VALVE REPAIR VERSUS REPLACEMENT FOR MITRAL-INSUFFICIENCY - WHEN IS A MECHANICAL VALVE STILL INDICATED

Objectives: Although many advantages of mitral valve reconstruction ha ve been demonstrated, whether specific subgroups of patients exist in whom mechanical valve replacement offers advantages over mitral recons truction remains undetermined. Methods: This study examined the late r esults of mitral valve surgery in patients with mitral insufficiency w ho received either a St, Jude Medical valve (n = 514) or a mitral valv e reconstruction with ring annuloplasty (n = 725) between 1980 and 199 6. Results: Overall operative mortality was 7.2% in the patients recei ving a St. Jude Medical mitral valve and 5.4% in those undergoing mitr al valve reconstruction (no significant difference); isolated mortalit y was 2.5% in the St, Jude Medical group and 2.2% in the valve reconst ruction group (no significant difference). The follow-up interval was more than 5 years for 340 patients with a mean of 39.8 months (98.5% c omplete). Overall 8-year freedom from late cardiac death, reoperation, and all valve-related complications was 72.8% for the St, Jude Medica l group and 64.8% for valve reconstruction group (no significant diffe rence). For patients with isolated, nonrheumatic mitral valve disease, 8-year freedom from late cardiac death and reoperation was better in the mitral valve reconstruction group (88.3%) than in the St, Jude Med ical valve group (86.0%; p = 0.05), Furthermore, Cox proportional haza rds regression revealed that mitral valve reconstruction was independe ntly associated with a lesser incidence of late cardiac death (p = 0.0 4), irrespective of preoperative New York Heart Association class. How ever, the St. Jude Medical valve offered better 8-year freedom from la te cardiac death, reoperation, and all valve-related complications tha n did mitral valve reconstruction in patients with multiple valve dise ase (77.0% vs 45.3%; p < 0.01). Conclusions: Therefore, mitral valve r econstruction appears to be the procedure of choice for isolated, nonr heumatic disease, whereas insertion of a St, Jude Medical valve should be preferred for patients with multiple valve disease.