Mitral Valve Repair Versus Replacement in Patients Undergoing Concomitant Aortic Valve Replacement.

Aim: Mitral valve repair (MVr) is associated with more favourable long-term outcomes than mitral valve replacement (MVR) in cases of isolated mitral valve disease suitable for repair. However, there is debate regarding whether the superiority of MVr extends to patients with concomitant aortic and mitral valve disease. Therefore, this meta-analysis was conducted to compare the survival benefits between aortic valve replacement (AVR) plus MVr with a double valve replacement (DVR).

Method: A comprehensive literature search was conducted on PubMed, EMBASE, and Cochrane until 20 October 2022. Studies comparing MVr and MVR in patients undergoing concomitant AVR were included. The primary outcome was long-term survival. The secondary outcomes were early mortality, mitral valve reoperation, and valve-related adverse events.

Results: Sixteen studies with a total of 140,638 patients were included in this analysis. Patients undergoing AVR plus MVr exhibited a favourable trend in long-term survival (HR 0.85; 95% CI 0.71-1.03; p=0.10; I²=58%). The reconstructed Kaplan-Meier curve revealed that the long-term survival at 5, 10, and 15 years was higher in the AVR plus MVr (80.95%, 67.63%, and 51.18%, respectively) than in the DVR group (76.62%, 61.36%, 43.21%, respectively). Aortic valve replacement plus MVr had a lower risk of early mortality (RR 0.67; 95% CI 0.58-0.79; p<0.001; I²=77%), thromboembolic events (RR 0.81; 95% CI 0.67-0.98; p=0.03; I²=5%), and haemorrhagic events (RR 0.87; 95% CI 0.78-0.98; p=0.01; I²=59%). Moreover, both groups displayed comparable rates of mitral valve reoperation (HR 1.73; 95% CI 0.86-3.48; p=0.13; I²=60%) and infective endocarditis (RR 1.60; 95% CI 0.65-3.93; p=0.31; I²=0%). However, the rate of reoperation for AVR plus MVr significantly increased in rheumatic heart disease patients (HR 3.30, 95% CI 1.66-6.59; p<0.0001).

Conclusions: Compared with DVR, AVR plus MVr was associated with favourable long-term survival, reduced early mortality risk, and a lower incidence of thromboembolic and haemorrhagic events without increasing the risk of mitral valve reoperation or infective endocarditis in unselected patients. However, higher reoperation rates were observed in rheumatic heart disease patients undergoing AVR plus MVr.