Risk of reoperation following rheumatic mitral repair: Long-term longitudinal analysis

To evaluate long-term outcomes of rheumatic mitral valve (MV) repair and identify the risk factors of MV reoperation.

This retrospective, single-center cohort study evaluated 337 patients who underwent MV repair for rheumatic disease between 2000 and 2022. The primary outcome was MV reoperation. Competing risk analyses using Fine-Gray models were performed, with death as the competing risk.

MV repair techniques included ring annuloplasty (81.0%), commissure procedures (33.5%), leaflet resection (2.7%), posterior mitral leaflet mobilization (14.8%), anterior mitral leaflet (AMVL) augmentation (4.2%), Alfieri procedure (2.7%), papillary muscle splitting (12.8%), and chordal procedures (30.6%). The 30-day mortality rate was 0.9%. Over a median follow-up of 15.2 years (interquartile range, 7.7-19.4 years; total, 4629.71 patient-years), 54 patients died, with a 20-year survival of 78.9% (95% CI, 73.6%-84.5%). Thirty-two patients required MV reoperation for regurgitation (n = 15), mitral stenosis (MS) (n = 14), and mixed lesions (n = 3). The cumulative risk of reoperation was 4.5% at 10 years and 12.7% at 20 years. Independent risk factors included tricuspid regurgitation velocity >3.4 m/s (hazard ratio [HR], 3.26; P = .005), moderate-to-severe MS (HR, 4.39; P < .001), AMVL augmentation (HR, 5.84; P = .001), and chordal procedures (HR, 2.99; P = .004). The 20-year reoperation rates were 1.0%, 12.7%, and 33.6% in patients with 0, 1, and ≥2 risk factors, respectively (P < .001).

The long-term durability of rheumatic MV repair is significantly affected by such risk factors as pulmonary hypertension, moderate-to-severe MS, AMVL augmentation, and chordal procedures. Repair is preferable in patients without these risk factors.