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Prosthetic choice in mitral valve replacement for severe chronic ischemic mitral regurgitation: Long-term follow-up

Published:February 02, 2021DOI:https://doi.org/10.1016/j.jtcvs.2021.01.094

      Abstract

      Background

      Prosthetic choice for mitral valve replacement is generally driven by patient age and patient and surgeon preference, and current guidelines do not discriminate between different etiologies of mitral valve disease. Our objective was to assess and compare short- and long-term outcomes after mitral valve replacement among patients with biological or mechanical prostheses in the setting of severe ischemic mitral regurgitation.

      Methods

      Between 2000 and 2016, 424 patients underwent mitral valve replacement for severe ischemic mitral regurgitation at our institution, using biological prosthesis in 188 (44%) and mechanical prosthesis in 236 (56%). A 1:1 propensity score match (n = 126 per group) and inverse probability of treatment weighting were used to compare groups. Short-term outcomes included in-hospital mortality and other cardiovascular adverse events. Long-term outcomes included survival and hospital readmission for cardiovascular causes, stroke, and major bleeding.

      Results

      In-hospital mortality and early postoperative adverse events were similar between groups in the propensity score match and inverse probability of treatment weighting cohorts. Overall long-term survival was similar at 5 and 9 years, but mechanical prosthesis recipients were more frequently readmitted to hospital for cardiovascular causes, including stroke and non-neurological bleeding in propensity score matching and inverse probability of treatment weighting analyses (all P values < .004). Type of prosthesis did not independently influence all-cause mortality (hazard ratio, 1.01; 95% confidence interval, 0.71-1.43; P = .959), but placement of a mechanical prosthesis was associated with increased risk of readmission for cardiovascular events (hazard ratio, 1.65; 95% confidence interval, 1.17-2.32; P = .004) among matched patients.

      Conclusions

      The type of prosthesis has no influence on long-term survival among patients with severe ischemic mitral regurgitation undergoing mitral valve replacement. There may be an increased risk of neurologic events and serious bleeding associated with mechanical prostheses.

      Graphical abstract

      Key Words

      Abbreviations and Acronyms:

      AF (atrial fibrillation), BP (biological prosthesis), CABG (coronary artery bypass grafting), IMR (ischemic mitral regurgitation), IPTW (inverse probability of treatment weight), MP (mechanical prosthesis), MR (mitral regurgitation), MVR (mitral valve replacement), PSM (propensity score matching), TIA (transient ischemic attack)
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      Linked Article

      • Commentary: Should all etiologies of mitral regurgitation treated equal?
        The Journal of Thoracic and Cardiovascular SurgeryVol. 165Issue 2
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          Mitral valve regurgitation (MR) is a very heterogenous disease, encompassing a variety of different etiologies, each presenting with their unique characteristics and considerations. Among them, ischemic mitral regurgitation (IMR) usually presents in older and more comorbid patients. Consequently, these patients usually have lower survival compared with patients with other MR etiologies.1 As optimizing long-term survival remains the main objective in mitral valve surgery, selecting the option most likely to accomplish that goal is of the utmost importance.
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      • Commentary: Valve options for ischemic mitral regurgitation in an era of new technologies: ViV(a) la bioprosthetic
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          Bernard and colleagues1 have presented their findings that prosthetic valve selection does not influence long-term survival in patients undergoing mitral valve replacement for ischemic mitral regurgitation; however, bioprosthetic valves appear to be associated with less morbidity. Guidelines on valve selection have generally cited patient age and suitability for lifelong anticoagulation, tempered by patient preference, as the dominant criteria for making recommendations. Evidence can be found to support bioprosthetic as well as mechanical valve use.
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      • Commentary: Mitral bioprosthesis versus mechanical prosthesis in severe chronic mitral regurgitation: Bioprosthesis wins the duel
        The Journal of Thoracic and Cardiovascular SurgeryVol. 165Issue 2
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          The most effective surgical strategy to address severe chronic ischemic mitral regurgitation (CIMR) is controversial due to conflicting results. Some authors report lower early mortality with MV repair compared with MV replacement,1,2 whereas others did not observe significant differences.3,4 MV replacement may offer greater freedom from mitral regurgitation recurrence compared with MV repair in the long-term5; on the opposite side, the adverse effects of implanting a prosthetic valve are fully recognized and may negatively influence mid- and long-term survival.
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