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Commentary: Mitral bioprosthesis versus mechanical prosthesis in severe chronic mitral regurgitation: Bioprosthesis wins the duel

Published:February 26, 2021DOI:https://doi.org/10.1016/j.jtcvs.2021.02.082
      Figure thumbnail fx1
      Francesco Formica, MD, Francesco Maestri, MD, Alan Gallingani, MD, and Francesco Nicolini, MD, PhD
      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,
      • Deja M.A.
      • Malinowski M.
      • Widenka K.
      • Stożyński N.
      • Bartuś K.
      • Kapelak B.
      • et al.
      Repair or replacement for secondary mitral regurgitation: results from Polish National Registry.
      ,
      • Yun-Dan D.
      • Wen-Jing D.
      • Xi-Jun X.
      Comparison of outcomes following mitral valve repair versus replacement for chronic ischemic mitral regurgitation: a meta-analysis.
      whereas others did not observe significant differences.
      • 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.
      ,
      • 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.
      MV replacement may offer greater freedom from mitral regurgitation recurrence compared with MV repair in the long-term
      • Dufendach K.
      • Aranda-Michel E.
      • Sultan I.
      • Gleason T.G.
      • Navid F.
      • Thomas F.
      • et al.
      Outcomes of mitral valve surgery for severe ischemic mitral regurgitation.
      ; 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),
      • Báez-Ferrer N.
      • Izquierdo-Gómez M.
      • Marí-López B.
      • Montoto-López J.
      • Duque-Gómez A.
      • García-Niebla J.
      • et al.
      Clinical manifestations, diagnosis, and treatment of ischemic mitral regurgitation: a review.
      or an increased preoperative posterior leaflet tethering angle (>22°),
      • Chan V.
      • Levac-Martinho O.
      • Sohmer B.
      • Elmistekawy E.
      • Ruel M.
      • Mesana T.G.
      When should the mitral valve be repaired or replaced in patients with ischemic mitral regurgitation?.
      MV replacement is preferred or strongly recommend. In this contest, the choice of the prosthetic valve is crucial.
      Bernard and colleagues
      • Bernard J.
      • Kalavrouziotis D.
      • Marzouk M.
      • Nader J.
      • Bernier M.
      • Pibarot P.
      • et al.
      Prosthetic choice in mitral valve replacement for severe chronic ischemic mitral regurgitation: long-term follow-up.
      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.
      • 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.
      This could overcome the operative risk of conventional redo surgery
      • Javadikasgari H.
      • Chemtob R.A.
      • Gillinov M.A.
      • Pettersson G.B.
      • Lowry A.M.
      • Desai M.Y.
      • et al.
      Outcome of mitral valve re-replacement for bioprosthetic structural valve deterioration.
      ,
      • Formica F.
      • Nicolini F.
      Commentary: mitral bioprosthesis degeneration: looking for a benchmark to tailor the correct procedure to the patient.
      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,
      • Bernard J.
      • Kalavrouziotis D.
      • Marzouk M.
      • Nader J.
      • Bernier M.
      • Pibarot P.
      • et al.
      Prosthetic choice in mitral valve replacement for severe chronic ischemic mitral regurgitation: long-term follow-up.
      we conclude that BP has to be the first choice in patients with severe CIMR when mitral repair is not advisable.

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