Mitral Repair Success Rates

[MikeHeim]

In several of my posts, I have referenced a study on the long-term success rates of Mitral Repair. My old link to the study was lost, but I found the same study now posted somewhere else. The full link to the study is:

http://circ.ahajournals.org/cgi/content/full/104/suppl_1/I-8

Here is the abstract:

Background? Mitral valve repair is considered the gold standard in surgery of degenerative mitral valve insufficiency (MVI), but the long-term results (>20 years) are unknown.

Methods and Results? We reviewed the first 162 consecutive patients who underwent mitral valve repair between 1970 and 1984 for MVI due to nonrheumatic disease. The cause of MVI was degenerative in 146 patients (90%) and bacterial endocarditis in 16 patients (10%). MVI was isolated or, in 18 cases, associated with tricuspid insufficiency. The mean age of the 162 patients (104 men and 58 women) was 56±10 years (age range 22 to 77 years). New York Heart Association functional class was I, II, III, and IV in 2%, 39%, 52%, and 7% of patients, respectively. The mean cardiothoracic ratio was 0.58±0.07 (0.4 to 0.8), and 72 (45%) patients had atrial fibrillation. Valve analysis showed that the main mechanism of MVI was type II Carpentier?s functional classification in 152 patients. The leaflet prolapse involved the posterior leaflet in 93 patients, the anterior leaflet in 28 patients, and both leaflets in 31 patients. Surgical technique included a Carpentier?s ring annuloplasty in all cases, a valve resection in 126 patients, and shortening or transposition of chordae in 49 patients. During the first postoperative month, there were 3 deaths (1.9%) and 3 reoperations (2 valve replacements and 1 repeat repair [1.9%]). Six patients were lost to follow-up. The remaining 151 patients with mitral valve repair were followed during a median of 17 years (range 1 to 29 years; 2273 patient-years). The 20-year Kaplan-Meier survival rate was 48% (95% CI 40% to 57%), which is similar to the survival rate for a normal population with the same age structure. The 20-year rates were 19.3% (95% CI 11% to 27%) for cardiac death and 26% (95% CI 17% to 35%) for cardiac morbidity/mortality (including death from a cardiac cause, stroke, and reoperation). During the 20 years of follow-up, 7 patients were underwent surgery at 3, 7, 7, 8, 8, 10, or 12 years after the initial operation. Valve replacement was carried out in 5 patients, and repeat repair was carried out in 2 patients. At the end of the study, 65 patients remained alive (median follow-up 19 years). Their median age was 76 years (age range 41 to 95 years). All except 1 were in New York Heart Association functional class I/II.

Conclusions? Mitral valve repair using Carpentier?s technique in patients with nonrheumatic MVI provides excellent long-term results with a mortality rate similar to that of the general population and a very low incidence of reoperation.

 

[Karlynn]

Interesting report Mike. Since we always say here that if you are going for a repair, have a surgeon who does repairs A LOT! So I'd be curious as to the stats for the surgeons who did those repairs mentioned in the article. Not a big thing, just one of those things that makes you go 'Hmmmm'?

It refers to Nonrhuematic valve disease. Is repair not recommended for those who've have rheumatic valve disease and if not, why not - anyone know?

One of the reasons I ask is that I was always told I had nonrheumatic mitral valve disease. But ever since reading that people who've had rheumatic fever can be harder to sedate (which I am) I've wondered if I had rheumatic fever that went un-dx'd. They had told me that they were going to try to repair my valve, but when they got "in there" it was almost gone. Just wondering if that is connected to rheumatic valve disease.

 

[Adrienne]

My surgeon, Dr. Michel Pellerin, of the Montreal Heart Institute (Institut de cardiologie de Montréal) did a two-year fellowship with Dr. Alain Carpentier (the doctor mentioned in the above article). Valve reconstruction is one of his big interests. That is why I would have no one else do my operation!!

The article was very interesting and very encouraging.

 

[Christina L]

I think rheumatic

I think rheumatic

fever causes the mitral valve to be stenotic whereas with mitral valve prolapse, the leaflets are floppy and redundant and thickened, but not hardened by rheumatic fever.

At least I think that is what the difference is.

Karlynn - I have also wondered the same thing about myself - wondering if I had rheumatic fever and it was not known. However, I believe that docs can tell by looking at the valve whether it was damaged congenitally or with disease.

Mike, thanks for posting this. It was scary to read about the number still alive after 20 years, but the quote saying that it was the same as the general population made me feel a lot better. I know that people with replacements have a very long life expectancy also - we live in a marvelous medical time in history.

Christina L

 

[weekycat]

Thanks Mike,

Thanks Mike,

I've been looking for these statistics since my repair. My surgeon was not sure about the origin of my MVP, but said that since I hadn't had rheumatic fever...that meant it was most likely congenital...so I don't think they can really tell by looking at it.

The thing that bothers me a little bit is this:
For the 10 patients who underwent reoperation for recurrent mitral valve regurgitation, valve analysis at the time of the first operation showed 2 of type I (annulus dilatation, perforation of leaflet) and 8 of type II (leaflet prolapse): 1 posterior leaflet, 3 anterior leaflet, and 4 complex anterior and posterior leaflet combination.

Mine would be the latter, I believe. I had both leaflets repaired and also the chordae repaired, since two of them had "blown".

The last echo I had was a year and a half ago...I believe my Cardio said I could wait three years, but I'm feeling some chest pressure and SOB once in a while lately...It's probably nothing...but maybe I should get it checked out just to put my mind at ease.

 

[Christina L]

I don't know -

I don't know -

I think most cardios can tell right away why the mitral valve is not working properly. I just got on the web and was reading that mitral valve disease caused by rheumatic fever usually comes later in life - I know I was found to have a murmur at a very young age - maybe around 2 or 3. I had the classic systolic click of mitral valve prolapse.

Jean - you know me, I am always looking for any other cause for heart problems than the heart itself - - but I know you mentioned you have hypothyroidism. Hypothyroidism can cause shortness of breath and a feeling of getting no air in at times.

I think you are fine heart wise. I had both anterior and posterior leaflets repaired also but I think the findings that Mike posted still give us incredible odds at a successful longterm repair.

Get yourself checked though. You are probably due for an echo. I know mine is coming up.

Christina L

 

[MikeHeim]

For those who don't want sort through the whole study, as incredibly dry and number-laden as it is, I pulled out a couple more sections.

The first one has to do with reoperation. Three patients required almost immediate reoperation, but here is the breakdown of the rest:

At 10 and 20 years, 94% and 92% of the patients were free from reoperation. The mitral valve reoperation rate was 0.4% patient-year. Only 1 patient had postoperative bacterial endocarditis and had been treated medically with success, for a linearized rate of 0.04% patient-year.

For the 7 patients who underwent late reoperation, 5 had a significant murmur at discharge, indicating that an incomplete repair probably was the cause of reoperation.

This lends credence to the statement that repairs either fail very quickly or last for a very long time. As far as the murmurs go, the assumption is that the attempted repair was not successful on the operating table (i.e. the repair didn't actually fail, the valve actually wasn't successfully repaired in the first place). This next part has to do with how complicated the repair was:

In type II involving the posterior leaflet alone (n=93), 98.5% of patients at 10 years and 96.9% of patients at 20 years were free from reoperation; in type II involving the anterior leaflet alone (n=28), 86.2% and 86.2% were free from reoperation, respectively; and in type II involving both leaflets, 88.1% and 82.6% were free from reoperation, respectively.

Both of my leaflets had to be repaired, so I guess I fit into the last category. One issue I have with the study is that there isn't a breakdown by age. I would like to see specifically what the long-term results were for those on the younger end of the study (it does mention that the youngest person studied was 22 at the time of surgery). Presumably, younger folks are more active and would possibly put more stress on the repaired valve than someone at a more advanced age. The study also touches on re-repairs, but there were only three people who had a repair redone during the study, so I don't think you can draw too many conclusions from that data.

I guess the biggest and most important statement in the whole article is that "Mitral valve repair using Carpentier?s technique in patients with nonrheumatic MVI provides excellent long-term results with a mortality rate similar to that of the general population and a very low incidence of reoperation."

That's all I was looking for in the first place.

 

[MikeHeim]

Mike, thanks for posting this. It was scary to read about the number still alive after 20 years, but the quote saying that it was the same as the general population made me feel a lot better. I know that people with replacements have a very long life expectancy also - we live in a marvelous medical time in history.

Christina-
I almost fell off my chair as well - LOL. They should have been required to write the comment about the general population BEFORE they went through the long-term survival.

 

[Karlynn]

Karlynn - I have also wondered the same thing about myself - wondering if I had rheumatic fever and it was not known. However, I believe that docs can tell by looking at the valve whether it was damaged congenitally or with disease.

So that would lead me to believe that the nonrheumatic MVP is a correct DX for me. My leaflets were so floppy they weren't even there!

 

[debster913]

Pretty interesting, Mike!

Fortunately, both you and I had super-skilled surgeons who specialize in MV repair (although USC is better, and I'm not just saying that because I had surgery there ).

In fact, my cardio and I were talking about that today. I'd dropped by to say hi because I had to miss work for a dental appointment, and we discussed (in addition to dental work) why it was so much better for me to have a repair instead of a replacement.

The odds certainly seem to be in our favor with mitral repairs! Especially since I fall in the "degenerative" category.

Debi (debster913)

P.S. I notice that you and I live in the same general area. How about a SoCal VR reunion sometime?

 

[Karlynn]

The odds certainly seem to be in our favor with mitral repairs! Especially since I fall in the "degenerative" category.

Debi (debster913)

Degenerates do better with repairs?

Oh, that's degenerATIVE! For a second, I thought we were learning new things about you.

 

[MikeHeim]

Fortunately, both you and I had super-skilled surgeons who specialize in MV repair (although USC is better, and I'm not just saying that because I had surgery there ).

P.S. I notice that you and I live in the same general area. How about a SoCal VR reunion sometime?

LOL - Most people who get together to argue USC vs. UCLA are talking football, not valve replacement!

I actually just posted down on the Reunion section that I would love to meet up with VR people on the night before the Long Beach cruise - for dinner, if possible. There are so many SoCal folks on this site that we should see if we could put together a side event...

 

[debster913]

That would be awesome, Mike! (Yup, actually I was making a football reference).

Yes, Karlynn, sometimes I feel like a degenerate. Hmmm. Me and my degenerate valve. Heh.

Debi (debster913)

 

[twinmaker]

My mitral stenosis was caused by Rheumatic Fever, which was undiagnosed. I never knew I had it, but my cardiologists were sure that that was what caused my problem. They explained that a person can have such a mild case of Rheumatic Fever that you never know yor've been sick with it, but it still does it's damage. And then there are those who have a horrible case of Rheumatic Fever and come away with just a murmur from it. I knew I had a murmur since sometime in my late teens, and the problem was full blown by the time I was 21 and a half. Had my first OHS (a repair or commissurotomy as it was called) in Sept. 1974, a month after I turned 22. It lasted seven years. I had my replacement in 1981 two days after my 29th birthday. The doctors told me that the repair wouldn't last much longer than 10 years. We were thankful to get seven out of it, as it bought us time to have our children. LINDA

 

[marky]

Very Interesting study!