Surgical Mitral Valve Repair Outcomes ‘Excellent’ at 2 Years: CTSN

Among patients with degenerative mitral regurgitation (MR) as well as concomitant tricuspid valve disease who have undergone surgical mitral valve repair, more than nine in 10 remain alive and free from reoperation or any episode of severe MR at 2 years, according to results from a new post hoc analysis.

Data on more than 300 patients from the Cardiothoracic Surgical Trial Network (CTSN), which looked at tricuspid repair during mitral surgery, indicate the incidence of the primary composite endpoint of death, MV reoperation, or severe MR at 2 years was 8.0%.

“These are really very rigorously collected data where we followed every patient scrupulously, wherever they went, and they had echos and all the clinical outcomes were adjudicated,” study co-author Annetine C. Gelijns, PhD (Icahn School of Medicine at Mount Sinai, New York, NY), told TCTMD. “It gives insight into a trial that was done in 39 centers in different parts of the world during the pandemic.”

While surgery is currently the preferred treatment for degenerative MR, mitral transcatheter edge-to-edge repair (M-TEER) has emerged as another option in severely symptomatic patients at high surgical risk. Ongoing trials like REPAIR MR and PRIMARY will eventually provide more data on how M-TEER performs in lower surgical risk patients, but the current study paints a clear picture of surgery’s benefits, according to Gelijns.

“The value of these data is that they provide really these contemporary benchmarks about how good [and] how durable mitral valve surgery is,” she said.

Moritz C. Wyler von Ballmoos, MD, PhD (Texas Health Resources, Fort Worth), who wasn’t involved in the study, agreed and also highlighted the robustness of the data with core lab-adjudicated echocardiography outcomes.

“It was very reassuring, I would say, to see the very high quality and consistency with which surgical mitral valve repair can be offered really across a multi-institutional and multinational study,” he told TCTMD. “It reaffirms what we’ve seen in other settings and with other data that surgical mitral valve repair is very repeatable, and centers and surgeons in general do an excellent job with that.”

2-Year Outcomes

The analysis, published online last week in JACC with first author Michael W.A. Chu, MD (London Health Sciences Centre, Canada), included 314 patients (median age 67.4 years; 24.2% female) who had surgical mitral valve repair for degenerative MR and echocardiographic data at 2 years. At discharge, 1.0% and 0.7% had moderate or severe MR, respectively.

The rate of mortality at 30 days was 1.0%, and this rose to 3.5% at 2 years. The 2-year rate of reoperation was 2.2%, with reasons including technical failure, fibrosis, and progression of disease. Among the 295 patients who survived to 2 years without reoperation, MR was moderate in 9.2% and severe in 1.4%, with 2.5% having a mean MV gradient of more than 5 mm Hg.

Also at 2 years, 8.9% of patients had new-onset atrial fibrillation, with 89.3% of events occurring within 30 days of surgery. Quality of life appeared to get better over time, with a median improvement in the Kansas City Cardiomyopathy Questionnaire of 20.5% from baseline to 2 years.

On multivariate analysis, anterior or bileaflet pathology was associated with a higher risk for treatment failure compared with posterior leaflet pathology (OR 2.48; 95% CI 1.09-5.68).

‘A Very, Very High Bar’

None of the results were all that surprising to study co-author Alan J. Moskowitz, MD (Icahn School of Medicine at Mount Sinai), who also spoke with TCTMD. “We anticipated that repair would be fairly durable and we showed that as well,” he said.

Gelijns added that the only minor surprise to her was the slight discrepancy between these data and current observational findings which tend to show a lower rate of events. “Many centers of excellence were saying that they had a 100% repair rate, but often patients weren’t followed for years as rigorously as in a clinical trial and went to other centers if they needed a mitral valve reoperation,” she said. “So, I think at first a little bit, . . . the surgeons thought: ‘Wow. That’s more than we thought originally.’”

Even so, Wyler von Ballmoos said the current study shows “excellent” and “extremely durable” outcomes.

“It’s important to know what the long-term durability looks like in any of the procedures that we do, . . .  and doing a mitral valve repair well makes all the difference in someone that has a 20, 30, 40-plus year life expectancy,” Wyler von Ballmoos said.

But also, “transcatheter therapies are becoming more commonplace and are currently being studied in new populations, such as intermediate- and low-risk patients even,” he continued. “There’s certainly a fair amount of equipoise and debate around when and how the transcatheter mitral valve repair approach would be appropriate, and certainly these data provide and corroborate a very, very high bar for transcatheter therapies to meet to keep pace with what we’re able to offer from a surgical site for mitral valve patients.”