Francesco Formica, MD, Francesco Maestri, MD, Alan Gallingani, MD, and Francesco Nicolini, MD, PhD
Central Message
Patients with severe chronic ischemic mitral regurgitation should receive a bioprosthesis, when valve repair is not advisable. Promising results of valve-in-valve technique should drive the choice.
See Article page 634.
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. However, because CIMR is a consequence of left ventricle (LV) disease, in some conditions, such as severe LV remodeling, increased tenting area (>2.5 cm2) and coaptation distance (>1 cm),6
or an increased preoperative posterior leaflet tethering angle (>22°),7
MV replacement is preferred or strongly recommend. In this contest, the choice of the prosthetic valve is crucial.Bernard and colleagues
8
have focused their research on identifying the ideal prosthesis in patients who underwent MV replacement for CIMR. During their 16-year study period, 236 (56%) patients who received a mechanical prosthesis (MP) and 188 (44%) patients who received a bioprosthesis (BP) were identified. By a propensity score matching and an inverse probability of treatment weight, a total of 126 paired patients were matched. The authors report interesting data at mean follow-up of 6 years. Matched patients with an MP experienced more cardiovascular events, such as increased risk of stroke and major bleeding. Another interesting result is the low and comparable incidence of late reintervention due to prosthesis dysfunction between the 2 matched groups (1.6% in MP patients vs 3.2% in BP patients). Because the readmission for cardiovascular causes, stroke, or major bleeding was strongly associated with the MP (hazard ratio, 1.65; 95% confidence interval, 1.17-2.32; P = .004), the obvious conclusion should be that surgeons should increase the use of BPs in patients with CIMR. This is an important take-home message from this study. Indeed, the authors point out that the prosthesis choice in patients with severe CIMR should not be driven by a patient's age alone, but also on the etiology of MV disease and the grade of LV dysfunction. However, among the weaknesses of this study is the lack of information regarding the entity of LV dysfunction (intended as grade of advanced LV remodeling) and the completeness of coronary revascularization. These factors may strongly influence the long-term course of these patients, as well as his or her need for lifelong anticoagulation therapy.Maybe MP could be a reasonable choice in a 50-year-old patient with a low grade of LV remodeling who is undergoing complete myocardial revascularization. However, in the era of transcatheter therapy, valve-in-valve procedures to manage a degenerated mitral BP are increasing.
9
This could overcome the operative risk of conventional redo surgery- Guerrero M.
- Vemulapalli S.
- Xiang Q.
- Wang D.D.
- Eleid M.
- Cabalka A.K.
- et al.
Thirty-day outcomes of transcatheter mitral valve replacement for degenerated mitral bioprostheses (valve-in-valve), failed surgical rings (valve-in-ring), and native valve with severe mitral annular calcification (valve-in-mitral annular calcification) in the United States: data from the Society of Thoracic Surgeons/American College of Cardiology/Transcatheter Valve Therapy Registry.
Circ Cardiovasc Interv. 2020; 13: e008425
10
,11
and therefore the prosthesis choice should be driven also on the potential valve-in-valve therapy criterion. Based on the results of the study by Bernard and colleagues,8
we conclude that BP has to be the first choice in patients with severe CIMR when mitral repair is not advisable.References
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- Thirty-day outcomes of transcatheter mitral valve replacement for degenerated mitral bioprostheses (valve-in-valve), failed surgical rings (valve-in-ring), and native valve with severe mitral annular calcification (valve-in-mitral annular calcification) in the United States: data from the Society of Thoracic Surgeons/American College of Cardiology/Transcatheter Valve Therapy Registry.Circ Cardiovasc Interv. 2020; 13: e008425
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Article info
Publication history
Published online: February 26, 2021
Accepted:
February 22,
2021
Received in revised form:
February 20,
2021
Received:
February 20,
2021
Footnotes
Disclosures: The authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
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Copyright
© 2021 by The American Association for Thoracic Surgery
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- Prosthetic choice in mitral valve replacement for severe chronic ischemic mitral regurgitation: Long-term follow-upThe Journal of Thoracic and Cardiovascular SurgeryVol. 165Issue 2
- PreviewProsthetic 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.
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