Repair versus replacement for degenerative mitral valve disease with coexisting ischemic heart disease

Objective: We sought to compare mitral valve repair and replacement as treatments for degenerative mitral valve disease with coexisting ischemic heart disease. Specifically, we sought to (1) identify differences between patients undergoing repair and replacement, (2) determine whether the choice of mitral valve procedure affected survival after adjusting for those differences, and (3) discover which patients were predicted to benefit from mitral valve repair and which from replacement. Methods: From 1973 to 1999, 679 patients (mean age, 67 ± 9.1 years; 73% men) with degenerative mitral valve and ischemic heart diseases underwent combined coronary artery bypass grafting and either mitral valve repair (66%) or replacement (34%). Factors associated with repair and replacement were used for multivariable propensity matching. Risk factors for death were identified by means of multivariable, multiphase hazard-function analysis. Results: Patients more likely to undergo repair had isolated posterior chordal rupture (P < .0001) or more recent date of operation (P < .0001); those more likely to undergo replacement were older (P = .0003) or had bileaflet prolapse (P < .0001). Unadjusted survival at 30 days and 1, 5, and 10 years was 97%, 92%, 79%, and 59% after repair and 94%, 88%, 70%, and 37% after replacement. After adjusting for comorbid factors, the extent and effect of ischemic heart disease, and propensity score, the survival benefit of repair became evident after 2 years (P = .01). Eighty-nine percent of patients were predicted to benefit from repair. Conclusions: In patients with degenerative mitral valve and ischemic heart diseases, mitral valve repair confers a survival advantage over replacement that becomes evident about 2 years after the operation.