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| Recurrent Mitral Regurgitation Following Repair: Should the Mitral Valve be Re-Repaired? |
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Back to 86th Annual Meeting Back to Program Outline Objective: Up to 10% of patients (pt) may require reoperation for regurgitation following mitral valve repair. The objective of this study was to evaluate the mid-term clinical and echocardiographic (echo) outcomes of reoperation for failed mitral valve repair, and to identify factors favoring re-repair versus replacement. Methods: We studied the clinical and echo data from 148 pt who had reoperation for recurrent mitral regurgitation (MR) following mitral valve repair (with or without coronary bypass) between January 1, 1970 and January 1, 2005. All pt had isolated degenerative mitral valve disease, and 39 had their first repair elsewhere. The mean age was 65 years (yr) and 103 (70 %) were men. At reoperation, 70 pt (47%) had class III-IV symptoms and 126/135 (93%) had moderate-to-severe MR. Results: The median duration from initial repair to reoperation was 1.8 yr (range 0-25 yr). The primary indications were regurgitation alone in 111 (75%), hemolysis in 27 (18%), systolic anterior motion in 4 (SAM - 3%), endocarditis in 3 (2%) and stenosis / other in 3 (2%). New valve pathology was found in 76 (51%) and failure of the initial repair in 58 (39%). The anterior leaflet was implicated in 66 (45%), the posterior leaflet in 63 (43%) and the annuloplasty in 43 (29%). The mitral valve was re-repaired in 67 (45%) and was replaced in 81 (55%). During re-repair, a modification of the annuloplasty was carried out in 54/67, an anterior leaflet procedure was performed in 34/67 and the posterior leaflet was addressed in 34/67. On pre-dismissal echo 61/64 pt had no greater than mild MR. Thirty-day survival was similar after re-repair and replacement (100% vs 96%, p=0.25), however five-year survival was significantly better after re-repair (81% vs 61%, p=0.009). The only other factor associated with improved survival was younger age at reoperation (HR=1.05, p=0.003). Of pt having re-repair, 6 had a third mitral operation (all replacements) at a median of 2.3 yr after reoperation (5 yr risk of reoperation 15% (95% CI 2-27%). Among pt having a valve replacement at initial reoperation, 1 had a third mitral operation at 13 years. Anterior leaflet repair was the only predictor of a third mitral operation (HR=15.7, p=0.01). At last follow-up, 58/67 pt who underwent re-repair were alive and 28/44 were in functional class I. On follow-up echo obtained between 1-5 years (n=100), EF was greater (p<0.001) and LVESD was smaller (p=0.002) in pt having re-repair compared to those having valve replacement. Conclusions: Recurrent mitral regurgitation after prior repair is frequently caused by new pathology, which can be re-repaired in almost half of pt. Mitral valve re-repair is associated with superior survival, improved EF and greater regression in ventricular dimension compared to valve replacement. Back to 86th Annual Meeting Back to Program Outline |
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