Rheumatic heart disease: mitral valve repair outperforms replacement

Hemodynamic challenges in the surgical treatment of rheumatic mitral valve disease

Rheumatic mitral valve disease remains a major global public health issue, responsible for nearly 320,000 deaths annually. Although mitral valve replacement (MVR) is the conventional approach, it exposes patients to complications related to long-term anticoagulation and prosthetic degradation. In parallel, mitral valve repair (MVRepair) is emerging as an alternative that preserves native anatomy, potentially reducing the need for anticoagulants and the risk of thromboembolic events.

This retrospective study, conducted on 166 patients, aims to precisely compare variations in postoperative hemodynamic parameters between mitral repair (n=72) and prosthetic replacement (n=94). By documenting the evolution of echocardiographic indices (LVEDD, LAESD, E-wave velocity, and ejection fraction), this work seeks to validate the short-term clinical efficacy of the repair technique compared to the replacement approach, in order to refine surgical strategies for patients under 60 years of age.

Study design and population

This retrospective study analyzed the clinical records of 166 patients suffering from rheumatic mitral valve disease, treated between September 2020 and December 2023 at the hospital affiliated with North Sichuan Medical College and Dazhou Third People's Hospital. Inclusion criteria required participants to be 60 years of age or younger, meet the diagnostic criteria for rheumatic mitral valve disease, and present surgical indications validated according to the Chinese consensus.

Exclusion criteria ruled out patients with concomitant cardiac pathologies (cardiomyopathy, malignant arrhythmias), those who had previously undergone mitral surgery, or those requiring associated procedures (coronary artery bypass grafting, aortic or tricuspid surgery).

Experimental groups and protocol

The sample was divided into two distinct cohorts according to the procedure performed:

• Observation group (n=72): Patients who underwent mitral valve repair (MVRepair). The technique consisted of the release of fused commissures, debridement of calcified plaques, lysis of subvalvular adhesions, and implantation of a valvuloplasty ring.
• Control group (n=94): Patients who underwent mitral valve replacement (MVR) with excision of the native valve.

The procedures were performed by the same lead surgeon under general anesthesia. Follow-up focused on the evaluation of hemodynamic parameters, specifically end-systolic and end-diastolic diameters, as well as Doppler flow velocities, analyzed preoperatively and at various postoperative control points.

Analysis of hemodynamic results: Repair versus Replacement

This retrospective study involving 166 patients (94 in the mitral valve replacement [MVR] group and 72 in the mitral valve repair [MVRepair] group) demonstrates a significant improvement in postoperative hemodynamic parameters in both cohorts, with a marked advantage for the conservative technique.

Intra-group improvements (mitral valve repair)

In patients who underwent MVRepair, all measured echocardiographic parameters showed a statistically significant improvement compared to preoperative values (p < 0.05). This includes left ventricular end-diastolic diameter (LVEDD), left atrial end-systolic diameter (LAESD), mitral E-wave velocity, left ventricular ejection fraction (LVEF), mitral valve area (MVA), pressure half-time (PHT), and mean pressure gradient (MPG). Furthermore, the grade of mitral regurgitation was significantly reduced both intraoperatively and at the time of discharge (p < 0.05).

Inter-group comparison: mitral valve repair vs. mitral replacement

The direct comparison between the two groups reveals significant differences in favor of valve repair on several key indicators:

Parameter	Observation	Significance
LVEDV, left atrial end-systolic diameter, E-wave velocity	Significantly lower in the MVr group	p < 0.05
Left ventricular posterior wall thickness (LVPWd)	Lower in the MVr group at 3 and 6 months	p < 0.05
Left ventricular end-diastolic volume (LVEDV)	Lower in the MVr group at 3 months	p < 0.05
Left ventricular ejection fraction (LVEF)	Lower in the MVr group at 6 months	p < 0.05

These data confirm that preserving the native valve allows for better recovery of chamber dimensions and more physiological mitral flow dynamics in the short term. Although LVEF is lower in the MVr group at 6 months, the authors emphasize that all cardiac remodeling indicators favor repair to limit post-surgical atrial and ventricular dilation.

Clinical analysis: Repair vs. Replacement

This retrospective study of 166 patients highlights a clear structural advantage of mitral valve repair (MVr) over replacement (MVR). Postoperatively, patients in the MVr group show a more marked decrease in left ventricular end-diastolic diameters (LVEDD) and left atrial end-systolic diameters (LAESD), reflecting more favorable cardiac remodeling. E-wave velocity, significantly lower after MVr, confirms better mitral filling dynamics compared to the prosthesis.

However, the clinical picture requires nuanced interpretation: although structural remodeling is superior, the study observes that at 6 months post-intervention, the left ventricular ejection fraction (LVEF) is paradoxically lower in the MVr group than in the MVR group. Although MVr improves overall mitral status compared to preoperative values, this mid-term difference in LVEF requires particular vigilance regarding the monitoring of contractile function after valve reconstruction.

Limitations and clinical implications

The study is based on a modest cohort (n=166) from two centers, limiting the scope of the long-term results. The retrospective design also requires caution regarding selection biases inherent in the surgical choices made by the same operator. These data, however, confirm, in hemodynamic terms, the value of valve preservation to limit prosthetic complications, while highlighting distinct myocardial recovery profiles between the two techniques.

Summary of clinical results

This retrospective study of 166 patients compares mitral valve repair (MVr, n=72) to valve replacement (MVR, n=94). At 6 months post-operatively, the MVr group shows left ventricular end-diastolic (LVEDD) and end-systolic (LAESD) diameters, as well as E-wave velocity, significantly lower than those of the MVR group (p<0.05). While the ejection fraction (LVEF) is lower in the MVr group at 6 months compared to replacement, the structural parameters indicate better preservation of cardiac architecture in the short term.

Concretely, for the practitioner:

• Prioritize repair: MVr allows for superior hemodynamic improvement compared to valve replacement during the 6-month follow-up, justifying an attempt at repair when anatomy permits.
• Echocardiographic monitoring: Be attentive to the evolution of ventricular volumes (LVEDV) and wall thickness (LVPWd) from the 3rd month, as MVr shows early morphological benefits compared to prostheses.
• Functional evaluation: Despite a lower LVEF in the MVr group at 6 months, the overall improvement in flows and diameters supports the preservation of the native valve in patients under 60 years of age.

Left ventricular end-diastolic diameter, an echocardiographic parameter used here to assess ventricular remodeling and compare post-operative hemodynamic benefits between valve repair and replacement. Mitral pressure half-time, measured to assess the improvement in mitral valve function after surgery. Mitral regurgitation, rheumatic valve disease included in this study, the severity level of which was significantly improved in the immediate post-operative period in patients who underwent repair. Mitral valve repair, surgical technique consisting of preserving the patient's native valve, associated in this study with superior hemodynamic improvement compared to valve replacement. Mitral valve replacement, surgery consisting of removing the original mitral valve to replace it with a mechanical or biological prosthesis, constituting the control group of this retrospective analysis. E-wave velocity at the mitral level, a hemodynamic indicator that showed significant improvement after valve repair, with post-operative values lower than those observed in the replacement group.

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