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Department of Surgery, University of Virginia, Charlottesville, Virginia
Accepted for publication March 5, 2008.
* Address correspondence to Dr Ailawadi, PO Box 800679, Charlottesville, VA 22908 (Email: gorav{at}virginia.edu).
Presented at the Fifty-fourth Annual Meeting of the Southern Thoracic Surgical Association, Bonita Springs, FL, Nov 7–10, 2007.
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Abstract |
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Methods: Consecutive elderly patients undergoing operation for mitral regurgitation at our institution from 1998 to 2006 were reviewed. Elderly patients (mean age, 78.0 ± 2.8 years) who underwent mitral repair (n = 70) or replacement (n = 47) were compared with cohorts of young patients (mean age, 58.9 ± 9.3 years) who underwent repair (n = 100) or replacement (n = 98) during the same period. Patient details and outcomes were compared using univariate, multivariate, and Kaplan–Meier analyses.
Results: Mitral replacement in elderly patients had higher mortality than repair (23.4%, 11 of 47 versus 7.1%, 5 of 70; p = 0.01) or as compared with either operation in the reference group (p < 0.0001). Postoperative stroke was higher in elderly replacement patients compared with repair (12.8%, 6 of 47 versus 0%; p = 0.003) or compared with either young cohort (p = 0.02). Compared with elderly repair patients, elderly replacement patients had more cerebrovascular disease (21.3%, 10 of 47 versus 4.3%, 3 of 70; p = 0.005) and rheumatic mitral valves (21.3%, 10 of 47 versus 0%; p = 0.0001). In the young group, overall complication and mortality were no different between replacement and repair. Long-term survival favored repair over replacement in elderly patients (p = 0.04). One elderly repair patient experienced late recurrence of persistent mitral regurgitation.
Conclusions: In patients age 75 years or older, mitral repair is associated with a lower risk of mortality, postoperative stroke, and prolonged intensive care unit and hospital stay compared with mitral replacement. Mitral repair can be performed in preference over replacement even in patients older than the age of 75.
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Introduction |
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TopAbstractIntroductionPatients and MethodsResultsCommentDiscussionReferences |
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The purpose of this investigation was to review our experience of MV repair versus MV replacement in elderly patients age 75 years or older who underwent isolated and concomitant cardiac procedures to determine what differences, if any, exist in regard to morbidity and mortality. In addition, long-term mortality after repair and replacement in elderly patients was compared. Finally, elderly patients were also compared with patients younger than 75 years undergoing MV repair or replacement.
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Patients and Methods |
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TopAbstractIntroductionPatients and MethodsResultsCommentDiscussionReferences |
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75 years) during a 9-year period (January 1, 1998, to December 31, 2006) at the University of Virginia. Patients with emergency operation, previous mitral prosthesis, and mitral stenosis were excluded from this study. A total of 117 elderly patients (mean age, 78.0 ± 2.8 years) who underwent MV repair (n = 70) or MV replacement (n = 47) were compared with each other as well as with a cohort of young patients (age <75 years). This reference group (mean age, 58.9 ± 9.3 years) included patients who underwent MV repair (n = 100) and MV replacement (n = 98) during the same period. Demographic and preoperative comorbidities were compared between age groups and between MV operations.
Elderly Patients
No differences in age or preoperative risk variables including diabetes, peripheral vascular disease, or chronic obstructive pulmonary disease were identified between elderly patients undergoing MV repair or replacement (Table 1). Twenty-nine (61.7%) elderly MV replacement patients were female, although this was not significantly different from elderly repair patients (48.6%; p = 0.16). New York Heart Association class was similar between elderly MV repair and replacement patients (2.22 ± 0.68 versus 2.10 ± 0.63; p = 0.32). Preoperative cerebrovascular disease was more common in elderly MV replacement patients (21.3%) than in elderly MV repair patients (4.3%; p = 0.005). Preoperative atrial fibrillation was not different. Indications for MV surgery were different between groups. Elderly repair patients were more likely to have degenerative (56.5%) or ischemic (42.9%) mitral regurgitation compared with elderly replacement patients, who had more rheumatic disease (21.3%), mitral annular calcification (12.8%), and endocarditis (4.3%; p = 0.0001). Coronary artery disease was less common in elderly MV replacement patients (34.8%) versus repair patients (57.1%; p = 0.02).
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Definitions
All patients had at least 3+ MR, and the degree of MR was determined by preoperative transthoracic echocardiogram. Mechanism of MV disease was diagnosed by direct surgical inspection, pathologic reports, and echocardiograms. Ischemic disease was further characterized by patients with at least one previous myocardial infarction, associated regional wall motion abnormality, normal valve leaflets and chordae, and the absence of other MV disease. Rheumatic disease and mitral annular calcification was identified by preoperative imaging, including echocardiography and cardiac catheterization, and confirmed at operation.
Operative Techniques
All procedures were performed through full or partial sternotomy by 6 surgeons during the study period. Patients were placed on cardiopulmonary bypass using standard techniques. Dual venous cannulation was performed either percutaneously or directly. Antegrade with or without retrograde cardioplegia was used, dependent on surgeon preference. When performed, coronary artery bypass grafting (CABG) or atrial ablation procedure was done before the mitral procedure. Tricuspid and aortic valve procedures were done after the mitral procedure. Transesophageal echocardiogram was used in all patients before MV surgery to help characterize the mechanism of MR and then after MV repair or replacement to evaluate the adequacy of MV surgery. All patients were considered for MV repair. Standard repair techniques including triangular leaflet resection (as described previously) [9], artificial neochord insertion, and semirigid or rigid annuloplasty ring insertion were used in MV repair patients. Subvalvar sparing technique for MV replacement patients was used in all patients whenever possible, and performed in 71.1% of valve replacements.
Follow-Up
Follow-up information was obtained during outpatient appointments and by phone interviews with the referring or primary care physicians. Additional data were also obtained from Social Security death registries. Follow-up data on survival and reoperation were available on 97.4% of all elderly patients. The mean duration of follow-up was 45.1 ± 32.9 months and 59.0 ± 34.6 months in elderly patients undergoing MV repair and replacement, respectively.
Statistical Analysis
Patient data were tabulated and stratified by age group for repair versus replacement. Continuous variables were compared using Student's t test or Wilcoxon rank-sum tests, and categorical variables were compared using 
2 analysis or Fisher's exact test, as appropriate. Logistic regression analysis of clinically relevant risk factors was used to identify independent predictors of 30-day mortality. Kaplan–Meier survival curve estimates were used to compare long-term survival between mitral repair and replacement in elderly patients. Statistical tests were performed with SAS 9.1.3 (SAS Institute, Inc, Cary, NC).
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Results |
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Outcomes
One elderly and 1 young patient each required return to cardiopulmonary bypass with replacement of their MV after attempted repair. No patient who underwent MV replacement required return to cardiopulmonary bypass for issues with their prosthetic valve. Elderly patients undergoing MV surgery collectively had higher 30-day hospital mortality than young patients (13.7%, 16 of 117 patients, versus 3.6%, 7 of 197 patients; p = 0.001). Elderly MV replacement patients had higher 30-day mortality (23.4%) than elderly repair patients (7.1%; p = 0.01; Table 3). In young patients, mortality differences were not evident between patients undergoing repair or replacement (2.0% versus 5.1%; p = 0.27).
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Prolonged ventilator course occurred more often in elderly replacement versus repair patients (21.3% versus 2.9%; p = 0.001). Prolonged stay in the intensive care unit occurred in 21.3% of elderly replacement patients and was significantly higher than in elderly repair patients (4.3%; p = 0.004). Young patients had equivalent intensive care unit and ventilator course independent of type of MV operation. Hospital length of stay was longer in elderly replacement patients than in elderly repair patients (14.0 ± 13.2 versus 8.6 ± 3.5 days; p = 0.01). Similarly, young replacement patients (11.3 ± 9.3 days) had longer lengths of stay than patients undergoing repair (8.5 ± 7.1 days; p = 0.02).
Univariate analysis was performed on young and old (315) patients to identify risk factors correlated with stroke and mortality (Table 4). The only risk factor associated with stroke was MV replacement (p = 0.03). Age, type of concomitant operation, and preoperative cerebrovascular disease were not associated with stroke. Univariate analysis of all patients documented that mortality was highly associated with age as patients who died were on average 10 years older (range, 42 to 83 years) than survivors (p = 0.003). Mitral valve replacement was significantly associated with mortality (p = 0.02). Other variables associated with mortality by univariate analysis included preoperative left ventricular dysfunction (p = 0.02), cause of MR (p = 0.03), and cardiopulmonary bypass time (p = 0.04). Other risk factors, including concomitant operation (whether CABG or other valve procedure) as well as New York Heart Association class, did not correlate with mortality. Operating surgeon did not correlate with mortality (p = 0.16).
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Long-Term Outcomes
Long-term survival curves indicate improved survival after MV repair over replacement in elderly patients (p = 0.041; Fig 1). After accounting for postoperative deaths, survival between repair and replacement in elderly patients was similar (p = 0.21). During the follow-up period, 1 elderly patient required eventual replacement 7 months after initial repair (1.4%). No elderly patient who underwent MV replacement required reoperation for his or her MV. After accounting for early postoperative mortality, long-term survival was equivalent in elderly patients undergoing repair (88.2%) versus replacement (91.5%; p = 0.76).
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Comment |
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TopAbstractIntroductionPatients and MethodsResultsCommentDiscussionReferences |
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Mitral valve repair has become the preferred approach for most causes of MR in young patients. In-hospital and long-term survival advantages exist for valve repair over replacement for degenerative MV disease [1–4]. Enriquez-Sarano and associates [3] reported significantly less hospital mortality with MV repair over replacement for degenerative MV disease (2.6% versus 10.3%). Ten-year survival rate was better for repair than replacement (68% ± 6% versus 52% ± 4%; p = 0.0001). A report from Gillinov and colleagues [2] supported long-term durability of MV repair for degenerative disease with 10-year freedom from reoperation of 93%. Patients with ischemic MR have also seen benefit to valve repair although this has been less well studied in part because of intrinsic disease that is inseparable from the process causing MR [15]. Good-risk patients with ischemic MR who undergo repair have 1- and 5-year survivals of 82% and 58% compared with 56% and 36% survival, respectively, in replacement patients [5]. Our group previously reported no reoperation for recurrent MR at 5 years after valve repair in patients with ischemic MR, supporting the longevity for repair in this group of patients [15]. In a study evaluating patients with degenerative or ischemic MR, Akins and coworkers [16] found a shorter length of stay (10 versus 12 days) and less hospital mortality (3% versus 12%) in patients who underwent MV repair versus replacement. The mean age of patients in the majority of these large series indicating superiority of MV repair over replacement is between 55 and 65 years of age [1–5, 16].
Mortality risk in elderly patients undergoing valve surgery is understandably higher than in younger patients. Our series confirmed higher mortality in all elderly patients undergoing mitral surgery compared with younger patients.
Mitral Repair Versus Replacement in Elderly
Few studies have evaluated MV repair and replacement in elderly patients (Table 6). Older reports contrast more recent reports indicating the lower operative mortality in elderly patients undergoing MV repair compared with replacement. Gogbashian and associates [6] compared MV repair with replacement in 292 patients aged 70 years or older and showed that in-hospital mortality for isolated MV repair (0.7%) was significantly better than for replacement (13.9%). Five-year survival also favored MV repair over replacement (MV repair, 81% ± 3%; MV replacement, 63% ± 3%). In the subset of patients age 70 years or older in the report by Enriquez-Sarano and coworkers [3], operative mortality for repair patients was 6.8% compared with 30.8% in replacement patients, and is remarkably similar to our results. Thourani and colleagues [8] demonstrated that MV replacement and age were both independent predictors of in-hospital and long-term mortality. Despite documented superior outcomes with MV repair in elderly patients in these recent series, authors have concluded that MV repair does not provide long-term benefit in patients older than the age of 60 [8]. In our series, we documented improved survival in elderly patients with ischemic MR undergoing repair, a finding that has been seen in other large series independent of age [5].
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Potential Explanations for Improved Outcomes
Lower mortality documented in our study in elderly patients undergoing repair can be attributable to several reasons. Preservation of the subvalvar apparatus improves long-term left ventricular function and survival [22–24]. Although techniques to preserve the subvalvar apparatus were used in the majority of patients undergoing replacement (71%) in our series, valve repair is still considered superior to replacement [6, 25]. Our experience describes shorter cardiopulmonary bypass times with valve repair, which may also be linked with lower mortality. Importantly, our experience of shorter cross-clamp and bypass times during mitral repair was seen in both elderly and young patients. Unrepairable valves that require replacement may be a harbinger of more-advanced heart disease and thus may bode worse outcomes.
Limitations
This is a single-institution retrospective review, a limitation to most of the literature comparing MV repair to replacement. As such, there may be a selection bias for valves that are able to be repaired. The repairability of a valve including the complexity of valve disease and degree of annular calcification is difficult to assess by reviewing operative notes of patients who underwent mitral replacement and is a clear limitation to the potential bias in our report. A standardized intraoperative assessment model would be helpful in this and future multicenter studies. Some baseline characteristics, including preoperative cerebrovascular disease origin of MR, and concomitant operations are different between repair versus replacement in our elderly patients. Importantly, concomitant valve operations were more common in replacement patients although this was not linked to mortality by multivariate analysis. Rheumatic valves were more commonly replaced, although we documented no mortality or stroke in those patients. Thus, the higher mortality in elderly replacement patients was not explained by the higher preponderance of patients with rheumatic disease. Although excellent early and mid-term outcomes after repair of rheumatic mitral disease have been reported, mortality is not as favorable as in patients with degenerative disease [26, 27]. In our report, operations for ischemic MR were associated with higher mortality. These findings are consistent with the literature, suggesting that elderly patients with ischemic origin have the highest mortality of any subgroup [11]. These differences between our repair and replacement patients can only be accounted for through a multicenter randomized trial. Finally, there is a relatively small sample size of elderly patients (n = 117). Further differences between repair and replacement in elderly patients may become apparent given more patients.
Conclusions
There is a perception that MV repair does not provide benefit in elderly patients. Despite shorter life expectancy in elderly patients, we document improved operative and long-term survival as well as lower stroke rates in patients age 75 years or older with mitral repair over replacement. The rate of return to cardiopulmonary bypass or reoperation for persistent MR is low. No differences in outcomes were identified when concomitant CABG or valve operation was required. Mitral repair can be performed over replacement when feasible even in patients older than the age of 75.
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Discussion |
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TopAbstractIntroductionPatients and MethodsResultsCommentDiscussionReferences |
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And my second question is, I was curious as to why 21% of your elderly replacement patients, these are patients older than 75, got a St. Jude valve?
Thank you.
DR AILAWADI: Thank you for your questions. The first question related to whether we could have matched it differently or if it was a larger sample size if we expect to see the same outcomes. Given the sample size that we had, we attempted to account for all these differences that you mentioned using multivariate analysis. So if we believe statistical methods, we would anticipate with larger sample sizes we would see a similar outcome.
With respect to your second question?
DR LAWTON: Twenty-one percent of your elderly replacement patients actually got a St. Jude valve. These are people older than 75.
DR AILAWADI: There were different reasons depending on the patient. A patient, for example, who is already on Coumadin (sodium warfarin) for A-fib (atrial fibrillation) who did very well with Coumadin may have gotten a St. Jude valve or patients that already had a mechanical valve in another position may have gotten a mechanical valve.
DR LAWTON: So would you say that you placed it because of ease?
DR AILAWADI: We know that repairing patients with mitral regurgitation when possible, even in the face of other valve prostheses, still has a better outcome. The Cleveland Clinic group has shown that very nicely.
DR LAWTON: Thank you.
DR JOHN M. KRATZ (Charleston, SC): Your replacement group had a fairly daunting 12% stroke rate, which probably contributed a good bit to your increased mortality in that group 2. A lot of us have been getting away from even short-term anticoagulation for a bioprostheses. Could you comment on that stroke group of 12% and your anticoagulation protocol? What do you think that had to do with your stroke rate?
DR AILAWADI: The anticoagulation protocols depended on the surgeon's choice. Some surgeons at our institution anticoagulate all mitral valves for a period of 3 months, others use the AHA (American Heart Association) guidelines to anticoagulate only patients that are considered high risk that have had a previous thromboembolism, A-fib patients. So we did not look at that specifically if there was a difference based on whether they were on anticoagulation or not. We did note that even though there were differences in preoperative cerebrovascular disease, this did not bear out in way of the outcome of stroke.
DR TARA KARAMLOU (Portland, OR): You first showed that patients were statistically much more likely when they are elderly to undergo replacement. I wonder then if your results actually just are reflecting your institutional bias toward repairs since you had only 47 patients who actually underwent replacement with a preponderance of repairs. So could you comment on that?
DR AILAWADI: The STS database takes all-comers. There are no provisions for patients that have mitral stenosis with a previous mitral prosthesis. I quoted the STS database reports a 36% repair rate for all mitral surgery. Our repair rate for mitral regurgitation is over 60%. Certainly we prefer to repair any valve in which it is possible despite their age. We feel that repair even in elderly provides a better long-term outcome.
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