Mitral Valve Repair Versus Replacement in Elderly With Degenerative Disease: Analysis of the STS Adult Cardiac...

It has been postulated that mitral valve repair in the elderly does not confer short-term benefits over mitral valve replacement with complete preservation of the chordal apparatus. Our purpose was to test this hypothesis using data from The Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS ACSD).

Patients aged 70 years or more undergoing primary isolated elective mitral valve repair or mitral valve replacement for degenerative disease were obtained from the STS ACSD versions 2.73 and 2.81. Patients with a concomitant tricuspid procedure, atrial fibrillation surgery, or atrial septal defect/patent foramen ovale repair were included. The two treatment groups were further stratified by age in years (70 to 74, 75 to 79, and 80 or more). Adjusted 30-day mortality rates were analyzed by mitral procedure and chordal preservation strategy.

The study included 12,043 patients, of whom 71% underwent mitral valve repair. Observed 30-day mortality after repair was lower than after replacement (2.2% versus 4.8%, respectively; p < 0.0001). Using repair as reference, adjusted operative mortality was higher for replacement in the overall cohort (odds ratio 1.83, 95% confidence interval: 1.45 to 2.31). There was no significant difference in mortality between complete versus partial chordal preservation in repair (odds ratio 1.24, 95% confidence interval: 0.80 to 1.93). Mitral valve replacement with chordal preservation remained inferior to repair (odds ratio 1.66, 95% confidence interval: 1.28 to 2.14). The failed repair rate was 7.9%, with a 30-day mortality of 6%.

In patients aged 70 years or more, degenerative mitral repair was associated with lower operative mortality compared with replacement, irrespective of chordal preservation strategy. Failed repairs reduced this short-term benefit compared with chordal-sparing replacement as evidenced by the similar operative mortality on an intention to treat analysis.