Long-Term Clinical Outcome in Elderly Patients Undergoing Mitral Valve Repair

Abstract

Background Long-term data on patients over 75 years undergoing mitral valve (MV) repair are scarce. At our high-volume institution, we, therefore, aimed to evaluate mortality, stroke risk, and reoperation rates in these patients.

Methods We investigated clinical outcomes in 372 patients undergoing MV repair with (n = 115) or without (n = 257) tricuspid valve repair. The primary endpoint was the probability of survival up to a maximum follow-up of 9 years. Secondary clinical endpoints were stroke and reoperation of the MV during follow-up. Univariate and multivariable Cox regression analysis was performed to assess independent predictors of mortality. Mortality was also compared with the age- and sex-adjusted general population.

Results During a median follow-up period of 37 months (range: 0.1–108 months), 90 patients died. The following parameters were independently associated with mortality: double valve repair (hazard ratio, confidence interval [HR, 95% CI]: 2.15, 1.37–3.36), advanced age (HR: 1.07, CI: 1.01–1.14 per year), diabetes (HR: 1.97, CI: 1.13–3.43), preoperative New York Heart Association (NYHA) functional class (HR: 1.41, CI: 1.01–1.97 per class), and operative creatinine_max levels (HR: 1.32, CI: 1.13–1.55 per mg/dL). The risk of stroke in the isolated MV and double valve repair groups at postoperative year 5 was 5.0 and 4.1%, respectively (p = 0.65). The corresponding values for the risk of reoperation were 4.0 and 7.0%, respectively (p = 0.36). Nine-year survival was comparable with the general population (53.2 vs. 53.1%).

Conclusion Various independent risk factors for mortality in elderly MV repair patients could be identified, but overall survival rates were similar to those of the general population. Consequently, our data indicates that repairing the MV in elderly patients represents a suitable and safe surgical approach.

Keywords

mitral valve - tricuspid valve - valve repair - mortality - age

• References

• 1 Gammie JS, Sheng S, Griffith BP. et al. Trends in mitral valve surgery in the United States: results from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg 2009; 87 (05) 1431-1437 , discussion 1437–1439
• 2 Ailawadi G, Swenson BR, Girotti ME. et al. Is mitral valve repair superior to replacement in elderly patients?. Ann Thorac Surg 2008; 86 (01) 77-85 , discussion 86
• 3 Badhwar V, Peterson ED, Jacobs JP. et al. Longitudinal outcome of isolated mitral repair in older patients: results from 14,604 procedures performed from 1991 to 2007. Ann Thorac Surg 2012; 94 (06) 1870-1877 , discussion 1877–1879
• 4 Silaschi M, Chaubey S, Aldalati O. et al. Is mitral valve repair superior to mitral valve replacement in elderly patients? Comparison of short- and long-term outcomes in a propensity-matched cohort. J Am Heart Assoc 2016; 5 (08) e003605
• 5 Seeburger J, Falk V, Garbade J. et al. Mitral valve surgical procedures in the elderly. Ann Thorac Surg 2012; 94 (06) 1999-2003
• 6 Shuhaiber J, Anderson RJ. Meta-analysis of clinical outcomes following surgical mitral valve repair or replacement. Eur J Cardiothorac Surg 2007; 31 (02) 267-275
• 7 Chan V, Ruel M, Mesana TG. Mitral valve replacement is a viable alternative to mitral valve repair for ischemic mitral regurgitation: a case-matched study. Ann Thorac Surg 2011; 92 (04) 1358-1365 , discussion 1365–1366
• 8 Feldman T, Kar S, Rinaldi M. et al. EVEREST Investigators. Percutaneous mitral repair with the MitraClip system: safety and midterm durability in the initial EVEREST (Endovascular Valve Edge-to-Edge REpair Study) cohort. J Am Coll Cardiol 2009; 54 (08) 686-694
• 9 Beckmann A, Meyer R, Lewandowski J, Frie M, Markewitz A, Harringer W. German Heart Surgery Report 2017: the Annual Updated Registry of the German Society for Thoracic and Cardiovascular Surgery. Thorac Cardiovasc Surg 2018; 66 (08) 608-621
• 10 Feldman T, Kar S, Elmariah S. et al. EVEREST II Investigators. Randomized comparison of percutaneous repair and surgery for mitral regurgitation: 5-year results of EVEREST II. J Am Coll Cardiol 2015; 66 (25) 2844-2854
• 11 Seeburger J, Katus HA, Pleger ST, Krumsdorf U, Mohr FW, Bekeredjian R. Percutaneous and surgical treatment of mitral valve regurgitation. Dtsch Arztebl Int 2011; 108 (48) 816-821
• 12 Renner A, Zittermann A, Aboud A, Hakim-Meibodi K, Börgermann J, Gummert JF. Early and mid-term clinical outcome in younger and elderly patients undergoing mitral valve repair with or without tricuspid valve repair. Interact Cardiovasc Thorac Surg 2015; 20 (01) 85-89
• 13 Torpy JM, Lynm C, Glass RM. JAMA patient page. Frailty in older adults. JAMA 2006; 296 (18) 2280
• 14 Harrell Jr FE, Lee KL, Mark DB. Multivariable prognostic models: issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors. Stat Med 1996; 15 (04) 361-387
• 15 Statistical Yearbook for the Federal Republic of Germany. Published by Federal Statistical Office, Destatis. Westermann Druck Zwickau GmbH; 2018: 40-41
• 16 Grossi EA, Zakow PK, Sussman M. et al. Late results of mitral valve reconstruction in the elderly. Ann Thorac Surg 2000; 70 (04) 1224-1226
• 17 Daneshmand MA, Milano CA, Rankin JS. et al. Influence of patient age on procedural selection in mitral valve surgery. Ann Thorac Surg 2010; 90 (05) 1479-1485 , discussion 1485–1486
• 18 Gaur P, Kaneko T, McGurk S, Rawn JD, Maloney A, Cohn LH. Mitral valve repair versus replacement in the elderly: short-term and long-term outcomes. J Thorac Cardiovasc Surg 2014; 148 (04) 1400-1406
• 19 David TE, Armstrong S, McCrindle BW, Manlhiot C. Late outcomes of mitral valve repair for mitral regurgitation due to degenerative disease. Circulation 2013; 127 (14) 1485-1492
• 20 Volkert D, Kreuel K, Stehle P. [“Nutrition beyond 65”--amount of usual drinking fluid and motivation to drink are interrelated in community-living, independent elderly people]. Z Gerontol Geriatr 2004; 37 (06) 436-443 [in German]
• 21 Gillinov AM, Cosgrove DM, Blackstone EH. et al. Durability of mitral valve repair for degenerative disease. J Thorac Cardiovasc Surg 1998; 116 (05) 734-743
• 22 Gillinov AM, Blackstone EH, Nowicki ER. et al. Valve repair versus valve replacement for degenerative mitral valve disease. J Thorac Cardiovasc Surg 2008; 135 (04) 885-893 , 893.e1–893.e2
• 23 Maisano F, Taramasso M, Nickenig G. et al. Cardioband, a transcatheter surgical-like direct mitral valve annuloplasty system: early results of the feasibility trial. Eur Heart J 2016; 37 (10) 817-825