Valve repair versus valve replacement


 * Associate Editor(s)-In-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.

Overview
Mitral valve surgery is indicated when the mitral regurgitation is severe or when the patient is symptomatic. Valve repair or replacement are the two types of surgeries available to treat these conditions. Decision between valve repair or valve replacement is made based on the type and severity of damage to mitral valve.

Mitral valve repair is recommended in following:

 * Limited damage to certain areas of the mitral valve leaflets or chordae tendineae
 * Limited calcification of the leaflets or annulus
 * Prolapse of less than one-third of either leaflet
 * Pure annular dilatation
 * Valvular perforations
 * Incomplete papillary muscle rupture

Mitral valve replacement is recommended in following:

 * Extensive calcification or degeneration of a leaflet or annulus
 * Prolapse of more than one-third of the leaflet tissue
 * Extensive chordal fusion, calcification, or papillary muscle rupture
 * Extensive damage of mitral valve secondary to endocarditis

Clinical trial data

 * Multiple studies have shown that there are better outcomes in terms of left ventricular function and survival with mitral valve repair compared to valve replacement.


 * In a 6 year follow-up study of 45 patients with isolated non-ischemic mitral regurgitation and EF ≤50%, who underwent either valve repair(27 patients) or replacement(18 patients) following results were observed:
 * 5 patients and 6 patients died in repair group and replacement group respectively.
 * 2 patients underwent valve replacement due to failure of valve repair while 1 patient in valve replacement group underwent re-operation due to prosthetic valve endocarditis.
 * Incidence of atrial fibrillation was similar between both groups.
 * Left ventricular end diastolic dimension(LVEDD), velocity time integral and ejection fraction(EF) improved with valve repair while LVEDD and EF worsened in valve replacement patients.


 * In another study, lower operative mortality (2.6% vs 10.3%), greater increase in left ventricular EF and higher 10 years survival rate (68% vs 52%) were observed among patients who underwent valve repair compared to valve replacement.


 * A survival benefit with valve repair may not be seen in high risk patients with ischemic MR.


 * Long term rates of re-operation appear to be similar in both valve repair and replacement. However, among patients who underwent mitral valve surgeries between 1984 and 1997, 10 year rates of re-operation was shown to be lower with valve repair.

Advantages of Mitral valve repair

 * 1) Improves left ventricular EF and function.
 * 2) Preserves native heart valve.
 * 3) Avoids long term use of anticoagulants.
 * 4) Lower risk for endocarditis.
 * 5) Has good overall outcome with good survival rates.

ACC/AHA Guidelines
Based on the above, ACC/AHA 2008 guidelines recommend mitral valve repair rather than mitral valve replacement if the anatomy is appropriate, including patients with rheumatic mitral valve disease and mitral valve prolapse (Grade 1C). The procedure should be performed at experienced surgical centers.