G.S. Kim et al. / Interactive CardioVascular and Thoracic Surgery
CONCLUSIONS In conclusion, although the outcomes of either MVr or replacement for moderate-to-severe mitral regurgitation in patients undergoing concomitant AVR show no statistical significance in terms of long-term survival and valve-related events rate, DVR seems more hazardous than AVR plus MVr based on the estimated HR in terms of survival. Moreover, it should be noted that DVR is associated with a higher risk of reoperation, while AVR plus MVr may lead to progressive native mitral valve dysfunction. Conflict of interest: None of the authors has a financial relationship with a commercial entity that has an interest in the subject of the presented manuscript or other conflicts of interest to disclose.
REFERENCES [1] Gillinov AM, Blackstone EH, Cosgrove DM, White J, Kerr P, Marullo A et al. Mitral valve repair with aortic valve replacement is superior to double valve replacement. J Thorac Cardiovasc Surg 2003;125:1372–87. [2] Hamamoto M, Bando K, Kobayashi J, Satoh T, Sasako Y, Niwaya K et al. Durability and outcome of aortic valve replacement with mitral valve repair versus double valve replacement. Ann Thorac Surg 2003;75:28–33. [3] Ho HQ, Nguyen VP, Phan KP, Pham NV. Mitral valve repair with aortic valve replacement in rheumatic heart disease. Asian Cardiovasc Thorac Ann 2004;12:341–5. [4] Kuwaki K, Kawaharada N, Morishita K, Koyanagi T, Osawa H, Maeda T et al. Mitral valve repair versus replacement in simultaneous mitral and aortic valve surgery for rheumatic disease. Ann Thorac Surg 2007;83:558–63. [5] Leavitt BJ, Baribeau YR, DiScipio AW, Ross CS, Quinn RD, Olmstead EM et al. Outcomes of patients undergoing concomitant aortic and mitral valve surgery in northern new England. Circulation 2009;120:S155–162. [6] Talwar S, Mathur A, Choudhary SK, Singh R, Kumar AS. Aortic valve replacement with mitral valve repair compared with combined aortic and mitral valve replacement. Ann Thorac Surg 2007;84:1219–25. [7] McGonigle NC, Jones JM, Sidhu P, Macgowan SW. Concomitant mitral valve surgery with aortic valve replacement: a 21-year experience with a single mechanical prosthesis. J Cardiothorac Surg 2007;2:24. [8] Urban M, Pirk J, Turek D, Netuka I. In patients with concomitant aortic and mitral valve disease is aortic valve replacement with mitral valve repair superior to double valve replacement? Interact CardioVasc Thorac Surg 2011;12:238–42. [9] Kim JB, Kim HJ, Moon DH, Jung SH, Choo SJ, Chung CH et al. Long-term outcomes after surgery for rheumatic mitral valve disease: valve repair versus mechanical valve replacement. Eur J Cardiothorac Surg 2010;37: 1039–46. [10] Lee JW, Choo SJ, Kim KI, Song JK, Kang DH, Song JM et al. Atrial fibrillation surgery simplified with cryoablation to improve left atrial function. Ann Thorac Surg 2001;72:1479–83.
[11] Kim JB, Bang JH, Jung SH, Choo SJ, Chung CH, Lee JW. Left atrial ablation versus biatrial ablation in the surgical treatment of atrial fibrillation. Ann Thorac Surg 2011;92:1397–404. [12] Akins CW, Miller C, Turina MI, Kouchoukos NT, Blackstone EH, Grunkemeier GL et al. Guidelines for reporting mortality and morbidity after cardiac valve interventions. Ann Thorac Surg 2008;85:1490–5. [13] Curtis LH, Hammill BG, Eisenstein EL, Kramer JM, Anstrom KJ. Using inverse probability-weighted estimators in comparative effectiveness analyses with observational databases. Med Care 2007;45(10 Suppl 2): S103–7. [14] Ridgeway G, McCaffrey D, Morral A. Twang: Toolkit for Weighting and Analysis of Nonequivalent Groups. R Package Version 1.0–2, 2010. [15] Milano A, Guglielmi C, De Carlo M, Di Gregorio O, Borzoni G, Verunelli F et al. Valve-related complications in elderly patients with biological, and mechanical aortic valves. Ann Thorac Surg 1998;66(Suppl):S82–7. [16] Mueller XM, Tevaearai HT, Stumpe F, Fischer AP, Hurni M, Ruchat P et al. Long-term results of mitral-aortic valve operations. J Thorac Cardiovasc Surg 1998;115:298–309. [17] Kim GS, Lee CH, Kim JB, Jung SH, Choo SJ, Chung CH et al. Echocardiographic evaluation of mitral durability following valve repair in rheumatic mitral valve disease: impact of Maze procedure. J Thorac Cardiovasc Surg 2012; doi: 10.1016/j.jtcvs.2012.10.007. [Epub ahead of print]
eComment. Repair versus mitral replacement in patients undergoing concomitant aortic valve replacement Author: Michael Poullis Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK doi: 10.1093/icvts/ivt499 © The Author 2013. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. I congratulate Kim et al. on a very large series on double valve procedures with an impressively low in-hospitality mortality rate [1]. Their work raises a number of interesting questions: Firstly, 410 patients undergoing double valve procedures were excluded. Did all these patients have rheumatic mitral stenosis, or did another reason exist for their exclusion? The data on double valve replacement in patients with mitral stenosis may have helped to provide a control for mechanical valve related events and potentially a Kaplan-Meier survival comparison (which was not included in the manuscript) for the mitral repair group. Kaplan-Meier survival curves are univariate in nature. Did a multivariate Cox model procedure have the same outcomes as the inverse probability treatment weighted method? A simple Kaplan-Meier technique may be inaccurate, despite inverse probability treatment weighting, as significant differences in aortic tissue valve replacement and aortic graft replacement existed in their adjusted data. Of note, preoperative atrial fibrillation and ejection fraction also approached significance in the adjusted data. With nearly 25% of patients suffering postoperative mitral valve dysfunction at five years after repair surgery, I would tentatively interpret this as a need for caution for mitral valve repair in patients having concomitant mechanical aortic vale replacement surgery, or in patients with a life expectancy greater than five years. Patients undergoing tissue or mechanical aortic valve replacement surgery are by definition different patient populations, regardless of any mitral valve procedure performed [2]. Propensity matching and Cox multivariate analysis are unlikely to adjust for this selection bias. I would be interested in knowing the outcomes for patients undergoing double valve replacement versus aortic valve replacement plus mitral valve repair, for tissue and mechanical valve replacement subgroups. I thank Kim et al. for their thoughtful analysis of a high-risk difficult subgroup of patients. Conflict of interest: none declared. References [1] Kim GS, Kim JB, Han S, Choo SJ, Chung CH, Lee JW et al. Mitral valve repair versus replacement for moderate-to-severe mitral regurgitation in patients undergoing concomitant aortic valve replacement. Interact CardioVasc Thorac Surg 2014;18:73–79. [2] Pullan M, Chalmers J, Mediratta N, Shaw M, McShane J, Poullis M. Statins and long-term survival postisolated valve surgery: the importance of valve type, position and procedure. Eur J Cardiothorac Surg 2013;doi:10.1093/ejcts/ ezt399.
ORIGINAL ARTICLE
method resulted in good balance between the DVR and AVR plus MVr populations, concomitant surgical histories of aortic graft replacement and implanted aortic valve type were different between the two groups, and also the potential remains for unmeasured confounders to have influenced the clinical outcomes. The sample size was small to draw a firm conclusion; and therefore, studies on larger populations are needed to verify the results of the current study. Functional MR was present in 38 (40.0%) and 11 (7.2%) patients in the AVR plus MVr and DVR groups, respectively. This factor also might have affected the decision to repair or replace the MV. Furthermore, because several surgeons performed the surgery, inter-surgeon variability in determining the reparability of the MV might have existed. This variability can have a significant impact on the study results. Finally, late (>6 months) postoperative echocardiography data were not available in 22.1% of the patients.
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CONCLUSIONS In conclusion, although the outcomes of either MVr or replacement for moderate-to-severe mitral regurgitation in patients undergoing concomitant AVR show no statistical significance in terms of long-term survival and valve-related events rate, DVR seems more hazardous than AVR plus MVr based on the estimated HR in terms of survival. Moreover, it should be noted that DVR is associated with a higher risk of reoperation, while AVR plus MVr may lead to progressive native mitral valve dysfunction. Conflict of interest: None of the authors has a financial relationship with a commercial entity that has an interest in the subject of the presented manuscript or other conflicts of interest to disclose.
REFERENCES [1] Gillinov AM, Blackstone EH, Cosgrove DM, White J, Kerr P, Marullo A et al. Mitral valve repair with aortic valve replacement is superior to double valve replacement. J Thorac Cardiovasc Surg 2003;125:1372–87. [2] Hamamoto M, Bando K, Kobayashi J, Satoh T, Sasako Y, Niwaya K et al. Durability and outcome of aortic valve replacement with mitral valve repair versus double valve replacement. Ann Thorac Surg 2003;75:28–33. [3] Ho HQ, Nguyen VP, Phan KP, Pham NV. Mitral valve repair with aortic valve replacement in rheumatic heart disease. Asian Cardiovasc Thorac Ann 2004;12:341–5. [4] Kuwaki K, Kawaharada N, Morishita K, Koyanagi T, Osawa H, Maeda T et al. Mitral valve repair versus replacement in simultaneous mitral and aortic valve surgery for rheumatic disease. Ann Thorac Surg 2007;83:558–63. [5] Leavitt BJ, Baribeau YR, DiScipio AW, Ross CS, Quinn RD, Olmstead EM et al. Outcomes of patients undergoing concomitant aortic and mitral valve surgery in northern new England. Circulation 2009;120:S155–162. [6] Talwar S, Mathur A, Choudhary SK, Singh R, Kumar AS. Aortic valve replacement with mitral valve repair compared with combined aortic and mitral valve replacement. Ann Thorac Surg 2007;84:1219–25. [7] McGonigle NC, Jones JM, Sidhu P, Macgowan SW. Concomitant mitral valve surgery with aortic valve replacement: a 21-year experience with a single mechanical prosthesis. J Cardiothorac Surg 2007;2:24. [8] Urban M, Pirk J, Turek D, Netuka I. In patients with concomitant aortic and mitral valve disease is aortic valve replacement with mitral valve repair superior to double valve replacement? Interact CardioVasc Thorac Surg 2011;12:238–42. [9] Kim JB, Kim HJ, Moon DH, Jung SH, Choo SJ, Chung CH et al. Long-term outcomes after surgery for rheumatic mitral valve disease: valve repair versus mechanical valve replacement. Eur J Cardiothorac Surg 2010;37: 1039–46. [10] Lee JW, Choo SJ, Kim KI, Song JK, Kang DH, Song JM et al. Atrial fibrillation surgery simplified with cryoablation to improve left atrial function. Ann Thorac Surg 2001;72:1479–83.
[11] Kim JB, Bang JH, Jung SH, Choo SJ, Chung CH, Lee JW. Left atrial ablation versus biatrial ablation in the surgical treatment of atrial fibrillation. Ann Thorac Surg 2011;92:1397–404. [12] Akins CW, Miller C, Turina MI, Kouchoukos NT, Blackstone EH, Grunkemeier GL et al. Guidelines for reporting mortality and morbidity after cardiac valve interventions. Ann Thorac Surg 2008;85:1490–5. [13] Curtis LH, Hammill BG, Eisenstein EL, Kramer JM, Anstrom KJ. Using inverse probability-weighted estimators in comparative effectiveness analyses with observational databases. Med Care 2007;45(10 Suppl 2): S103–7. [14] Ridgeway G, McCaffrey D, Morral A. Twang: Toolkit for Weighting and Analysis of Nonequivalent Groups. R Package Version 1.0–2, 2010. [15] Milano A, Guglielmi C, De Carlo M, Di Gregorio O, Borzoni G, Verunelli F et al. Valve-related complications in elderly patients with biological, and mechanical aortic valves. Ann Thorac Surg 1998;66(Suppl):S82–7. [16] Mueller XM, Tevaearai HT, Stumpe F, Fischer AP, Hurni M, Ruchat P et al. Long-term results of mitral-aortic valve operations. J Thorac Cardiovasc Surg 1998;115:298–309. [17] Kim GS, Lee CH, Kim JB, Jung SH, Choo SJ, Chung CH et al. Echocardiographic evaluation of mitral durability following valve repair in rheumatic mitral valve disease: impact of Maze procedure. J Thorac Cardiovasc Surg 2012; doi: 10.1016/j.jtcvs.2012.10.007. [Epub ahead of print]
eComment. Repair versus mitral replacement in patients undergoing concomitant aortic valve replacement Author: Michael Poullis Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK doi: 10.1093/icvts/ivt499 © The Author 2013. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. I congratulate Kim et al. on a very large series on double valve procedures with an impressively low in-hospitality mortality rate [1]. Their work raises a number of interesting questions: Firstly, 410 patients undergoing double valve procedures were excluded. Did all these patients have rheumatic mitral stenosis, or did another reason exist for their exclusion? The data on double valve replacement in patients with mitral stenosis may have helped to provide a control for mechanical valve related events and potentially a Kaplan-Meier survival comparison (which was not included in the manuscript) for the mitral repair group. Kaplan-Meier survival curves are univariate in nature. Did a multivariate Cox model procedure have the same outcomes as the inverse probability treatment weighted method? A simple Kaplan-Meier technique may be inaccurate, despite inverse probability treatment weighting, as significant differences in aortic tissue valve replacement and aortic graft replacement existed in their adjusted data. Of note, preoperative atrial fibrillation and ejection fraction also approached significance in the adjusted data. With nearly 25% of patients suffering postoperative mitral valve dysfunction at five years after repair surgery, I would tentatively interpret this as a need for caution for mitral valve repair in patients having concomitant mechanical aortic vale replacement surgery, or in patients with a life expectancy greater than five years. Patients undergoing tissue or mechanical aortic valve replacement surgery are by definition different patient populations, regardless of any mitral valve procedure performed [2]. Propensity matching and Cox multivariate analysis are unlikely to adjust for this selection bias. I would be interested in knowing the outcomes for patients undergoing double valve replacement versus aortic valve replacement plus mitral valve repair, for tissue and mechanical valve replacement subgroups. I thank Kim et al. for their thoughtful analysis of a high-risk difficult subgroup of patients. Conflict of interest: none declared. References [1] Kim GS, Kim JB, Han S, Choo SJ, Chung CH, Lee JW et al. Mitral valve repair versus replacement for moderate-to-severe mitral regurgitation in patients undergoing concomitant aortic valve replacement. Interact CardioVasc Thorac Surg 2014;18:73–79. [2] Pullan M, Chalmers J, Mediratta N, Shaw M, McShane J, Poullis M. Statins and long-term survival postisolated valve surgery: the importance of valve type, position and procedure. Eur J Cardiothorac Surg 2013;doi:10.1093/ejcts/ ezt399.
ORIGINAL ARTICLE
method resulted in good balance between the DVR and AVR plus MVr populations, concomitant surgical histories of aortic graft replacement and implanted aortic valve type were different between the two groups, and also the potential remains for unmeasured confounders to have influenced the clinical outcomes. The sample size was small to draw a firm conclusion; and therefore, studies on larger populations are needed to verify the results of the current study. Functional MR was present in 38 (40.0%) and 11 (7.2%) patients in the AVR plus MVr and DVR groups, respectively. This factor also might have affected the decision to repair or replace the MV. Furthermore, because several surgeons performed the surgery, inter-surgeon variability in determining the reparability of the MV might have existed. This variability can have a significant impact on the study results. Finally, late (>6 months) postoperative echocardiography data were not available in 22.1% of the patients.
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![[Mitral valve repair versus mitral valve replacement].](/assets/img/hold.png)
