Characteristics and Outcomes of Mitral Valve Repair vs. Replacement After Failed Repair for Degenerative Mitral Regurgitation: An Analysis of the STS Adult Cardiac Surgery Database

M. Ibrahim¹, O. Toubat², R. Smith³, A. Sperry⁴, R. Habib⁵, L. Bonnell⁶, C. Elenbaas⁷, P. Fiorilli², R. Bonow⁸, M. Acker², W. Y. Szeto^4
1University of Pennsylvania, wyndmoor, Pennsylvania ²Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania ³Cardiac Surgical Specialists, Plano, Texas ⁴University of Pennsylvania, Philadelphia, Pennsylvania ⁵The Society of Thoracic Surgeons, CHICAGO, Illinois ⁶The Society of Thoracic Surgeons, Philadelphia, Pennsylvania ⁷Society of Thoracis Surgeons, Chicago, Illinois ⁸Northwestern Feinberg School of Medicine, Chicago, Illinois

Purpose: Mitral valve repair is associated with superior survival and freedom from valve-related complications in degenerative mitral regurgitation (MR). Whether mitral re-repair is superior to replacement after failed mitral repair is unclear. We investigated the national characteristics and surgical outcomes of mitral re-repair versus replacement after failed repair for degenerative MR.

Methods: Patients undergoing planned isolated surgical mitral valve repair for degenerative MR were identified from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS ACSD) between July 2011 and December 2023. Patients with a history of endocarditis or prior mitral valve intervention were excluded. Cases with early mitral reintervention during or within 30-days of index mitral valve repair (N=292) were excluded. Failed mitral repair was defined as all subsequent reoperations on the mitral valve derived from the STS-ACSD and were stratified to re-repair or replacement subgroups. Pre-operative characteristics of the re-repair and replacement subgroups were compared at the time of the index surgery as well as at re-intervention using Chi-Squared Tests for categorical variables and Student’s t-test for continuous variables. Predictors for re-repair vs replacement were calculated via multivariable logistic regression (backward selection), with and without adjustment for time to reintervention.

Results: There were 85,707 patients that underwent mitral valve repair for degenerative MR during the study period. Of these, 1,752 (2%) patients required reoperation on the mitral valve, including 411 (23.5%) re-repairs and 1,341 (76.5%) replacements. Figure shows the time to reintervention between patients undergoing re-repair and replacement. In contradistinction to the expected pattern of progressive reoperation, most patients (n=908, 52.8%) required early reintervention ( < 2yrs). Earlier reintervention was associated with greater likelihood of re-repair compared to later reintervention (28.2% vs 18.4%, p< 0.0001). The overall re-repair rate did not change if the reoperating surgeon was different from that at index operation. Patients who received neochords at initial mitral valve repair had a greater-than-expected need for early reintervention (p < 0.001) but were more likely to be successfully re-repaired (62.2% vs 43.3%, p< 0.001). Conversely, those who underwent mitral valve resection and leaflet valvuloplasty at index repair were more likely to undergo subsequent replacement (9.7% vs 16.9%, p=0.003). Additional factors associated with re-repair versus replacement are shown in Table. Unadjusted operative mortality (0.5% vs 2.6%), combined morbidity and mortality (6.8% vs 16.7%), and median length of stay (5 vs 7 days) were lower in those undergoing re-repair compared to replacement.

Conclusion: In this largest analysis of reoperations for degenerative MR, most patients were found to undergo replacement after failed repair. Younger, healthier patients who received neochords at initial repair were more successfully re-repaired. Analysis of long-term survival and outcomes are underway and could support the strategy of re-repair for eligible patients.

Identify the source of the funding for this research project: Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania