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

Published:February 02, 2021DOI:



      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.


      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.


      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.


      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)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Thoracic and Cardiovascular Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Grigioni F.
        • Enriquez-Sarano M.
        • Zehr K.J.
        • Bailey K.R.
        • Tajik A.J.
        Ischemic mitral regurgitation: long-term outcome and prognostic implications with quantitative Doppler assessment.
        Circulation. 2001; 103: 1759-1764
        • Acker M.A.
        • Parides M.K.
        • Perrault L.P.
        • Moskowitz A.J.
        • Gelijns A.C.
        • Voisine P.
        • et al.
        Mitral-valve repair versus replacement for severe ischemic mitral regurgitation.
        N Engl J Med. 2014; 370: 23-32
        • Chiang Y.P.
        • Chikwe J.
        • Moskowitz A.J.
        • Itagaki S.
        • Adams D.H.
        • Egorova N.N.
        Survival and long-term outcomes following bioprosthetic vs mechanical aortic valve replacement in patients aged 50 to 69 years.
        JAMA. 2014; 312: 1323-1329
        • Russo A.
        • Grigioni F.
        • Avierinos J.F.
        • Freeman W.K.
        • Suri R.
        • Michelena H.
        • et al.
        Thromboembolic complications after surgical correction of mitral regurgitation incidence, predictors, and clinical implications.
        J Am Coll Cardiol. 2008; 51: 1203-1211
        • Glaser N.
        • Jackson V.
        • Holzmann M.J.
        • Franco-Cereceda A.
        • Sartipy U.
        Aortic valve replacement with mechanical vs. biological prostheses in patients aged 50-69 years.
        Eur Heart J. 2016; 37: 2658-2667
        • Nishimura R.A.
        • Otto C.M.
        • Bonow R.O.
        • Carabello B.A.
        • Erwin III, J.P.
        • Fleisher L.A.
        • et al.
        2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines.
        Circulation. 2017; 135: e1159-e1195
        • Baumgartner H.
        • Falk V.
        • Bax J.J.
        • De Bonis M.
        • Hamm C.
        • Holm P.J.
        • et al.
        2017 ESC/EACTS guidelines for the management of valvular heart disease.
        Eur Heart J. 2017; 38: 2739-2791
        • Reineke D.C.
        • Heinisch P.P.
        • Winkler B.
        • Englberger L.
        • Carrel T.P.
        Mitral valve replacement in patients under 65 years of age: mechanical or biological valves?.
        Curr Opin Cardiol. 2015; 30: 146-150
        • Kron I.L.
        • Acker M.A.
        • Adams D.H.
        • Ailawadi G.
        • Bolling S.F.
        • Hung J.W.
        • et al.
        2015 The American Association for Thoracic Surgery consensus guidelines: ischemic mitral valve regurgitation.
        J Thorac Cardiovasc Surg. 2016; 151: 940-956
        • Austin P.C.
        An introduction to propensity score methods for reducing the effects of confounding in observational studies.
        Multivariate Behav Res. 2011; 46: 399-424
        • Zhang Z.
        • Kim H.J.
        • Lonjon G.
        • Zhu Y.
        • AME Big-Data Clinical Trial Collaborative Group
        Balance diagnostics after propensity score matching.
        Ann Transl Med. 2019; 7: 16
        • Gammie J.S.
        • Chikwe J.
        • Badhwar V.
        • Thibault D.P.
        • Vemulapalli S.
        • Thourani V.H.
        • et al.
        Isolated mitral valve surgery: the Society of Thoracic Surgeons Adult Cardiac Surgery database analysis.
        Ann Thorac Surg. 2018; 106: 716-727
        • Goldstein D.
        • Moskowitz A.J.
        • Gelijns A.C.
        • Ailawadi G.
        • Parides M.K.
        • Perrault L.P.
        • et al.
        Two-year outcomes of surgical treatment of severe ischemic mitral regurgitation.
        N Engl J Med. 2016; 374: 344-353
        • Al-Radi O.O.
        • Austin P.C.
        • Tu J.V.
        • David T.E.
        • Yau T.M.
        Mitral repair versus replacement for ischemic mitral regurgitation.
        Ann Thorac Surg. 2005; 79: 1260-1267
        • Grossi E.A.
        • Goldberg J.D.
        • LaPietra A.
        • Ye X.
        • Zakow P.
        • Sussman M.
        • et al.
        Ischemic mitral valve reconstruction and replacement: comparison of long-term survival and complications.
        J Thorac Cardiovasc Surg. 2001; 122: 1107-1124
        • Reece T.B.
        • Tribble C.G.
        • Ellman P.I.
        • Maxey T.S.
        • Woodford R.L.
        • Dimeling G.M.
        • et al.
        Mitral repair is superior to replacement when associated with coronary artery disease.
        Ann Surg. 2004; 239: 671-675
        • Velazquez E.J.
        • Lee K.L.
        • Jones R.H.
        • Al-Khalidi H.R.
        • Hill J.A.
        • Panza J.A.
        • et al.
        Coronary-artery bypass surgery in patients with ischemic cardiomyopathy.
        N Engl J Med. 2016; 374: 1511-1520
        • Stone G.W.
        • Lindenfeld J.
        • Abraham W.T.
        • Kar S.
        • Lim D.S.
        • Mishell J.M.
        • et al.
        Transcatheter mitral-valve repair in patients with heart failure.
        N Engl J Med. 2018; 379: 2307-2318
        • Obadia J.F.
        • Messika-Zeitoun D.
        • Leurent G.
        • Iung B.
        • Bonnet G.
        • Piriou N.
        • et al.
        Percutaneous repair or medical treatment for secondary mitral regurgitation.
        N Engl J Med. 2018; 379: 2297-2306
        • Goldstone A.B.
        • Chiu P.
        • Baiocchi M.
        • Lingala B.
        • Patrick W.L.
        • Fischbein M.P.
        • et al.
        Mechanical or biologic prostheses for aortic-valve and mitral-valve replacement.
        N Engl J Med. 2017; 377: 1847-1857
        • Kaneko T.
        • Aranki S.
        • Javed Q.
        • McGurk S.
        • Shekar P.
        • Davidson M.
        • et al.
        Mechanical versus bioprosthetic mitral valve replacement in patients <65 years old.
        J Thorac Cardiovasc Surg. 2014; 147: 117-126
        • Gillinov A.M.
        • Blackstone E.H.
        • Rajeswaran J.
        • Mawad M.
        • McCarthy P.M.
        • Sabik III, J.F.
        • et al.
        Ischemic versus degenerative mitral regurgitation: does etiology affect survival?.
        Ann Thorac Surg. 2005; 80: 811-819
        • Seipelt R.G.
        • Schoendube F.A.
        • Vazquez-Jimenez J.F.
        • Doerge H.
        • Voss M.
        • Messmer B.J.
        Combined mitral valve and coronary artery surgery: ischemic versus non-ischemic mitral valve disease.
        Eur J Cardiothorac Surg. 2001; 20: 270-275
        • Mohammadi S.
        • Kalavrouziotis D.
        • Cresce G.
        • Dagenais F.
        • Dumont E.
        • Charbonneau E.
        • et al.
        Bilateral internal thoracic artery use in patients with low ejection fraction: is there any additional long-term benefit?.
        Eur J Cardiothorac Surg. 2014; 46: 425-431

      Linked Article

      • Commentary: Should all etiologies of mitral regurgitation treated equal?
        The Journal of Thoracic and Cardiovascular SurgeryVol. 165Issue 2
        • Preview
          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.
        • Full-Text
        • PDF
      • Commentary: Valve options for ischemic mitral regurgitation in an era of new technologies: ViV(a) la bioprosthetic
        The Journal of Thoracic and Cardiovascular SurgeryVol. 165Issue 2
        • Preview
          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.
        • Full-Text
        • PDF
      • Commentary: Mitral bioprosthesis versus mechanical prosthesis in severe chronic mitral regurgitation: Bioprosthesis wins the duel
        The Journal of Thoracic and Cardiovascular SurgeryVol. 165Issue 2
        • Preview
          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.
        • Full-Text
        • PDF