baseline characteristics and operative variables for time (since surgery) to recurrence or death. In these models, surgery was the initial state, death the terminal event, and recurrence a time-dependent intermediate state. Although survival analysis models estimate HRs to characterize the transition time between 2 states (alive to death), this approach enabled us to estimate the HRs for risk factors separately for each transition; surgery to recurrence, surgery to death, and time to death after recurrence. A clock-forward approach was used for the time scale. A Markov proportional hazards model was used to estimate HRs for predictors at transitions from surgery to death, surgery to recurrence, or recurrence to death (19). The hazard function for transition from state i to state j is given by λij(t) = λij,0(t)exp(Xijβ), where Xij are transition-specific covariates and λij,0 is the baseline hazard for the transition from i to j. We investigated whether the time a patient experienced a recurrence was associated with time to subsequent death. Cox proportional hazard models included all clinically relevant variables as well as statistically significant variables in univariate analysis. Proportional hazard assumptions were evaluated with scaled Schoenfeld residuals. The predictive ability for each Cox model was described using a concordance index (c-index). The c-index ranged from 0.5 (no predictive ability) to 1.0 (perfect prediction).
Incidences of MR recurrence were calculated (95% confidence intervals [CIs]) after surgery using person-years. Nonoverlapping time windows of 0 to 1 year, 1 to 2 years, 2 to 5 years, and 5 years or more were selected to distinguish short-, mid-, and long-term outcomes. Rate ratios were calculated in these time intervals to compare MR occurrence between anterior and posterior or bileaflet and posterior.
A level of p = 0.05 was considered statistically significant. All analyses were performed using R version 2.15.3 (R Foundation for Statistical Computing, Vienna, Austria) and the multistate analysis package mstate version 0.2.6 (20).
Pre-operative baseline characteristics are shown in Table 1. The mean age of patients was 64 ± 13 years, and 864 (71%) were men. Frequent comorbidities included AF (25%), hypertension (35%), coronary artery disease (26%), and New York Heart Association (NYHA) functional class III/IV status (30%). Mean LV end-diastolic diameter was 59.9 ± 7.4 mm, LV end-systolic dimension was 36.8 ± 6.8 mm, and LVEF was 63 ± 9%. The posterior leaflet of the MV was singularly affected in 62%, bileaflet prolapse was present in 26%, and ruptured chordae tendineae were found in 64%. MV repair was performed between 1996 and 2000 in 755 (62%) patients in the current analysis. During surgery (Table 2), mitral leaflet resection was performed in 61%, leaflet plication in 27%, chordal transfer in 4%, artificial Gore-Tex neochordae (W.L. Gore & Associates, Inc., Flagstaff, Arizona) insertion in 13%, and annuloplasty in 96%. Roughly one-quarter (24%) underwent coronary artery bypass graft surgery, and in these patients, the etiology of MR was documented as nonischemic by the operating surgeon. Post-operative intra-aortic balloon counterpulsation was required in 1.4%, and 2% had mild “residual” MR documented in the operating room.
Recurrence and significance of MR
Among the 1,218 patients studied, follow-up duration was 11.0 ± 4.5 years (median 11.5 years; interquartile range [IQR]: 9.2 to 13.6 years) and was 99% complete. The events noted during overall follow-up were as follows: there were 133 patients with a diagnosis of recurrent MR after repair occurring at a median of 3.7 years (IQR: 1.1 to 7.6 years) post-operatively. The 15-year overall incidence of recurrent MR was 13.3 ± 1.2%. There were 87 cardiac reoperations during follow-up (64 were related to mitral dysfunction), which occurred at a median time of 4.5 years (IQR: 0.9 to 9.1 years). The 15-year incidence of mitral reoperation was 6.9 ± 1.0%. A total of 452 patients died post-operatively at a median of 8.2 years (IQR: 4.3 to 11.5 years) following MV repair. The 15-year overall mortality was 44.0 ± 1.9% (Online Figure 1).
To assess the clinical significance of recurrent MR following repair of degenerative MV disease, we first analyzed the influence of this event upon cardiac reverse remodeling at the latest follow-up echocardiogram. Those with recurrent MR had significantly larger residual LV chamber size and myocardial hypertrophy (Table 3).
We next studied the association between recurrent MR and death in a Cox proportional hazard model. The predictors of overall mortality are presented in Table 4. After controlling for potentially influential variables, the following were associated with increased mortality risk: age, NYHA functional class, smoking history, coronary disease, LVEF, no annuloplasty, and recurrent MR expressed as a time-dependent variable (HR: 1.72; 95% CI: 1.24 to 2.39). Thus, echocardiogram-documented recurrence of moderate or greater MR resulted in both adverse cardiac remodeling and an increased likelihood of death.
Determinants of recurrent MR
Recognizing that the recurrence of even moderate MR was a serious event, we next sought to understand the predictors of this problem. In comparing baseline characteristics of patients with and without MR (Table 1), we identified a trend for post-operative recurrent MR patients to be older and more likely to have hypertension or diabetes. Although echocardiographically assessed LV size, systolic function, and mass were not different between groups, patients with recurrent MR were less likely to have ruptured chordae tendineae and posterior leaflet prolapse (Table 1). Direct comparison of operative characteristics (Table 2) demonstrated that those with recurrent MR were more likely to have been operated on prior to 1996 and to have spent more time on cardiopulmonary bypass. Intraoperatively, they were also less likely to have undergone posterior leaflet resection but more frequently required artificial neochord placement and had residual (mild) MR identified immediately post-procedure.
Multivariate predictors of post-repair MR recurrence are shown in Table 5 (Cox proportional hazards models) and Table 6 (multistate transitional models). These 2 methods of analysis demonstrated almost identical results whereby increasing age, surgery before 1996, hypertension, longer bypass time, mild residual MR identified immediately post-repair (Figures 2A and 3A⇓⇓), bileaflet or anterior leaflet prolapse (Figures 2B and 3B), absence of leaflet resection, and absence of prosthetic annuloplasty band (Figure 2C) were all independently associated with an increased likelihood of degenerative MR recurrence following primary MV repair.
Interestingly, rates of MR recurrence decreased over time (1-year rate of MR recurrence: 2.7 [95% confidence interval: 1.9 to 3.9] vs. a subsequent rate of MR recurrence: 0.8 [95% confidence interval: 0.6 to 1.0] per 100 person-years; p < 0.001), but the HR related to these predictors remained constant (all p > 0.14).
The multistate transition-specific method was used to determine predictors of MR recurrence after MV repair (Table 6) identified using the Cox proportional hazards model. We also analyzed the predictors of mortality with and without MR recurrence. Interestingly, the predictors were different in patients who developed MR recurrence. The risk of death without MR recurrence was predicted by age, NYHA functional class, associated coronary artery bypass grafting, and absence of annuloplasty, whereas death following MR recurrence was only associated with age and male sex.
MR recurrence in subgroups
In view of the observation of both diminished MR recurrence (Table 5) and mitral reoperation rates over time (Figure 4), rates were analyzed among subsets of patients operated on after 1996. Importantly, there were no statistically significant interactions identified between era of operation and studied risk factors (i.e., residual MR or prolapse localization; all p > 0.43).
Among those undergoing MV repair during the latter portion of the study (1996 to 2000, n=755), a total of 59 patients developed moderate or greater recurrent MR and 25 required mitral reoperation following hospital dismissal. In this group of patients, the rate of MR recurrence was 1.5 per 100 patient-years (95% CI: 0.6 to 2.5 per 100 patient-years) in the first year after repair and 0.9 per 100 patient-years (95% CI: 0.6 to 1.1 per 100 patient-years) thereafter. These rates were higher (all p ≤ 0.03) in patients with mild intraoperative residual MR immediately post-operatively (Figure 3A) compared with patients without residual MR. Indeed, mild residual MR immediately following repair was associated with a higher likelihood of progression to moderate or greater MR recurrence at all time points thereafter.
Further analyzing the subset of patients who underwent repair during or after 1996 by leaflet prolapse categories, several interesting trends emerged. In comparison to patients with posterior leaflet prolapse, those with anterior leaflet disease had higher rates of MR recurrence at all time points after surgery (all p < 0.03) (Figure 3B). In contrast, those with bileaflet prolapse only had a higher likelihood of MR recurrence (compared with posterior leaflet) during the first year after surgery (p = 0.001), and there was only a nonsignificant trend toward a higher rate of MR recurrence thereafter (p = 0.06) (Figure 3B).
On the basis of data from a large multisurgeon heart valve center of excellence over 1 decade with 99% follow-up, this study detailed the long-term recurrence of MR in patients undergoing degenerative MV repair. The results reflected an important evolution in surgical technique, repair volumes, and repair experience over time. We uniquely accounted for the competing risk of death, which otherwise masks the true long-term recurrence rate for MR. We were thus able to more accurately study risk factors predisposing to repair failure, along with predictors of death in those with and without MR recurrence following repair. We found that the 15-year incidence of recurrent MR was 13.3% and the mitral reoperation rate was 6.9%. Importantly, recurrent MR following MV repair was associated with adverse LV remodeling as well as increased likelihood of late death (Central Illustration). Results of mitral repair in a more contemporary era (after 1996) revealed a lower rate of MR recurrence: 1) after the first post-surgical year (0.9 per 100 patient-years); 2) in those without mild intraoperative residual MR; and 3) in patients without isolated anterior leaflet prolapse.
Competing risk of death
Accounting for patient attrition by death is an important concept that has not been prioritized in prior multisurgeon analyses of long-term outcomes following MV repair. The current multistate analysis allowed us to understand MR recurrence after controlling for unavailability of patients for follow-up due to death. The results we presented are timely in that they reflected the excellent long-term durability of low-risk and effective MV repair operations in a specialized heart valve center. It is important to remember that the aim of valve repair is to completely, or almost entirely, eliminate degenerative MR burden. Although surgical mitral repair techniques have further evolved over the past 2 decades (3,11,21), we offered a contemporary reappraisal of the predictors of MR recurrence, providing crucial guidance to clinicians, imagers, and surgeons caring for patients with degenerative MV disease. Finally, the importance of eliminating MR at the time of correction of degenerative valve disease was eminently apparent. Patients who undergo incomplete reduction of MR have elevated risks of adverse left ventricular, remodeling, heart failure, and late death.
Previous studies have analyzed mitral reoperation and MR recurrence in populations of patients following degenerative MV repair (13–15,22). David et al. (4) recently published results of a single-surgeon series of 840 patients undergoing MV repair for MR due to degenerative disease between 1985 and 2004 with a median 10.4 years of follow-up. The authors found that age, LVEF, and functional class were independent predictors of late cardiac- and valve-related death. Recurrent severe MR occurred in 37 patients, and moderate leakage was found in 61 patients. The 20-year risk of mitral reoperation was thus 5.9%, and the freedom from recurrent moderate or severe MR was 69.2% as predicted by age, anterior leaflet prolapse, extent of myxomatous disease, lack of mitral annuloplasty, and duration of cardiopulmonary bypass. As the authors reported, “This is equivalent to almost one-third of all patients developing significant recurrent MR by 20 years.” Despite this, the excellent results of this world-class master technician’s repair experience have been difficult to match by others to date (14,23,24). The predictors of MR recurrence in our large multisurgeon series were strikingly similar. Uniquely, however, our current report established for the first time that MR risk falls following the first year after repair and that MR recurrence is prognostically influential upon long-term survival.
Evolution in surgical technique
Over the period of our study, several technical improvements in MV repair have been noted. The evolution of posterior leaflet prolapse repair from McGoon plication (25) to the Schaff triangular resection (26) occurred early in the current repair series at Mayo Clinic. As such, the learning curve for posterior leaflet repair was mastered earlier than for nonposterior leaflet subsets. The superb stability of posterior leaflet repair was reflected in the negligible very long-term rates of MR recurrence and reoperation in this disease subset. Involvement of the anterior leaflet in bileaflet disease often represents “bystander pathology.” In a significant proportion of such cases, the anterior leaflet may be only mildly myxomatous and can thus be addressed by the annuloplasty as an adjunct to posterior leaflet repair, without any anterior leaflet manipulation at all. It is also possible that some of these patients subsequently undergo anterior leaflet disease progression resulting in slightly more recurrence than that seen in posterior leaflet prolapse alone. Despite this possibility, a limited number of options exist to treat anterior leaflet prolapse aside from chordal-based maneuvers; as anterior leaflet resection may cause leaflet restriction that impedes the normal anterior leaflet excursion so critically important to long-term MV competence. It is interesting to note, however, that in our most recent experience presented (1996 to 2000), long-term MR recurrence rate past the first year after bileaflet MV repair became indistinguishable from that seen following posterior leaflet correction alone. Isolated anterior leaflet prolapse, however, was quite different. The historical use of chordal shortening and/or transfer, which was quite prevalent initially, subsequently diminished with time in our practice. Instead, Gore-Tex neochord replacement has become the primary tool utilized to treat anterior leaflet prolapse. As previously concluded by others, freedom from recurrent MR improved as surgeons gained greater familiarity with the technical nuances of artificial neochord placement and length adjustment (7). We have further noted that some patients who return for reoperation following failed Gore-Tex neochord resuspension often bear evidence of the cord itself tearing through the leaflet tissue. Experienced mitral repair surgeons have noted, not infrequently, that the second loop of these neochords can erode through the diseased anterior leaflet surface when tissue quality is poor. If not immediately recognized and corrected by adding an additional loop and/or protecting the knot with a pledget, this may lead to catastrophic early failure following cardiac reanimation. The nearly 2 decades of subsequent experience with the Gore-Tex neochords have led to a greater familiarity with this technique, and the analysis of future long-term outcomes will be important to test our hypothesis.
Prior studies have analyzed either mitral reoperation alone, which underestimates the senescence rate of mitral repair, or echocardiographic studies, which generally have not accounted for the competing risks of death (13–15). The current report conveyed several important messages that differentiate it from existing series. First, our findings demonstrated for the first time in a contemporary multisurgeon practice very low MR recurrence following repair of isolated posterior leaflet prolapse, providing an important contemporary comparator against which forthcoming percutaneous technology will be compared. Second, we showed that recurrent MR was associated with poor subsequent outcome, including poor reverse remodeling, along with an increased risk of MV reoperation and death in a competing risk analysis accounting for lack of reoperation in the oldest patients with recurrent MR. These findings caution surgeons to consider the not insignificant consequences of residual mild intraoperative and subsequent recurrent moderate MR following mitral repair.
Third, the potential technical complexity of repair for anterior and bileaflet prolapse subsets indicate that referral to high-volume MV repair specialists may be necessary to optimize quality and diminish both short- and long-term recurrence risks (27). Due to the fact that these subsets are technically challenging and associated with greater recurrence overall, current consensus statements also indicate that the performance of early MV repair in asymptomatic or minimally symptomatic patients should occur at centers where high-quality repair expertise exists (8). Fourth, these results largely confirm those detailed in the single-center experiences of experts such as David et al. (4), Castillo et al. (3), and Okada et al. (5) and likely allow generalizability to multisurgeon valve repair practices in certain centers of excellence. Finally, the average age of patients in our series was older than those reported previously, reflecting an evolution in the demographics of patients undergoing MV repair in the current era. As such, although it is possible that tissue quality of these individuals was less robust than it might have been in younger patients, the incidence of recurrent MR with time was nonetheless low.
The present study was observational and retrospective, bearing associated biases. However, follow-up was comprehensive and included assessments of clinical visits and echocardiograms performed at our Institution and elsewhere. After the initial echocardiogram (i.e., within 30 days), one-third to one-half of subsequent studies were not performed nor reviewed at Mayo Clinic. Because the quality of echocardiograms performed elsewhere could not be individually confirmed, it is theoretically possible that some patients who were not available for follow-up at Mayo Clinic had MR recurrence and escaped detection. It was reassuring, however, that 99% of patients were followed from diagnosis until death or at least 5 years post-operatively. The fact that residual/recurrent MR was highly significant in predicting outcomes such as persistent LV and left atrial enlargement, as well as excess long-term mortality when analyzed in a time-dependent manner, supports the importance of high-quality echocardiographic surveillance for MR recurrence following MV repair. Finally, because the primary endpoint of our study was residual MR following MV repair, patients who underwent attempted repair and had a replacement were not included in the present analysis.
The overall risk of recurrent MR is very low: 0.9 per 100 patient-years following the first year post-MV repair. Despite this reassurance, recurrent moderate-or-greater MR is a serious problem associated with adverse consequences, including left heart enlargement and death. Contemporary results indicate that those with posterior-leaflet or bileaflet disease who undergo repair supported by annuloplasty and continue to be free of mild or greater MR early after surgery have the lowest long-term recurrence rates. Early referral for MV repair should thus be predicated upon the assurance of near complete elimination of regurgitation to reduce the long-term risk associated with MR recurrence. Further work will be necessary to understand how recent technical improvements in repair quality will affect long-term outcomes.
COMPETENCY IN PATIENT CARE AND PROCEDURAL SKILLS: In patients with degenerative MR due to posterior-leaflet or bileaflet disease undergoing surgical repair with annuloplasty, recurrence risks are low. Mild or greater early post-operative MR is associated with adverse ventricular remodeling and higher rates of recurrent MR, need for reoperation, and death than in patients with none-to-trivial early post-operative MR.
TRANSLATIONAL OUTLOOK: Further studies are needed to understand the impact of technical advances that improve the quality of MV repair on long-term outcomes in patients undergoing surgery to correct severe degenerative MR.
For supplemental methods and a supplemental figure, please see the online version of this article.
Dr. Enriquez-Sarano has received a research grant from Edwards. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. Suri and Clavel contributed equally to this work.
- Abbreviations and Acronyms
- left ventricular
- left ventricular ejection fraction
- mitral regurgitation
- mitral valve
- New York Heart Association
- Received August 6, 2015.
- Revision received October 16, 2015.
- Accepted October 27, 2015.
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