s Mitral Valve Repair Superior to Replacement inlderly Patients?orav Ailawadi, MD, Brian R. Swenson, MD, MS, Micah E. Girotti, BS,eo M. Gazoni, MD, Benjamin B. Peeler, MD, John A. Kern, MD,ynn M. Fedoruk, MD, and Irving L. Kron, MD
epartment of Surgery, University of Virginia, Charlottesville, Virginia
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Background. Mitral valve replacement is more fre-uently performed and perceived to be equivalent toepair in elderly patients, despite the superiority ofepair in younger patients. Our objective was to compareitral repair to replacement in elderly patients age 75
ears or older. Patients younger than 75 years undergoingitral valve surgery served as a reference population.Methods. Consecutive elderly patients undergoing op-
ration for mitral regurgitation at our institution from998 to 2006 were reviewed. Elderly patients (mean age,8.0 � 2.8 years) who underwent mitral repair (n � 70) oreplacement (n � 47) were compared with cohorts ofoung patients (mean age, 58.9 � 9.3 years) who under-ent repair (n � 100) or replacement (n � 98) during the
ame period. Patient details and outcomes were com-ared using univariate, multivariate, and Kaplan–Meiernalyses.Results. Mitral replacement in elderly patients had
igher mortality than repair (23.4%, 11 of 47 versus 7.1%,of 70; p � 0.01) or as compared with either operation in
he reference group (p < 0.0001). Postoperative stroke
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ddress correspondence to Dr Ailawadi, PO Box 800679, Charlottesville,A 22908; e-mail: [email protected].
2008 by The Society of Thoracic Surgeonsublished by Elsevier Inc
as higher in elderly replacement patients comparedith repair (12.8%, 6 of 47 versus 0%; p � 0.003) or
ompared with either young cohort (p � 0.02). Comparedith elderly repair patients, elderly replacement patientsad more cerebrovascular disease (21.3%, 10 of 47 versus.3%, 3 of 70; p � 0.005) and rheumatic mitral valves21.3%, 10 of 47 versus 0%; p � 0.0001). In the youngroup, overall complication and mortality were no dif-erent between replacement and repair. Long-term sur-ival favored repair over replacement in elderly patientsp � 0.04). One elderly repair patient experienced lateecurrence of persistent mitral regurgitation.
Conclusions. In patients age 75 years or older, mitralepair is associated with a lower risk of mortality, post-perative stroke, and prolonged intensive care unit andospital stay compared with mitral replacement. Mitralepair can be performed in preference over replacementven in patients older than the age of 75.
itral valve (MV) repair is preferred over replace-ment to treat mitral insufficiency with improved
hort-term and long-term survival [1–5]. Patients withegenerative mitral regurgitation (MR) have superiorutcomes with repair over replacement [1–4]. Good-riskatients with ischemic mitral regurgitation also benefit
rom MV repair compared with replacement, with betterarly and late (5-year) survival, in part because of pres-rvation of the subvalvar apparatus [5]. Older patients,owever, are often not considered appropriate candi-ates for MV repair because of comorbidities [6] and theerception that they may not tolerate a return to cardio-ulmonary bypass for an inadequate MV repair. Further-ore, older patients are professed to benefit least from
epair owing to short life expectancy. Because of theseactors, most surgeons perform MV replacement in el-erly patients. The Society of Thoracic Surgeons (STS)atabase indicates that MV repair is performed in only
ccepted for publication March 5, 2008.
resented at the Fifty-fourth Annual Meeting of the Southern Thoracicurgical Association, Bonita Springs, FL, Nov 7–10, 2007.
6.1% of MV operations in patients older than 70 yearsationally, significantly less than in younger age popula-
ions [7]. There is discrepancy in the literature regardinghe benefit of repair in elderly patients. Some authors citemproved in-hospital and long-term survival in elderlyatients age 70 years or older undergoing isolated MVepair [6], whereas others suggest MV repair provides noenefit in patients older than the age of 60 years [8].The purpose of this investigation was to review our
xperience of MV repair versus MV replacement inlderly patients age 75 years or older who underwentsolated and concomitant cardiac procedures to deter-
ine what differences, if any, exist in regard to morbiditynd mortality. In addition, long-term mortality afterepair and replacement in elderly patients was com-ared. Finally, elderly patients were also compared withatients younger than 75 years undergoing MV repair oreplacement.
atients and Methods
pproval for this investigation was obtained by the
78 AILAWADI ET AL Ann Thorac SurgMITRAL VALVE REPAIR IN ELDERLY 2008;86:77–86A
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irginia Health System, including a waiver for the needo obtain patient consent. All patients undergoing MVperations are entered into a database. A retrospectiveeview was performed of all MV operations for mitralegurgitation in elderly patients (age �75 years) during a-year period (January 1, 1998, to December 31, 2006) athe University of Virginia. Patients with emergency op-ration, previous mitral prosthesis, and mitral stenosisere excluded from this study. A total of 117 elderlyatients (mean age, 78.0 � 2.8 years) who underwent MVepair (n � 70) or MV replacement (n � 47) wereompared with each other as well as with a cohort ofoung patients (age �75 years). This reference groupmean age, 58.9 � 9.3 years) included patients whonderwent MV repair (n � 100) and MV replacement
n � 98) during the same period. Demographic andreoperative comorbidities were compared between ageroups and between MV operations.
lderly Patientso differences in age or preoperative risk variables
able 1. Demographics for Repair Versus Replacement Stratifi
Continuous variables are reported as mean � standard deviation; p valu%); p values derived from �2 test or Fisher’s exact test.
OPD � chronic obstructive pulmonary disease; IMR � ischemicalcification; MR � mitral regurgitation; NYHA � New York Hea
ncluding diabetes, peripheral vascular disease, or t
hronic obstructive pulmonary disease were identifiedetween elderly patients undergoing MV repair or re-lacement (Table 1). Twenty-nine (61.7%) elderly MVeplacement patients were female, although this was notignificantly different from elderly repair patients48.6%; p � 0.16). New York Heart Association classas similar between elderly MV repair and replace-ent patients (2.22 � 0.68 versus 2.10 � 0.63; p � 0.32).
reoperative cerebrovascular disease was more com-on in elderly MV replacement patients (21.3%) than
n elderly MV repair patients (4.3%; p � 0.005). Preop-rative atrial fibrillation was not different. Indicationsor MV surgery were different between groups. Elderlyepair patients were more likely to have degenerative56.5%) or ischemic (42.9%) mitral regurgitation com-ared with elderly replacement patients, who hadore rheumatic disease (21.3%), mitral annular calci-
cation (12.8%), and endocarditis (4.3%; p � 0.0001).oronary artery disease was less common in elderlyV replacement patients (34.8%) versus repair pa-
rived from Student’s t test. b Categorical variables are reported as N
al regurgitation; LV � left ventricular; MAC � mitral annularociation.
ed b
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79Ann Thorac Surg AILAWADI ET AL2008;86:77–86 MITRAL VALVE REPAIR IN ELDERLY
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oung Patientsifferences between patients undergoing MV repair and
eplacement identified in the elderly group were alsoonfirmed in young patients (Table 1). Young MV re-lacement patients had more cerebrovascular disease
han the young repair patients (18.4% versus 7.0%; p �.02). As in the elderly group, young MV repair patientsere more likely to have degenerative (48%) or ischemicitral regurgitation (46%) compared with young replace-ent patients, who more often had rheumatic valves
43.9%) and endocarditis (14.3%; p � 0.0001). Coronaryrtery disease was more common in young repair pa-ients than in young replacement patients (41% versus1.4%; p � 0.003). Young replacement patients were moreften female compared with repair patients (56.1% versus8%; p � 0.01). Preoperative atrial arrhythmias wereore common in young replacement patients than in
epair patients (37.8% versus 23.0%; p � 0.03).
efinitionsll patients had at least 3� MR, and the degree of MRas determined by preoperative transthoracic echocar-iogram. Mechanism of MV disease was diagnosed byirect surgical inspection, pathologic reports, and echo-ardiograms. Ischemic disease was further characterizedy patients with at least one previous myocardial infarc-
ross-clamp time (min) 120 � 50 86PB time (min) 158 � 50 119
Categorical variables are reported as N (%); p values derived from �2
tandard deviation; p values derived from Student’s t test.
PB � cardiopulmonary bypass; LV � left ventricular; N/A � not avai
al valve leaflets and chordae, and the absence of otherV disease. Rheumatic disease and mitral annular cal-
ification was identified by preoperative imaging, includ-ng echocardiography and cardiac catheterization, andonfirmed at operation.
perative Techniquesll procedures were performed through full or partial
ternotomy by 6 surgeons during the study period. Pa-ients were placed on cardiopulmonary bypass usingtandard techniques. Dual venous cannulation was per-ormed either percutaneously or directly. Antegrade withr without retrograde cardioplegia was used, dependentn surgeon preference. When performed, coronary ar-ery bypass grafting (CABG) or atrial ablation procedureas done before the mitral procedure. Tricuspid and
ortic valve procedures were done after the mitral pro-edure. Transesophageal echocardiogram was used in allatients before MV surgery to help characterize theechanism of MR and then after MV repair or replace-ent to evaluate the adequacy of MV surgery. All pa-
ients were considered for MV repair. Standard repairechniques including triangular leaflet resection (as de-cribed previously) [9], artificial neochord insertion, andemirigid or rigid annuloplasty ring insertion were usedn MV repair patients. Subvalvar sparing technique for
V replacement patients was used in all patients when-
Fisher’s exact test. b Continuous variables are reported as mean �
rly a
rs O
epai� 70
(35.7%(12.9%(1.4%(1.4%(100%N/A
(1.4%(13.2%(10.0%(2.9%(7.1%(45.7%
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80 AILAWADI ET AL Ann Thorac SurgMITRAL VALVE REPAIR IN ELDERLY 2008;86:77–86A
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ver possible, and performed in 71.1% of valveeplacements.
ollow-Upollow-up information was obtained during outpatientppointments and by phone interviews with the referringr primary care physicians. Additional data were alsobtained from Social Security death registries. Follow-upata on survival and reoperation were available on 97.4%f all elderly patients. The mean duration of follow-upas 45.1 � 32.9 months and 59.0 � 34.6 months in elderlyatients undergoing MV repair and replacement,espectively.
tatistical Analysisatient data were tabulated and stratified by age group
or repair versus replacement. Continuous variablesere compared using Student’s t test or Wilcoxon
ank-sum tests, and categorical variables were com-ared using �2 analysis or Fisher’s exact test, as appro-riate. Logistic regression analysis of clinically rele-ant risk factors was used to identify independentredictors of 30-day mortality. Kaplan–Meier survivalurve estimates were used to compare long-term sur-ival between mitral repair and replacement in elderlyatients. Statistical tests were performed with SAS.1.3 (SAS Institute, Inc, Cary, NC).
esults
perative Details—Elderly Patientsechniques used for elderly patients undergoing MVepair (70 patients) included 25 patients with triangulareaflet resection (35.7%), 9 patients with quadrangulareaflet resection (12.9%), and 1 patient each with artificialeochord insertion and with edge-to-edge repair (1.4%).
able 3. Operative and Mortality Outcomes for Repair Versus
semirigid or rigid annuloplasty ring was inserted invery elderly patient undergoing MV repair. Elderlyatients undergoing MV replacement had the followingrostheses inserted: 21 patients with Hancock porcinealve (44.7%), 10 patients with Carpentier-Edwards bo-ine pericardial valve (34.0%), and 16 patients with St.ude mechanical valve (21.2%; Table 2). Atrial ablationnd ligation of the appendage was not different betweenroups. Concomitant valve operations, including eitherortic valve or tricuspid valve operation, were moreommonly performed in elderly replacement com-ared with elderly repair patients (23.4% versus 10%;� 0.05). Conversely, CABG was less commonly per-
ormed in elderly replacement patients (31.9%) com-ared with repair patients (45.7%), but this was notignificantly different (p � 0.14). Differences in theumber of bypassed vessels approached significanceith more bypasses being performed in elderly repairatients compared with replacement patients (2.6 � 1.1ersus 1.9 � 1.0 bypasses; p � 0.08). Elderly patientsndergoing MV replacement had longer cardiopulmo-ary bypass times than those undergoing repair (156 �0 versus 128 � 49 minutes; p � 0.003). Similarly,ross-clamp times were longer in elderly MV replace-ent patients compared with repair patients (117 � 55
ersus 94 � 46 minutes; p � 0.01).
perative Details—Young Patientsepair techniques used for young patients undergoingV repair included 47 patients with triangular leaflet
esection (47%), 4 patients with quadrangular leafletesection (4%), 3 patients with artificial neochord inser-ion, and 1 patient with edge-to-edge repair (1%; Table 2).n addition, 1 patient had bovine pericardial patch repairf leaflet perforation (1%). A semirigid or rigid annulo-lasty ring was inserted in all but 3 young patients
Fisher’s exact test. b Continuous variables are reported as mean �
Rep
Year
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al regurgitation; MV � mitral valve.
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81Ann Thorac Surg AILAWADI ET AL2008;86:77–86 MITRAL VALVE REPAIR IN ELDERLY
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ndergoing repair (97%). Young patients undergoing MVeplacement had the following prostheses inserted: 59atients with St. Jude mechanical valve (60.2%), 16 pa-
ients with Hancock porcine valve (16.2%), 14 patientsith Carpentier-Edwards pericardial valve (14.2%), and 9atients with Onyx mechanical valve (9.2%). Young pa-
ients undergoing MV replacement more commonly hadoncomitant valve surgery compared with repair patients25.8% versus 12%; p � 0.02; Table 2). Although thencidence of aortic valve replacement was similar be-
able 4. Demographics and Perioperative Details Related to S
ween groups, tricuspid annuloplasty was more com-only performed in young patients with MV replace-ent compared with repair patients (16.3% versus 4.0%;� 0.003). Consistent with the group of elderly patients,
he incidence of CABG was less common in young MVeplacement compared with repair patients (24.5%versus4%; p � 0.005). The number of bypassed vessels was notignificantly different between young MV repair patients2.4 � 1.2 bypasses) and young replacement patients2.0 � 1.0 bypasses; p � 0.15).
ary bypass; IMR � ischemic mitral regurgitation; LV � lefttion; MV � mitral valve; NYHA � New York Heart Association.
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82 AILAWADI ET AL Ann Thorac SurgMITRAL VALVE REPAIR IN ELDERLY 2008;86:77–86A
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utcomesne elderly and 1 young patient each required return to
ardiopulmonary bypass with replacement of their MVfter attempted repair. No patient who underwent MVeplacement required return to cardiopulmonary bypassor issues with their prosthetic valve. Elderly patientsndergoing MV surgery collectively had higher 30-dayospital mortality than young patients (13.7%, 16 of 117atients, versus 3.6%, 7 of 197 patients; p � 0.001). ElderlyV replacement patients had higher 30-day mortality
23.4%) than elderly repair patients (7.1%; p � 0.01; Table). In young patients, mortality differences were notvident between patients undergoing repair or replace-ent (2.0% versus 5.1%; p � 0.27).Although the overall complication rate in elderly MV
eplacement patients compared with elderly repair pa-ients was similar (31.9% versus 18.6%; p � 0.10; Table 3),ostoperative stroke was higher in elderly replacementatients (12.8%, 6 of 47 patients), whereas no strokesccurred in elderly repair patients (p � 0.003). The strokeate in elderly replacement patients was also significantlyigher than in young patients independent of MV oper-tion (p � 0.02). Acute renal failure was more common inlderly replacement patients than in elderly repair pa-ients (17.0% versus 4.3%; p � 0.03). The difference innfectious complications in elderly replacement patientspproached significance compared with repair patients17.0% versus 5.7%; p � 0.06). In young patients, differ-nces in renal failure, stroke, infections, and respiratoryailure were not observed between patients undergoingepair and replacement.
Prolonged ventilator course occurred more often inlderly replacement versus repair patients (21.3% versus.9%; p � 0.001). Prolonged stay in the intensive care unitccurred in 21.3% of elderly replacement patients andas significantly higher than in elderly repair patients
4.3%; p � 0.004). Young patients had equivalent inten-ive care unit and ventilator course independent of typef MV operation. Hospital length of stay was longer inlderly replacement patients than in elderly repair pa-ients (14.0 � 13.2 versus 8.6 � 3.5 days; p � 0.01).imilarly, young replacement patients (11.3 � 9.3 days)ad longer lengths of stay than patients undergoingepair (8.5 � 7.1 days; p � 0.02).
Univariate analysis was performed on young and old315) patients to identify risk factors correlated withtroke and mortality (Table 4). The only risk factorssociated with stroke was MV replacement (p � 0.03).ge, type of concomitant operation, and preoperative
erebrovascular disease were not associated with stroke.nivariate analysis of all patients documented that mor-
ality was highly associated with age as patients who diedere on average 10 years older (range, 42 to 83 years)
han survivors (p � 0.003). Mitral valve replacement wasignificantly associated with mortality (p � 0.02). Otherariables associated with mortality by univariate analysisncluded preoperative left ventricular dysfunction (p �.02), cause of MR (p � 0.03), and cardiopulmonary
ypass time (p � 0.04). Other risk factors, including a
oncomitant operation (whether CABG or other valverocedure) as well as New York Heart Association class,id not correlate with mortality. Operating surgeon didot correlate with mortality (p � 0.16).Multivariate analysis on all patients was performed to
ccount for confounding factors and included clinicallyelevant risk factors of elderly age, MV replacement,oncomitant operations, reoperation, and cause of MRTable 5). After logistic regression, mortality was associ-ted with age of 75 years or older (odds ratio, 3.6; p � 0.01)nd highly associated with MV replacement (odds ratio,.6; p � 0.001). Concomitant operation and reoperativetatus were not associated with mortality. The cause of
R was also associated with mortality by multivariatenalysis. Ischemic MR was highly associated with mor-ality (odds ratio, 3.9; p � 0.01). Operation for rheumaticisease was not associated with mortality as none of
hese patients died (Table 4) and thus was not included inultivariate analysis. The risk factor left ventricular dys-
unction, although associated by univariate analysis, wasot associated with mortality after accounting for otherariables (p � 0.31). Cardiopulmonary bypass time wasssociated with mortality by univariate analysis but wasot included in the logistic regression model because
onger cardiopulmonary bypass times were highly asso-iated with MV replacement (Table 2), and the inclusionf this variable would be a surrogate variable for MVeplacement.
The diagnosis of ischemic MR was a predictor ofortality. There were no differences in mortality in
oung patients with ischemic MR who underwent repairr replacement (repair, 4%, 2 of 46 patients; replacement,%, 0 of 10 patients; p � 1.0). Mortality of elderly patientsith ischemic MR was significantly better with mitral
epair (13%, 4 of 30 patients) than for replacement (42%,of 14 patients; p � 0.05).
eoperative procedure 0.9 0.3–3.4 0.92schemic regurgitation as
indication3.9 1.3–11.5 0.01
ABG � coronary artery bypass grafting; LV � left ventricular.
fter MV repair over replacement in elderly patients (p �
0st1muomp(
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83Ann Thorac Surg AILAWADI ET AL2008;86:77–86 MITRAL VALVE REPAIR IN ELDERLY
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.041; Fig 1). After accounting for postoperative deaths,urvival between repair and replacement in elderly pa-ients was similar (p � 0.21). During the follow-up period,
elderly patient required eventual replacement 7onths after initial repair (1.4%). No elderly patient who
nderwent MV replacement required reoperation for hisr her MV. After accounting for early postoperativeortality, long-term survival was equivalent in elderly
atients undergoing repair (88.2%) versus replacement91.5%; p � 0.76).
omment
itral valve repair for MR was performed in nearly 60%f patients age 75 years or older at our institution, inontrast to reports from the Society of Thoracic Surgeonsatabase (36%) [7]. Major centers have documented an
ncrease in the ability to repair valves in more recentimes [10]. Older patients are often not considered to beandidates for mitral repair because of (1) concerns ofoor tolerance with return to cardiopulmonary bypass,
able 6. Selected Literature Examining Valvular Surgery in th
uthor, YearNumber of
Patients Age (y) Type of Pr
lexander, 2000 [17] 92 �80 MVR � CAB
agendran, 2005 [18] 58 �80 MVR (56%)/M
sai, 1994 [19] 73 �80 MVR � CABMVP � CA
remes, 1989 [20] 188 �70 MVR (82%)/M
oldsmith, 1999 [21] 43 �75 MVR (49%)/M
ogbashian, 2006 [6] 292 �70 MVR (25%)/M
nriquez-Sarano, 1995 [3] 83 �75 MVR (39)/M
ig 1. Long-term survival with mitral valve repair (dashed line)ersus replacement (solid line) in elderly patients.
2) unclear benefit of repair in elderly patients, and (3) theact that valve repair can be difficult [11]. In our series,lderly patients fared better with MV repair comparedith replacement with better 30-day and late survival.he improved late survival in elderly repair patients wasdmittedly in large part attributable to better operativeortality compared with replacement. Stroke, complica-
ion rate, and length of stay were improved in elderlyatients undergoing repair. By multivariate analysis,ortality was independently and highly associated withV replacement. Mortality was also independently as-
ociated with elderly age and ischemic MR. Only 2 deathsccurred in young patients with ischemic MR, suggesting
ow mortality independent of operation in young pa-ients. Elderly patients with ischemic MR, however, hadignificantly worse outcome with replacement. Rheu-atic disease was not identified as an independent
ariable associated with mortality as all rheumatic pa-ients survived. Our mortality rate for elderly patientsndergoing repair (7.1%) and replacement (23.4%) com-ares favorably with reports in the literature indicatingperative mortality of 0.7% to 12.6% for elderly patientsndergoing MV repair [6, 12] and 14.3% to 27% forlderly patients undergoing MV replacement [12–14]. Aurprisingly large number of elderly patients receivedechanical valves. The choice for mechanical valve in
lderly patients was based on a number of reasons.lderly patients with preoperative atrial fibrillation or areviously placed mechanical aortic valve who were
olerating anticoagulation therapy were offered thehoice of a mechanical valve. A smaller proportion ofatients with small left ventricles were thought to better
olerate the lower-profile mechanical MV when theiralve needed replacement.Mitral valve repair has become the preferred approach
or most causes of MR in young patients. In-hospital andong-term survival advantages exist for valve repair overeplacement for degenerative MV disease [1–4]. En-
derly
ure Mortality Conclusions
19.6% Mortality highest for MVR/CABG compared toother valve operations
(44%) 15.5% Mitral replacement riskfactor for mortality
8%)/(42%)
28.6% versus 22.6% (NS) Mitral procedure in elderlyhas high mortality
(18%) 14.7% vs 16.2% (NS) Good risk patients shouldbe offered surgery
(75%) 13.9% versus 0.7% (p �0.002) favoring repair
Benefit of repair lost withconcomitant CABG
4) 30.8% versus 6.8% (p �0.0005) favoring repair
Valve repair significantlyimproves outcome
e El
oced
G
VP
G (5BGVP
VP
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VR � mitral valve replacement; NS � not significant.
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84 AILAWADI ET AL Ann Thorac SurgMITRAL VALVE REPAIR IN ELDERLY 2008;86:77–86A
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iquez-Sarano and associates [3] reported significantlyess hospital mortality with MV repair over replacementor degenerative MV disease (2.6% versus 10.3%). Ten-ear survival rate was better for repair than replacement68% � 6% versus 52% � 4%; p � 0.0001). A report fromillinov and colleagues [2] supported long-term durabil-
ty of MV repair for degenerative disease with 10-yearreedom from reoperation of 93%. Patients with ischemic
R have also seen benefit to valve repair although thisas been less well studied in part because of intrinsicisease that is inseparable from the process causing MR
15]. Good-risk patients with ischemic MR who undergoepair have 1- and 5-year survivals of 82% and 58%ompared with 56% and 36% survival, respectively, ineplacement patients [5]. Our group previously reportedo reoperation for recurrent MR at 5 years after valveepair in patients with ischemic MR, supporting theongevity for repair in this group of patients [15]. In atudy evaluating patients with degenerative or ischemic
R, Akins and coworkers [16] found a shorter length oftay (10 versus 12 days) and less hospital mortality (3%ersus 12%) in patients who underwent MV repair versuseplacement. The mean age of patients in the majority ofhese large series indicating superiority of MV repairver replacement is between 55 and 65 years of age1–5, 16].
Mortality risk in elderly patients undergoing valveurgery is understandably higher than in younger pa-ients. Our series confirmed higher mortality in all el-erly patients undergoing mitral surgery compared withounger patients.
itral Repair Versus Replacement in Elderlyew studies have evaluated MV repair and replacement
n elderly patients (Table 6). Older reports contrast moreecent reports indicating the lower operative mortality inlderly patients undergoing MV repair compared witheplacement. Gogbashian and associates [6] compared
V repair with replacement in 292 patients aged 70 yearsr older and showed that in-hospital mortality for iso-
ated MV repair (0.7%) was significantly better than foreplacement (13.9%). Five-year survival also favored MVepair over replacement (MV repair, 81% � 3%; MVeplacement, 63% � 3%). In the subset of patients age 70ears or older in the report by Enriquez-Sarano andoworkers [3], operative mortality for repair patients was.8% compared with 30.8% in replacement patients, ands remarkably similar to our results. Thourani and col-eagues [8] demonstrated that MV replacement and ageere both independent predictors of in-hospital and
ong-term mortality. Despite documented superior out-omes with MV repair in elderly patients in these recenteries, authors have concluded that MV repair does notrovide long-term benefit in patients older than the agef 60 [8]. In our series, we documented improved survival
n elderly patients with ischemic MR undergoing repair,finding that has been seen in other large series inde-
endent of age [5]. m
itral Repair With Concomitant Coronary Arteryypass Graftinghe concept of benefit of MV repair over replacement inatients who require concomitant CABG is controversial.he report by Thourani and associates [8] documentedquivalent survival with MV repair and replacement inatients requiring CABG. This finding is also supportedy Gogbashian and colleagues [6] who documented in-ospital mortality for CABG with MV repair of 1.4%ompared with CABG with MV replacement of 5.3% (notignificant). Perhaps unexpectedly in that report, isolated
V replacement patients had higher mortality (13.9%)han concomitant MV replacement with CABG (5.3%). Inontrast, Enriquez-Sarano and associates [3] documentedsurvival benefit at 6 years with MV repair over replace-ent in patients with concomitant CABG (74% � 6%
ersus 34% � 8%). In a multivariate analysis, Nagendrand coworkers [18] documented concomitant CABG asn independent risk factor for mortality in octogenariansndergoing MV surgery. Our report did not identifyorse mortality with concomitant CABG by multivariate
nalysis.
otential Explanations for Improved Outcomesower mortality documented in our study in elderlyatients undergoing repair can be attributable to severaleasons. Preservation of the subvalvar apparatus im-roves long-term left ventricular function and survival
22–24]. Although techniques to preserve the subvalvarpparatus were used in the majority of patients under-oing replacement (71%) in our series, valve repair is stillonsidered superior to replacement [6, 25]. Our experi-nce describes shorter cardiopulmonary bypass timesith valve repair, which may also be linked with lowerortality. Importantly, our experience of shorter cross-
lamp and bypass times during mitral repair was seen inoth elderly and young patients. Unrepairable valves
hat require replacement may be a harbinger of more-dvanced heart disease and thus may bode worseutcomes.
imitationshis is a single-institution retrospective review, a limita-
ion to most of the literature comparing MV repair toeplacement. As such, there may be a selection bias foralves that are able to be repaired. The repairability of aalve including the complexity of valve disease andegree of annular calcification is difficult to assess byeviewing operative notes of patients who underwentitral replacement and is a clear limitation to the poten-
ial bias in our report. A standardized intraoperativessessment model would be helpful in this and futureulticenter studies. Some baseline characteristics, in-
luding preoperative cerebrovascular disease origin ofR, and concomitant operations are different between
epair versus replacement in our elderly patients. Impor-antly, concomitant valve operations were more commonn replacement patients although this was not linked to
ortality by multivariate analysis. Rheumatic valves
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85Ann Thorac Surg AILAWADI ET AL2008;86:77–86 MITRAL VALVE REPAIR IN ELDERLY
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ere more commonly replaced, although we docu-ented no mortality or stroke in those patients. Thus, the
igher mortality in elderly replacement patients was notxplained by the higher preponderance of patients withheumatic disease. Although excellent early and mid-erm outcomes after repair of rheumatic mitral diseaseave been reported, mortality is not as favorable as inatients with degenerative disease [26, 27]. In our report,perations for ischemic MR were associated with higherortality. These findings are consistent with the litera-
ure, suggesting that elderly patients with ischemic originave the highest mortality of any subgroup [11]. Theseifferences between our repair and replacement patientsan only be accounted for through a multicenter random-zed trial. Finally, there is a relatively small sample size oflderly patients (n � 117). Further differences betweenepair and replacement in elderly patients may becomepparent given more patients.
onclusionshere is a perception that MV repair does not provideenefit in elderly patients. Despite shorter life expect-ncy in elderly patients, we document improved opera-ive and long-term survival as well as lower stroke ratesn patients age 75 years or older with mitral repair overeplacement. The rate of return to cardiopulmonaryypass or reoperation for persistent MR is low. Noifferences in outcomes were identified when concomi-
ant CABG or valve operation was required. Mitral repairan be performed over replacement when feasible evenn patients older than the age of 75.
eferences
1. Braunberger E, Deloche A, Berrebi A, et al. Very long-termresults (more than 20 years) of valve repair with Carpentier’stechniques in nonrheumatic mitral valve insufficiency. Cir-culation 2001;104(Suppl 1):I-8–11.
2. Gillinov AM, Cosgrove DM, Blackstone EH, et al. Durabilityof mitral valve repair for degenerative disease. J ThoracCardiovasc Surg 1998;116:734–43.
3. Enriquez-Sarano M, Schaff HV, Orszulak TA, Tajik AJ,Bailey KR, Frye RL. Valve repair improves the outcome ofsurgery for mitral regurgitation. A multivariate analysis.Circulation 1995;91:1022–8.
4. Suri RM, Schaff HV, Dearani JA, et al. Survival advantageand improved durability of mitral repair for leaflet prolapsesubsets in the current era. Ann Thorac Surg 2006;82:819–26.
5. Gillinov AM, Wierup PN, Blackstone EH, et al. Is repairpreferable to replacement for ischemic mitral regurgitation?J Thorac Cardiovasc Surg 2001;122:1125–41.
6. Gogbashian A, Sepic J, Soltesz EG, Nascimben L, Cohn LH.Operative and long-term survival of elderly is significantlyimproved by mitral valve repair. Am Heart J 2006;151:1325–33.
7. Savage EB, Ferguson TB Jr, DiSesa VJ. Use of mitral valverepair: analysis of contemporary United States experiencereported to the Society of Thoracic Surgeons National Car-diac Database. Ann Thorac Surg 2003;75:820–5.
8. Thourani VH, Weintraub WS, Guyton RA, et al. Outcomes and
long-term survival for patients undergoing mitral valve repair
versus replacement: effect of age and concomitant coronaryartery bypass grafting. Circulation 2003;108:298–304.
9. Gazoni LM, Fedoruk LM, Kern JA, et al. A simplifiedapproach to degenerative disease: triangular resections ofthe mitral valve. Ann Thorac Surg 2007;83:1658–64.
0. Detaint D, Sundt TM, Nkomo VT, et al. Surgical correction ofmitral regurgitation in the elderly: outcomes and recentimprovements. Circulation 2006 25;114:265–72.
1. Cohn LH, Kowalker W, Bhatia S, et al. Comparative mor-bidity of mitral valve repair versus replacement for mitralregurgitation with and without coronary artery disease. 1988.Updated in 1995. Ann Thorac Surg 1995;60:1452–3.
2. Grossi EA, Zakow PK, Sussman M, et al. Late results ofmitral valve reconstruction in the elderly. Ann Thorac Surg2000;70:1224–6.
3. Nair CK, Biddle WP, Kaneshige A, Cook C, Ryschon K,Sketch MH Sr. Ten-year experience with mitral valve re-placement in the elderly. Am Heart J 1992;124:154–9.
4. Collart F, Feier H, Kerbaul F, et al. Valvular surgery inoctogenarians: operative risks factors, evaluation of Euro-score and long term results. Eur J Cardiothorac Surg 2005;27:276–80.
5. Gazoni LM, Kern JA, Swenson BR, et al. A change inperspective: results for ischemic mitral valve repair aresimilar to mitral valve repair for degenerative disease. AnnThorac Surg 2007;84:750–7.
6. Akins CW, Hilgenberg AD, Buckley MJ, et al. Cardiacoperations in patients 80 years old and older. Ann ThoracSurg 1997;64:606–14.
7. Alexander KP, Anstrom KJ, Muhlbaier LH, et al. Outcomesof cardiac surgery in patients � or � 80 years: results fromthe National Cardiovascular Network. J Am Coll Cardiol2000;35:731–8.
8. Nagendran J, Norris C, Maitland A, Koshal A, Ross DB. Ismitral valve surgery safe in octogenarians? Eur J Cardiotho-rac Surg 2005;28:83–7.
9. Tsai TP, Chaux A, Matloff JM, et al. Ten-year experience ofcardiac surgery in patients aged 80 years and over. AnnThorac Surg 1994;58:445–50.
0. Fremes SE, Goldman BS, Ivanov J, Weisel RD, David TE,Salerno T. Valvular surgery in the elderly. Circulation 1989;80(Suppl 1):I-77–90.
1. Goldsmith I, Lip GY, Kaukuntla H, Patel RL. Hospitalmorbidity and mortality and changes in quality of lifefollowing mitral valve surgery in the elderly. J Heart ValveDis 1999;8:702–7.
2. David TE, Uden DE, Strauss HD. The importance of themitral apparatus in left ventricular function after correctionof mitral regurgitation. Circulation 1983;68(Suppl 2):II-76–82.
3. Komeda M, David TE, Rao V, Sun Z, Weisel RD, Burns RJ.Late hemodynamic effects of the preserved papillary mus-cles during mitral valve replacement. Circulation 1994;90(Suppl 2):II-190–4.
4. Lee EM, Shapiro LM, Wells FC. Importance of subvalvularpreservation and early operation in mitral valve surgery.Circulation 1996;94:2117–23.
5. Jebara VA, Dervanian P, Acar C, et al. Mitral valve repairusing Carpentier techniques in patients more than 70 yearsold. Early and late results. Circulation 1992;86(Suppl 2):II-53–9.
6. Piciche M, El Khoury G, D’udekem D’akoz Y, Noirhomme P.Surgical repair for degenerative and rheumatic mitral valvedisease. Operative and mid-term results. J Cardiovasc Surg2002;43:327–35.
7. Kumar AS, Rao PN, Saxena A. Results of mitral valvereconstruction in children with rheumatic heart disease.
Ann Thorac Surg 1995;60:1044–7.
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R JENNIFER SUE LAWTON (St. Louis, MO): Thank you forour manuscript and also thank you for such a thought-rovoking investigation. It is important to stress, and you did inour presentation, that these are all patients with mitral regur-itation and that you excluded stenosis. And if we are going toocus on the elderly population, because I think that is whereou would like to make a statement in that the elderly don’t dos well with mitral replacement, I think it is important to notehat there are significant differences in the elderly replacementroup and the elderly repair group, both preoperatively and
ntraoperatively. The elderly replacement group had a higherncidence of cerebrovascular disease before surgery. You alsoad a higher percentage of women in the replacement group,lthough that was not statistically significant. You had a higherercentage of rheumatic patients, annular calcification patients,nd also endocarditis patients in the replacement group. Youlso had longer cardiopulmonary bypass time and cross-clampime, which could also lead to higher mortality and stroke, andou also had an increased percentage of concomitant valveurgery, both aortic and tricuspid, at the same operation, as wells a higher percentage of reoperations in the replacement group,lthough that was not statistically significant. So if you couldomment, perhaps if we had a larger group of patients we couldatch them better preoperatively, would you see the same
nding, do you think?And my second question is, I was curious as to why 21% of
our elderly replacement patients, these are patients older than5, got a St. Jude valve?Thank you.
R AILAWADI: Thank you for your questions. The first ques-ion related to whether we could have matched it differently orf it was a larger sample size if we expect to see the sameutcomes. Given the sample size that we had, we attempted toccount for all these differences that you mentioned usingultivariate analysis. So if we believe statistical methods, weould anticipate with larger sample sizes we would see a similarutcome.With respect to your second question?
R LAWTON: Twenty-one percent of your elderly replacementatients actually got a St. Jude valve. These are people older
han 75.
R AILAWADI: There were different reasons depending on theatient. A patient, for example, who is already on Coumadin
sodium warfarin) for A-fib (atrial fibrillation) who did very well
ith Coumadin may have gotten a St. Jude valve or patients that i
lready had a mechanical valve in another position may haveotten a mechanical valve.
R LAWTON: So would you say that you placed it because ofase?
R AILAWADI: We know that repairing patients with mitralegurgitation when possible, even in the face of other valverostheses, still has a better outcome. The Cleveland Clinicroup has shown that very nicely.
R LAWTON: Thank you.
R JOHN M. KRATZ (Charleston, SC): Your replacementroup had a fairly daunting 12% stroke rate, which probablyontributed a good bit to your increased mortality in that group. A lot of us have been getting away from even short-termnticoagulation for a bioprostheses. Could you comment on thattroke group of 12% and your anticoagulation protocol? What doou think that had to do with your stroke rate?
R AILAWADI: The anticoagulation protocols depended on theurgeon’s choice. Some surgeons at our institution anticoagulatell mitral valves for a period of 3 months, others use the AHAAmerican Heart Association) guidelines to anticoagulate onlyatients that are considered high risk that have had a previous
hromboembolism, A-fib patients. So we did not look at thatpecifically if there was a difference based on whether they weren anticoagulation or not. We did note that even though thereere differences in preoperative cerebrovascular disease, thisid not bear out in way of the outcome of stroke.
R TARA KARAMLOU (Portland, OR): You first showed thatatients were statistically much more likely when they arelderly to undergo replacement. I wonder then if your resultsctually just are reflecting your institutional bias toward repairsince you had only 47 patients who actually underwent replace-ent with a preponderance of repairs. So could you comment
n that?
R AILAWADI: The STS database takes all-comers. There areo provisions for patients that have mitral stenosis with arevious mitral prosthesis. I quoted the STS database reports a6% repair rate for all mitral surgery. Our repair rate for mitralegurgitation is over 60%. Certainly we prefer to repair any valven which it is possible despite their age. We feel that repair even
