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Ann Thorac Surg 2003;75:820-825
© 2003 The Society of Thoracic Surgeons

Original article: cardiovascular

Use of mitral valve repair: analysis of contemporary United States experience reported to the Society of Thoracic Surgeons National Cardiac Database

Edward B. Savage, MDa*, T. Bruce Ferguson, Jr, MDb, Verdi J. DiSesa, MDa

a Department of Cardiovascular-Thoracic Surgery, Rush Presbyterian-St. Luke’s Medical Center, Chicago, IL, USA
b Louisiana State University Health Sciences Center, Marrero, LA, USA

Accepted for publication October 8, 2002.

* Address reprint requests to Dr Savage, Suite 1156, 1725 West Harrison St, Chicago, IL 60612, USA.
e-mail: chstcutter{at}aya.yale.edu


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
 References
 
BACKGROUND: The Society of Thoracic Surgeons National Cardiac Database data indicate that the performance of mitral repair has increased significantly (1990 to 23.2%, 1999 to 32.0%, p < 0.0001). We examined contemporary (1999 to 2000) usage of mitral repair in the United States.

METHODS: We analyzed National Cardiac Database data to determine the operative approach for a diagnosis of mitral regurgitation.

RESULTS: A total of 21,741 isolated and combined mitral valve procedures were identified. The overall frequency of repair was 37.7% (8206). For procedures isolated to the mitral valve, the frequency of repair was 35.7% (3027/8486) whereas repair was more common with concomitant CABG (42.9% [3088/7193], p < 0.0001). The proportion of patients having repair decreased with age (41.2% [386/936] in 20 to 39 years, 36.1% [3513/9746] in > 70 years, p = 0.0016). Repair was more common in males (43.5% [4720/10860]) than females (32.0% [3472/10842], p < 0.0001). Repair was less common as NYHA Class increased (Class I, 47.8% [949/1984] vs Class IV, 33.2% [1803/5427]) and for emergent operative status (21.2% [156/736] vs 38.5% [8000/20773] for elective/urgent, both p < 0.0001). The number of prior operations did not affect the use of repair. Simple annuloplasty was performed in the majority of reported repairs (62.8% [3837/6115]), more so with associated CABG as compared to isolated repair (70.2% [2167/3088] vs 55.2% [1670/3027]; p < 0.0001).

CONCLUSIONS: Mitral repair was performed in over one-third of the patients reported in 1999 to 2000 and has increased since the National Cardiac Database inception. Repair usage differed based on sex, age, gravity of illness, and associated procedures. This provides a base line from which to expand the application of repair.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 Acknowledgments
 References
 
The advantages of mitral valve repair compared with replacement have been well documented and include maintenance of ventricular geometry, reduced requirement for chronic anticoagulation, excellent long-term durability, and reduced incidence of endocarditis. However mitral valve repair, beyond simple annuloplasty, requires skills additional to those necessary for replacement including an understanding of the three-dimensional structure of the mitral valve, conceptualization of the effects of various repair techniques, and the ability to integrate and combine these techniques for successful repair. Furthermore, mitral valve repair is time-consuming and may, despite the best efforts of the surgical team, result in immediate failure thereby requiring valve replacement. Many techniques for mitral valve repair have been developed and repair durability verified within the past 20 years. In fact, data from the Society of Thoracic Surgeons National Cardiac Database (NCD) demonstrate that the performance of mitral repair has increased relative to replacement over the last decade (1990 to 23.2%, 1999 to 32.0%, p < 0.0001, Fig 1). However mitral valve repair techniques can be complex, difficult to learn without specialized training and difficult to incorporate into a surgical practice if the volume of mitral surgery is low. The purpose of this study was to analyze in detail current utilization of mitral valve repair in the United States. Data from 1999 to 2000 were analyzed and interpreted to reflect current practice. Limitations of the NCD are discussed. Data were further compared with a gold standard and recommendations for future practice are made.



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  		Fig 1. Application of mitral valve repair with or without coronary artery bypass graft (CAB), for all mitral valve procedures both isolated and with associated procedures, is plotted as a percentage of the total number of mitral valve procedures. Application of repair increased overall from 24.6% to 39.8%. Without associated CAB from 20.3% to 34.8%. With associated CAB from 30.8% to 46.0%. (All MVR = inclusive of MVR and MVR + CAB; MVR = mitral valve procedure with or without associated "non-CAB" procedures; MVR + CAB = MVR with CAB.)

 

   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 Acknowledgments
 References
 
The NCD was queried to extract all reported patients with a diagnosis of mitral insufficiency, inclusive of other diagnoses, that underwent a mitral valve procedure exclusively or as part of a multicomponent open-heart procedure. Queries and analysis were performed based on fields on the Cardiac Surgery Data Collection Form, version 2.35. Logistic regression was used to test for a significant increase in the use of repair over time (Fig 1). All other statistical comparisons were done using Chi-square for an nx2 table where n was the number of groups. A p value less than 0.05 was considered significant.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 Acknowledgments
 References
 
Data extraction for the years 1999 and 2000 identified 21,741 isolated and combined mitral valve procedures for patients carrying a diagnosis of mitral regurgitation. Of these, 8206 (37.7%) patients underwent mitral valve repair. A total of 8486 patients had isolated procedures on the mitral valve (Table 1). Of these, 3027 (35.7%) had valve repair. In contrast, of the 7193 patients that had mitral surgery with associated coronary artery bypass grafting, 3088 (42.9%, p < 0.0001) underwent valve repair. An associated diagnosis of mitral stenosis, in addition to mitral regurgitation, was reported for 5262 patients. Of these, only 1028 (19.7%) had the valve repaired. Excluding the patients with an additional diagnosis of mitral stenosis (Table 1), of 5943 patients who had isolated mitral valve procedures, 2517 (42.4%) had a repair, and of the 5401 patients who had an associated coronary artery bypass graft (CABG) procedure, 2503 (46.3%) had a repair (p = 0.0083). A majority of the repair procedures were isolated annuloplasty, with annuloplasty more common when associated CABG was performed (55.2% v. 70.2%, p = 0.0001).


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  		Table 1. Relative Use of Various Repair Techniques and Replacement for Isolated Mitral Valve Surgery With or Without Associated CABG

 
Demographic data are detailed in Table 2. The use of repair decreased with age from 41.2% in patients 20 to 39 years old, to 36.1% in patients aged more than 70 years (p = 0.0016). Repair was more commonly performed in males (43.5%) than females (32.0%, p < 0.0001), and in Caucasians (38.4%) than other ethnic groups (33.0%, p = 0.0004). Subanalysis based on gender and age is presented in Table 3. Broken down into subgroups, the significantly greater use of mitral repair in males persisted when analyzed based on associated coronary disease, mitral stenosis, or age.


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  		Table 2. Demographics of Mitral Valve Repair Versus Replacement

 

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  		Table 3. Subanalysis Based on Gender and Age

 
The impact of preoperative cardiac status on use of valve repair is detailed in Table 4. Repair was less common as NYHA Class increased from Class I (47.8%) to Class IV (33.2%, p < 0.0001). In contrast, repair was more common in patients with a left ventricular ejection fraction between 21% and 40% than in those with ejection fractions less than 21% or more than 40% (p < 0.0001). There was no difference in repair usage if the patient had suffered either a recent or a remote myocardial infarction. Repair was less commonly used if the patient was in atrial fibrillation (39.1% v. 31.1%, p < 0.0001); in the presence of active endocarditis (17.8%) as opposed to treated endocarditis (30.9%, p < 0.0001); and for procedures done as emergencies (21.2%) compared with procedures considered to be elective or urgent (38.5%, p < 0.0001). Repair was less common in patients having reoperations, but the number of prior procedures did not influence the use of repair. Repair was less common if the previous operative procedure was a valve procedure (11.6%) as opposed to coronary revascularization (30.0%, p < 0.0001).


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  		Table 4. Use of Repair Based on Preoperative Cardiac Status

 
As detailed in Table 5, repair was utilized less often in the presence of renal failure (31.8%) than in its absence (38.3%, p < 0.0002). The prevalence of repair was not changed if the patients had peripheral vascular disease, but was less common with the presence of cerebrovascular disease (p < 0.0001).


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  		Table 5. Use of Repair Based on Comorbidities

 
Table 6 summarizes patients in whom mitral valve repair was performed with associated procedures. Repair was much less common when the aortic valve was replaced with a mechanical prosthesis (14.2%) than when the valve was repaired (74.2%, p < 0.0001) or replaced with a bioprosthesis (40.4%, p < 0.0001).


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  		Table 6. Use of Repair With Associated Procedures

 

   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
Acknowledgments
 References
 
At the outset the limitations of the NCD should be set forth. Participation in the STS NCD is voluntary and data are submitted and compiled by participants. Participation incurs an institutional expense, which may be a disincentive for participation by smaller programs. Furthermore, the completeness and quality of the data may vary among institutions as personnel with variable knowledge of details of mitral valve surgery complete data collection forms. Participation has increased significantly since inception of the database, so it currently presents a more accurate reflection of trends than it did 10 years ago. The demographics of participating institutions has probably changed over the life of the database. Therefore, trends demonstrated by the database reflect, but do not absolutely represent national trends. An additional shortcoming is the limited information submitted by participating institutions due to the design of the data collection form. No information about valvular pathology or the etiology of the regurgitation is collected so an analysis of the surgical approach based on these parameters is not possible. Furthermore, although annuloplasty alone can be differentiated from reconstruction with or without annuloplasty, details of the reconstruction (eg, anterior or posterior leaflet repair) are not included so an analysis on the basis of type and complexity of repair is not possible. Finally, it should be noted on review of the data that the totals for many analysis groups differ; this represents missing data and is another potential source of error. Nevertheless given the penetration of the NCD, it is not unreasonable to draw certain conclusions and make recommendations based on the data.

Realizing these constraints, the NCD demonstrates that valve repair has clearly penetrated into the national practice of cardiac surgery. In the fifth quintile of the 1990s decade fully 42.4% of purely regurgitant valves (no stenosis reported) were repaired. However, a review of all the repairs reveals that the majority of these were repaired by simple annuloplasty. This suggests that many valves that might have been repairable using complex repair techniques were instead replaced. The fact that repair usage was reduced in patients more than 70 years of age could be attributed to the fact that these patients are candidates for bioprostheses that, like valve repair, do not obligate the long-term use of anticoagulation. Reduced rates of valve repair in females could be attributed to the noted higher use of repair with associated CABG (Table 1) combined with a greater prevalence of ischemic disease in men. However, this is not borne out in the data presented. When CABG is broken out, the prevalence of repair is still higher in men. We have tried to break this out in Table 3 by excluding an associated diagnosis of mitral stenosis, yet the higher prevalence of repair in males persists. Perhaps the greatest limitation of this analysis is the absence of data reported to the NCD about etiology. The most favorable situation for valve repair is a degenerative, ischemic, or dilated etiology of the regurgitation, rheumatic valves are much less amenable to repair [1]. In order to overcome this limitation, CABG has been used as a crude surrogate for ischemic etiology and the presence of mitral stenosis a crude surrogate for rheumatic etiology in the above analysis.

Mitral valve repair can be performed with low operative mortality (3.4%) as reported by Muehrcke and Cosgrove [2] who combined data from nine published series. In addition, multiple studies have documented the long-term durability and low incidence of long-term complications of mitral valve repair [3, 4]. At 15 years, these results include 93.9% freedom from thromboembolism, 96.6% freedom from endocarditis, 95.6% freedom from anticoagulant-related hemorrhage, 87.3% freedom from reoperation (degenerative disease, 92.7%; rheumatic disease, 76.1%), and little or no mitral regurgitation in 91% of survivors [5]. In comparison with replacement, the long-term results of mitral valve repair are better. Enriquez-Sarano and coworkers [6] compared repair with replacement and noted an independent beneficial effect of valve repair on overall survival (hazard ratio, 0.39; p = 0.00001), operative mortality (odds ratio, 0.27; p = 0.026), late survival (hazard ratio, 0.44; p = 0.001), and postoperative ejection fraction (p = 0.001). Most surgeons agree that every patient with mitral valve regurgitation who requires surgery should be approached with the intent to repair rather than replace the valve. The ability to repair the valve has been incorporated into the indications for referral for surgery [7].

To put this data in perspective it is useful to have a "gold standard" to point to for comparison. Mohty and colleagues [8] from the Mayo Clinic compared 679 repairs and 238 replacements performed from 1980 to 1995. Realizing a referral bias (those patients who had potentially repairable valves might be preferentially referred), this experience suggests a standard for rates of utilization of repair. Of the 917 patients reviewed, the overall rate of repair (74%) for isolated mitral insufficiency (from 1980 to 1995) is almost twice that of the national rate of 42.4% (1999 to 2000, excluding mitral stenosis, Table 1) suggesting that nationally many more patients could benefit from mitral valve repair.

To approach this standard it may behoove the cardiac surgical community to adopt a more formal approach to educating surgeons in these techniques. Many of these techniques were described after practicing surgeons finished their training, and many recent trainees may not have been exposed to these techniques in their training. The residency review committee does not distinguish repair from replacement in the minimum case requirements for certification. Furthermore, if mitral valve surgery is a small component of a surgeon’s practice the opportunity to apply these techniques may be uncommon. Finally, although the benefits of repair are well described, many medical insurers do not differentiate between repair and replacement, and may not allow specific referral to a surgeon with expertise in mitral repair.

In summary, this analysis provides a snapshot of the current practice of mitral valve repair in the United States and discusses the limitations of data derived from the NCD. With this in mind, we suggest that mitral valve repair may be underutilized, consider some possible causes of this practice, and offer recommendations for increasing repair utilization.


   Acknowledgments
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
References
 
The authors would like to acknowledge the assistance of Laura P. Coombs, PhD, for database query and data and statistical analysis; Mary Eiken, RN, Director of the STS National Cardiac Database; and Robert Walter, PhD, for manuscript and statistical review.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Muehrcke D.D., Cosgrove D.M. Mitral valvuloplasty. In: Edmunds L.H., Jr, ed. Cardiac surgery in the adult. New York: McGraw-Hill, 1997:1012.
  2. Muehrcke D.D., Cosgrove D.M. Mitral valvuloplasty. In: Edmunds L.H., Jr, ed. Cardiac surgery in the adult. New York: McGraw-Hill, 1997:1017.
  3. Cohn L.H., Couper G.S., Aranki S.F., et al. Long-term result of mitral valve reconstruction for regurgitation of myxomatous mitral valve. J Cardiovasc Surg 1994;107:143-151.
  4. David T.E., Armstrong S., Sun Z., Daniel L. Late results of mitral valve repair for mitral regurgitation due to degenerative diseases. Ann Thorac Surg 1993;56:7-12.[Abstract/Free Full Text]
  5. Deloche A., Jebara V.A., Relland J.Y.M., et al. Valve repair with Carpentier technique. J Thorac Cardiovasc Surg 1990;99:990-1001.[Abstract]
  6. Enriquez-Sarano M., Schaff H.V., Orszulak T.A., Tajik A.J., Bailey K.R., Frye R.L. Valve repair improves the outcome of surgery for mitral regurgitation: a multivariate analysis. Circulation 1995;91:1022-1028.[Abstract/Free Full Text]
  7. Bonow R.O., Carabello B., de Leon A.C., et al. ACC/AHA guidelines for the management of patients with valvular heart disease. Executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Valvular Heart Disease). Circulation 1998;98:1949-1984.[Free Full Text]
  8. Mohty D., Orszulak T.A., Schaff H.V., Avierinos J.-F., Tajik J.A., Enriquez-Sarano M. Very long-term survival, and durability of mitral valve repair for mitral valve prolapse. Circulation 2001;104:I-1-7.



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