Four decades of experience with mitral valve repair: analysis of differential indications, technical evolution, and long-term outcome

Objective: To determine the long-term outcomes of mitral valvuloplasty for myxomatous valve disease, rheumatic valve disease, and functional mitral regurgitation.

Methods: A total of 1503 patients underwent mitral valvuloplasty by a single surgeon between February 1972 and April 2008 and were retrospectively reviewed for short- and long-term results. Overall mean age was 60.3 + or - 13.7 years, and 57% were male. The cause was rheumatic in 193 patients, myxomatous in 1042 patients, and ischemic and nonischemic functional mitral regurgitation in 236 patients. Ring annuloplasty was performed in 1306 patients (87%). Commissurotomy was the primary repair for rheumatic valves, posterior leaflet resection and reconstruction was the most common repair for myxomatous valves (527/1042 [51%]), and ring reduction annuloplasty was the primary operation for functional mitral regurgitation.

Results: The 30-day mortality was 19 of 1503 patients (1.3%) and significantly higher in the functional mitral regurgitation group (11/236 patients, 4.7% vs 0.5% in the rheumatic group and 0.6% in the myxomatous group, P < .01). The 10-, 20-, and 30-year survivals were similar for the rheumatic and myxomatous groups (77%, 56%, and 39% vs 79%, 62%, and 52%, respectively) but significantly less for the functional mitral regurgitation group (44%, 4%, and 0%, respectively, log-rank P < .0001). The 10- and 20-year freedom from reoperation rates were significantly better for the myxomatous group than for the rheumatic group (90% and 82% vs 66% and 34%, log-rank P < .0001), with a 30-year freedom from reoperation of only 10% for rheumatic repair. In the myxomatous group, freedom from reoperation was lower in patients with anterior leaflet pathology (P = .0008).

Conclusion: Follow-up data to 36 years demonstrate that cause strongly determines survival and durability of mitral valvuloplasty; patients with rheumatic valve disease who survive more than 20 years require reoperation, whereas functional mitral regurgitation carries the highest short- and long-term mortality rates and lowest freedom from reoperation. Mitral valvuloplasty for myxomatous valves demonstrates the longest durability, with many patients free from reoperation at 30 years.