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| Four Decades of Experience with Mitral Valve Repair: Analysis of Differential Indications, Technical Evolution and Long-Term Outcome | |
Daniel J. DiBardino, Andrew W. ElBardissi, Ann Maloney, R Scott McClure, Oswaldo Razo-Vasquez, Judah A. Askew, Lawrence H. Cohn; Cardiac Surgery, Harvard Medical School, Boston, MA
Methods: Patients having MVP by a single surgeon were retrospectively reviewed and current survival and reoperation data were collected. Emphasis was on repair strategy and long-term survival/reoperation status by MV disease etiology. Results: There were 1,469 MV repairs since 2/23/1972; overall mean age was 60 yrs and 57% were male. Etiologies included 1,010 myxomatous (mean age 60+/-13 yrs, 66% male), 193 rheumatic (mean 55+/-15 yrs, 85% female), 129 ischemic (mean 70+/-10 yrs) and 93 functional/cardiomyopathic (FCM, mean 67+/-11 yrs). Repair strategies evolved over four decades and included commissurotomy, papillary muscle splitting, leaflet resection with reconstruction and ring annuloplasty, commissuroplasty, fold-o-plasty, Gortex chord creation and edge-to-edge repair. The 30 day mortality was n=19/1,469 (1.29%) while overall 10, 20 and 30 year actuarial survival was 72%, 47% and 35%. Rheumatic and myxomatous actuarial survival was similar at 10, 20 and 30 years (77%, 55%, 38% versus 77%, 55%, 27%, respectively) while Cox proportional hazards modeling determined ischemic [Hazard Ratio (HR) 4.671, p<0.0001] and FCM etiology [HR 3.298, p<0.0001] as significant predictors of poor survival. Combined MVP/CABG had decreased survival versus isolated MVP at all time points (61% versus 33% at 20 years, p<0.0001). Length of stay was less for right parasternal (5.9 days) and lower mini-sternotomy (6.5 days) than for right thoracotomy (10.9 days) and full sternotomy (8.6 days, p<0.0001). Overall actuarial 10, 20 and 30 year freedom from reoperation was 84%, 60% and 18%; 83% of myxomatous valves remained free from reoperation at 20 years (versus 32% of rheumatics) while only 9% of rheumatics remained so at 30 years. Cox proportional hazard estimates of freedom from reoperation found rheumatic disease (HR 18.52, p<0.001, figure 1) and prolonged cardiopulmonary bypass time (HR 1.020, p=0.0004) among significant predictors of reoperation. Conclusion: These follow-up data up to 36 years support repair as the procedure of choice for the majority of MV disease. Disease etiology strongly determines survival and durability; rheumatics enjoy the longest survival but require reoperation more frequently. Myxomatous MVP demonstrates the longest proven durability, approaching 30 years postoperatively. 
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