Risk of Reoperation Following Rheumatic Mitral Repair: Long-term Longitudinal Analysis.

Objectives: To evaluate long-term outcomes of rheumatic mitral valve (MV) repair and identify the risk factors of MV reoperation.

Methods: This retrospective, single center cohort study evaluated 337 patients who underwent MV repair for rheumatic disease from 2000 to 2022. The primary outcome was MV reoperation. Competing risk analyses utilizing Fine-Gray models were performed with death as the competing risk.

Results: MV repair techniques included ring-annuloplasty (81.0%), commissure procedures (33.5%), leaflet resection (2.7%), posterior mitral leaflet mobilization (14.8%), anterior mitral leaflet (AMVL) augmentation (4.2%), Alfieri procedure (2.7%), papillary muscle splitting (12.8%), and chordal procedures (30.6%). The 30-day mortality rate was 0.9%. Over a median follow-up of 15.2 years (IQR 7.7-19.4 years; total 4629.71 patient-years), 54 patients died, with a 20-year survival of 78.9% (95% CI, 73.6-84.5%). Thirty-two patients required MV reoperation for regurgitation (n=15), stenosis (MS) (n=14), and mixed lesions (n=3). The cumulative risks of reoperation at 10 and 20 years were 4.5% and 12.7%, respectively. Independent risk factors included tricuspid regurgitation velocity>3.4 m/s (HR 3.26, p=0.005), moderate-to-severe MS (HR 4.39, p<0.001), AMVL augmentation (HR 5.84, p=0.001), and chordal procedures (HR 2.99, p = 0.004). The 20-year reoperation rates were 1.0%, 12.7%, and 33.6% in patients with 0, 1, and ≧ 2 risk factors, respectively (p<0.001).

Conclusions: The long-term durability of rheumatic MV repair is significantly affected by risk factors such as pulmonary hypertension, moderate-to-severe MS, AMVL augmentation, and chordal procedures. Repair is preferable in patients without these risk factors.