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Ann Thorac Surg 2000;70:1224-1226
© 2000 The Society of Thoracic Surgeons

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Original articles: cardiovascular

Late results of mitral valve reconstruction in the elderly

^a Division of Cardiothoracic Surgery, New York University Medical Center, New York, USA

Address reprint requests Dr Grossi, New York University Medical Center, Suite 9-V, 530 First Ave, New York, New York 10028
e-mail: grossi{at}cv.med.nyu.edu

	Abstract

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Background. This study attempts to confirm favorable results with mitral valve reconstruction (MVP) in patients greater than or equal to 70 years of age and to examine complication rates by actual analysis.

Methods. Between June of 1980 and December of 1997, 278 patients 70 years of age or older (mean, 75.2 years; range, 70 to 87 years) underwent MVP for mitral regurgitation. Most involved insertion of an annuloplasty ring. Concomitant procedures were performed in 72.3%, and 55.0% required coronary revascularization.

Results. For isolated MVP, the in-hospital mortality rate was 6.5% and 17.0% when combined with coronary revascularization. The mortality rate when combined with another valve procedure was 13.2%. The 5-year freedom from late cardiac death was 100% in the isolated MVP group and 79.7% for MVP with a concomitant procedure (p = 0.006). Complications were analyzed using actual (cumulative incidence) analysis to eliminate the competing risk of noncardiac death. Mean NYHA class improved from 3.32 to 1.71 postoperatively. Repair failure was rare, with a 5-year freedom from reoperation of 91.2%.

Conclusions. These findings confirm the favorable outcome of MVP in elderly patients. Late repair failures are rare; comorbid disease is an important predictor of outcome.

	Introduction

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That elderly persons are becoming an increasingly large percentage of the United States population has been widely noted. Mitral valve reconstruction (MVP) offers elderly patients with mitral regurgitation the advantages of preservation of left ventricular function, elimination of the necessity for a repeat operation for bioprosthetic valve degeneration, and avoidance of anticoagulation. However, the effectiveness and durability of mitral reconstruction in elderly patients with their more fragile valve tissue remains questionable. Furthermore, an increasing percentage of elderly patients who need MVP also require coronary artery bypass grafting (CABG) or another valve procedure.

Although a number of studies have addressed valve surgery in elderly patients, most of these reports do not distinguish the results of aortic valve procedures from those of mitral valve procedures [1, 2] or do not separate the outcomes of mitral replacement from those of mitral reconstruction [3]. In addition, the recently developed approach of actual or cumulative incidence analysis [4] has shed new light on analysis of valve surgery complications [5]. We have previously reported favorable results with mitral valve reconstruction (MVP) in a group of patients 70 years of age or older [6]. The present study was intended to expand these findings by extending the follow-up interval in a larger group of patients and using actual analysis to examine complication rates.

	Material and methods

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Patient population
From June 1980 through December 1997, 278 consecutive patients 70 years of age or older underwent mitral valve reconstruction surgery for severe mitral insufficiency at our institution. Moderate systemic hypothermia and cold blood cardioplegia were used throughout the series, with retrograde cardioplegia delivery used extensively in the last decade. The mean ± standard deviation of the age of all patients in the study was 75.2 ± 3.70 years; 37 patients (13.3%) were 80 years of age or older, and 58.3% were male. Other preoperative patient characteristics are shown in Table 1. Concomitant procedures were performed in 201 patients (72.3%), with 153 (55.0%) requiring coronary artery bypass and 53 (19.1%) requiring a second valve procedure. Of the 278 patients, 48 (17%) were operated upon as emergencies.

	Results

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The in-hospital mortality rate for isolated MVP was 6.5% (5 of 77), and the overall mortality rate was 12.6% (35 of 278). When MVP was combined with coronary artery bypass, the mortality rate was 17.0% (26/153), and when it was combined with another valve procedure, the mortality rate was 13.2% (7/53). Univariate predictors of in-hospital mortality are shown in Table 3. Multivariate analysis revealed significant predictors of in-hospital mortality to be preoperative New York Heart Association class IV (odds ratio, 4.20; p = 0.001) and angina (odds ratio, 2.74; p= 0.04). Diabetes was a borderline predictor of in-hospital mortality (odds ratio, 2.15; p = 0.07). Operative year was not associated with a significant difference in operative mortality.

Multivariate analysis of late results showed only diabetes to be a predictor of late cardiac death (odds ratio, 2.1; p = 0.01). Actuarial survival from late cardiac death was 100% at 5 years for isolated MVP and 79.7% for combined procedures. Actual (cumulative incidence) analysis showed the 5-year freedom from reoperation to be 92.6% for isolated MVP and 91.8% for combined procedures. Freedom from late cardiac death and reoperation combined for all patients was 78.9% at 5 years. Actual freedom from all valve-related complications (thromboembolic problems, endocarditis, and anticoagulant related problems) at 5 years was 85.5% for all patients. Actual analysis showed 5-year freedom from reoperation and all valve related complications to be 78.4% for isolated MVP and 79.2% for combined procedures. Among isolated MVP patients, 76.7% were free of late cardiac death, reoperation, and all valve related complications at 5 years, as were 60.4% of patients with combined procedures. The mean New York Heart Association Class at follow-up for all patients was 1.71.

	Comment

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It has been suggested that mitral valve reconstruction might offer special benefits to the elderly because this procedure spares the subvalvular apparatus, has been shown to be durable, and does not require long-term anticoagulation. The findings presented here strongly demonstrate that mitral valve reconstruction can be accomplished with low mortality and morbidity in patients greater than 70 years. Survival from late cardiac death was 100% in patients with isolated MVP. Furthermore, despite the increased fragility of mitral tissue that often accompanies advanced age, mitral reconstruction was found to give durable results with a 5-year freedom from reoperation of 92%. In addition, more than 85% of all patients were free of thromboembolic, endocarditis-related, and anticoagulant-related complications 5 years after operation. The 5-year survival from all late death in our patient was virtually identical with that of the general population.

Although there are a number of studies in the literature that discuss the relative advantages of the use of mechanical compared with bioprosthetic valve replacement in the elderly [1, 2, 5], it is difficult to find current studies comparing mitral reconstruction with mitral replacement in the elderly. In a study of 100 patients 65 years of age or older with ischemic mitral regurgitation and concomitant coronary artery bypass, Bolling and coworkers reported an operative mortality rate of 4% for mitral reconstruction and a 1-year actuarial survival rate of 90% [7]. To compare the present findings with relevant studies of mitral valve replacement, a study by Pupello and colleagues of 161 isolated mitral valve replacements with bioprosthetic valves in patients 70 years of age or older reported an operative mortality rate of 14.3% and a 95% freedom from valve structural deterioration at 8 years [8]. Other studies have reported operative mortality rates for isolated mitral valve replacement in patients older than 65 years ranging from 4.8% to 27% [9–11].

The data presented here indicate that mitral reconstruction in patients 70 years of age or older fulfills its promise of preservation of left ventricular function, elimination of reoperation for bioprosthetic valve degeneration, and avoidance of anticoagulation-related complications and other valve-related complications. Late repair failures are rare even in this age group. Isolated mitral reconstruction in elderly patients may be associated with a better freedom from late cardiac death and valve related complications than mitral replacement.

	Acknowledgments

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Supported in part by The Foundation for Research in Cardiac Surgery and Cardiovascular Biology.

	References

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1. Holper K., Wottke M., Lewe T., et al. Bioprosthetic and mechanical valves in the elderly. Ann Thorac Surg 1995;60:S443-S446.
2. Kobayashi Y., Eishi K., Nagata S., et al. Choice of replacement valve in the elderly. J Heart Valve Dis 1997;64:404-409.
3. Lee E.M., Porter J.N., Shapiro L.M., Wells F.C. Mitral valve surgery in the elderly. J Heart Valve Dis 1997;6:22-31.[Medline]
4. Grunkemeier G.L., Jamieson W.R.E., Miller C. Actuarial versus actual risk of porcine structural valve deterioration. J Thorac Cardiovasc Surg 1994;108:709-718.[Abstract/Free Full Text]
5. Grossi E.A., Galloway A.C., Zakow P.K., et al. Choice of mitral prosthesis in the elderly. An analysis of actual outcome. Circulation 1998;98(19(Suppl):II116-II119.
6. Grossi E.A., Galloway A.C., LeBoutillier M., III, et al. Mitral valve repair in the elderly. Cardiol in the Elderly 1995;3:269-272.
7. Bolling S.F., Deeb M., Bach D.S. Mitral valve reconstruction in elderly, ischemic patients. Chest 1996;109:35-40.[Abstract/Free Full Text]
8. Pupello D.F., Bessone L.N., Hiro S.P., et al. Bioprosthetic valve longevity in the elderly. Ann Thorac Surg 1995;60:S270-S275.
9. Nair C.K., Biddle W.P., Kaneshige A., Cook C., Ryschon K., Sketch M.H., Sr Ten-year experience with mitral valve replacement in the elderly. Am Heart J 1992;125:154-159.
10. Antunes M.J. Valve replacement in the elderly. Is the mechanical valve a good alternative? J Thorac Cardiovasc Surg 1989;98:485-491.[Abstract]
11. Jamieson W.R., Burr L.H., Munro I., Miyagishima R.T., Gerein A.N. Cardiac valve replacement in the elderly. Ann Thorac Surg 1989;48:173-185.[Abstract]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Eugene A. Grossi Peter K. Zakow Aubrey C. Galloway Stephen B. Colvin Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Grossi, E. A. Articles by Colvin, S. B. Search for Related Content PubMed PubMed Citation Articles by Grossi, E. A. Articles by Colvin, S. B.