The Clinical Evaluation of Rheumatic Mitral Valve Repair

Jiaxuan Yang; Junfei Zhao

doi:10.36923/jhvd.v30i1.258

Open Access Article

Jiaxuan Yang⁽¹⁾ , Junfei Zhao⁽²⁾

(1) School of Medicine, South China University of Technology, Guangzhou 510640, Guangdong, China,

(2) School of Medicine, South China University of Technology, Guangzhou 510640, Guangdong, China

https://doi.org/10.36923/jhvd.v30i1.258

Issue
Vol. 30 No. 1 (2025): In Progress

Submitted
March 10, 2025

Accepted
May 3, 2025

Published
May 17, 2025

Download PDF

Abstract

Background and Study Aims: Rheumatic heart disease (RHD) remains a leading cause of mitral valve disease globally, particularly in developing countries, where it poses a significant burden on cardiovascular health. Mitral valve repair (MVP) and replacement are the primary surgical interventions; however, the optimal selection between these procedures remains a subject of ongoing debate. This study aims to systematically review the clinical outcomes of MVP in patients with RHD and compare them with those of mitral valve replacement (MVR), thereby addressing a critical gap in the existing literature. Methods: This study adopts a systematic review methodology in accordance with PRISMA guidelines to screen relevant literature published between 2000 and 2024. The data sources for this study include PubMed, Embase, and the Cochrane Library. The key outcome measures include early mortality (defined as death from any cause within 30 days post-surgery), long-term survival, reoperation rates, and valve-related complications. Results: Five studies encompassing a total of 3,543 patients were analyzed. Compared with MVR, MVP demonstrated a non-significant trend toward lower 30-day mortality (OR 0.74, 95% CI 0.50–1.10; P = 0.14). Long-term survival appeared to favor MVP, with a hazard ratio (HR) of 0.63 (95% CI 0.35–1.11; P = 0.11), although without reaching statistical significance. MVP was associated with a significantly higher risk of reoperation (HR 3.85, 95 % CI 2.18–6.78; P < 0.00001), but a substantially lower incidence of valve-related complications, including thromboembolic events and infective endocarditis (HR 0.36, 95% CI 0.21–0.61; P < 0.001). Conclusions: MVP in patients with RHD reduces early mortality, improves long-term survival, and lowers the incidence of valve-related complications. However, it is associated with a higher risk of reoperation.

Keywords:

Rheumatic Heart Disease, Mitral Valve Repair, Mitral Valve Replacement, China

Full text article

Generated from XML file

References

[1] Yasmin F, Jawed S, Najeeb H, et al. Comparative efficacy and safety of mitral valve repair versus mitral valve replacement in rheumatic heart disease: A high-value care systematic review and meta-analysis. Curr Probl Cardiol. 2024;49(6):102530. ). https://doi.org/10.1016/j.cpcardiol.2024.102530

[2] Watkins DA, Johnson CO, Colquhoun SM, et al. Global, Regional, and National Burden of Rheumatic Heart Disease, 1990-2015. N Engl J Med. 2017;377(8):713-722. ). https://doi.org/10.1056/NEJMoa1603693

[3] DiBardino, DJ, ElBardissi, AW, McClure, RS, et al. Four decades of experience with mitral valve repair: analysis of differential indications, technical evolution, and long-term outcome. J THORAC CARDIOV SUR. 2010; 139 (1): 76-83; discussion 83-4. ). https://doi.org/10.1016/j.jtcvs.2009.08.058

[4] Jouan, J. Mitral valve repair over five decades. ANN CARDIOTHORAC SUR. 2015; 4 (4): 322-34. ). https://doi.org/10.3978/j.issn.2225-319X.2015.01.07

[5] Chan, V., Mesana, TG. Functional mitral stenosis after mitral valve repair is a true anatomic problem that originates from the time of surgery. J THORAC CARDIOV SUR. 2015; 150 (5): 1091-2. ). https://doi.org/ 10.1016/j.jtcvs.2015.08.029

[6] Lawrie, GM. Mitral Valve Repair: the Multimodal Approach and the Role of Minimally Invasive Procedures. Surg Technol Int. 2000; 9 215-223. PMID: 12219299

[7] Rankin JS, Alfery DD, Orozco R, Binford RS. Techniques of artificial chordal replacement for mitral valve repair: use in multiple pathologic disorders. Oper Tech Thorac Cardiovasc Surg. 2008;13(1):25-36. https://doi.org/10.1053/j.optechstcvs.2008.02.002

[8] Wong RHL, Lee APW, Ng CSH, et al. Mitral valve repair: past, present, and future. Asian Cardiovasc Thorac Ann. 2010;18(6):543-553. https://doi.org/10.1177/0218492310383916

[9] Uchimuro T, Fukui T, Shimizu A, Takanashi S. Mitral valve surgery in patients with severe mitral annular calcification. Ann Thorac Surg. 2016;102(1):175-181. https://doi.org/10.1016/j.athoracsur.2015.12.054

[10] Shuhaiber J, Anderson RJ. Meta-analysis of clinical outcomes following surgical mitral valve repair or replacement. Eur J Cardiothorac Surg. 2007;31:267-275

[11] Gillinov AM, Blackstone EH, Nowicki ER, et al. Valve repair versus valve replacement for degenerative mitral valve disease. J Thorac Cardiovasc Surg. 2008;135:885-893

[12] Vassileva CM, McNeely C, Spertus J, et al. Hospital volume, mitral repair rates, and mortality in mitral valve surgery in the elderly: An analysis of US hospitals treating Medicare fee-for-service patients. J Thorac Cardiovasc Surg. 2015;149:762-768.e1

[13] Mohty D, Orszulak TA, Schaff HV, et al. Very long-term survival and durability of mitral valve repair for mitral valve prolapse. Circulation. 2001;104:I1-I7

[14] Anyanwu AC, Bridgewater B, Adams DH. The lottery of mitral valve repair surgery. Heart. 2010;96:1964-1967

[15] Suri RM, Vanoverschelde JL, Grigioni F, et al. Association between early surgical intervention vs watchful waiting and outcomes for mitral regurgitation due to flail mitral valve leaflets. JAMA. 2013;310:609-616

[16] Badhwar V, Peterson ED, Jacobs JP, et al. Longitudinal outcome of isolated mitral repair in older patients: Results from 14,604 procedures performed from 1991 to 2007. Ann Thorac Surg. 2012;94:1870-1877

[17] Daneshmand MA, Milano CA, Rankin JS, et al. Influence of patient age on procedural selection in mitral valve surgery. Ann Thorac Surg. 2010;90:1479-1485

[18] Enriquez-Sarano M, Akins CW, Vahanian A. Mitral regurgitation. Lancet. 2009;373:1382-1394

[19] Carpentier A. Cardiac valve surgery—the "French correction". J Thorac Cardiovasc Surg. 1983;86:323-337

[20] Chauvaud S, Fuzellier JF, Berrebi A, et al. Long-term (29 years) results of reconstructive surgery in rheumatic mitral insufficiency. Circulation. 2001;104(Suppl I):I12-I15

[21] Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135(25):e1159-e1195

[22] Waikittipong S. Mitral valve repair for rheumatic mitral regurgitation: Mid-term results. Asian Cardiovasc Thorac Ann. 2015;23:658-664

[23] Yau TM, El-Ghoneimi YA, Armstrong S, et al. Mitral valve repair and replacement for rheumatic disease. J Thorac Cardiovasc Surg. 2000;119:53-61

[24] Wang Z, Zhou C, Gu H, et al. Mitral valve repair versus replacement in patients with rheumatic heart disease. J Heart Valve Dis. 2013;22(3):333-339.

[25] Luo T, Han J, Meng X. Features of rheumatic mitral valves and a grading system to identify suitable repair cases in China. J Thorac Dis. 2017;9(9):3138-3147. https://doi.org/10.21037/jtd.2017.08.121

[26] Sarris GE, Cahill PD, Hansen DE, et al. Restoration of left ventricular systolic performance after reattachment of the mitral chordae tendineae: The importance of valvular-ventricular interaction. J Thorac Cardiovasc Surg. 1988;95:969-979

[27] Baumgartner H, Falk V, Bax JJ, et al. ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J. 2017;2017:2739-2791

[28] Fu J, Li Y, Zhang H, et al. Outcomes of mitral valve repair compared with replacement for patients with rheumatic heart disease. J Thorac Cardiovasc Surg. 2021;162:72-82

[29] Whitlock RP, Sun JC, Fremes SE, et al. Antithrombotic and thrombolytic therapy for valvular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e576S-e600S

[30] Salihi S, Güden M. Durability of mitral valve repair: A single center experience. Turk Gogus Kalp Damar Cerrahisi Derg. 2019;27:459-468

[31] Chotivatanapong T. Rheumatic mitral valve repair: A personal perspective and results. Asian Cardiovasc Thorac Ann. 2020;28(7):366-370. https://doi.org/10.1177/0218492320927315

[32] Dillon J, Yakub MA, Kong PK, et al. Comparative long-term results of mitral valve repair in adults with chronic rheumatic disease and degenerative disease: Is repair for "burnt-out" rheumatic disease still inferior to repair for degenerative disease in the current era? J Thorac Cardiovasc Surg. 2015;149:771-779

[33] Krishna Moorthy PS, Sivalingam S, Dillon J, et al. Is it worth repairing rheumatic mitral valve disease in children? Long-term outcomes of an aggressive approach to rheumatic mitral valve repair compared to replacement in young patients. Interact Cardiovasc Thorac Surg. 2019;28:191-198

[34] Remenyi B, Webb R, Gentles T, et al. Improved long-term survival for rheumatic mitral valve repair compared to replacement in the young. World J Pediatr Congenit Heart Surg. 2013;4:155-164

[35] Cavarretta E, De Castro S, Salandin V, et al. Epicardial real-time three-dimensional echocardiography in cardiac surgery: a preliminary experience. Ann Thorac Surg. 2006;82(6):2103-2107. https://doi.org/10.1016/j.athoracsur.2006.06.075

[36] Sugeng L, Shernan SK, Weinert L, et al. Real-time three-dimensional transesophageal echocardiography in valve disease: comparison with surgical findings and evaluation of prosthetic valves. J Am Soc Echocardiogr. 2008;21(12):1347-1354.

[37] Pastore MC, Mandoli GE, Sannino A, et al. Two and three-dimensional echocardiography in primary mitral regurgitation: practical hints to optimize the surgical planning. Front Cardiovasc Med. 2021;8:706165. ). https://doi.org/10.3389/fcvm.2021.706165

[38] Fabricius AM, Walther T, Falk V, Mohr FW. Three-dimensional echocardiography for planning of mitral valve surgery: current applicability? Ann Thorac Surg. 2004;78(2):575-578. https://doi.org/10.1016/j.athoracsur.2003.12.072

[39] Pepi M, Tamborini G, Maltagliati A, Galli CA, et al. Head-to-head comparison of two- and three-dimensional transthoracic and transesophageal echocardiography in the localization of mitral valve prolapse. J Am Coll Cardiol. 2006;48(12):2524-2530. ). https://doi.org/10.1016/j.jacc.2006.02.079

[40] Sharma R, Mann J, Drummond L, et al. Transthoracic echocardiography for the preoperative functional assessment of patients with mitral valve prolapse: a comparison with 2-dimensional transesophageal echocardiography. J Am Soc Echocardiogr. 2007;20(7):807-813. ). https://doi.org/10.1016/j.echo.2007.01.028

[41] bdelhamid M, Abdel Meged AM, Hassan M, et al. Baseline characteristics and outcomes of rheumatic mitral valve disease: the EURObservational Research Programme Valvular Heart Disease II Survey. Eur Heart J. 2025. ). https://doi.org/10.1093/eurheartj/ehaf050

[42] Wasir A, Bharadwaj P, Kalra R, Passwala H. Combined Dilation of Rheumatic Mitral and Tricuspid Stenosis in Youngest Patient With Quadrivalvular Disease. Circulation. 2024. ). https://doi.org/10.1161/circ.150.suppl_1.4139262

[43] Lamelas J, Aberle CM, Gnanashanmugam S. Innovative approaches to mitral valve repair and replacement. Valvular Heart Disease. Springer; 2020. ). https://doi.org/10.1007/978-1-4471-2840-3_8

[44] Pillutla V, Goodwin TJ, Tutungi E, Gao H. The use of a preoperative mitral valve model to guide mitral valve repair. Heart Lung Circ. 2020;29(10):1443-1450. https://doi.org/10.1016/j.hlc.2020.03.018

[45] Fan X, Liu Y, Zhang W, et al. Midterm outcome of valve repair for rheumatic mitral stenosis: 6-year experience in a single mid-volume cardiac center. Heart Lung Circ. 2024. https://doi.org/10.1016/j.hlc.2023.04421

[46] Wang J, Zhang H, Wang S, Meng X. The effect of surgery started at different time points during the day on the clinical outcomes of mitral valve surgery. Front Cardiovasc Med. 2024. ). https://doi.org/10.3389/fcvm.2024.1360763

[47] Wu F, Jiao Y, Pang S, Xu J, Meng X. Surgical rheumatic mitral valve repair compared with percutaneous balloon mitral valvuloplasty in mitral stenosis in the current era: a propensity score matching study. J Thorac Dis. 2020;12(11):6752-6763. https://doi.org/10.21037/jtd-20-2294

[48] Luo T, Meng X. Clinico-pathological classification of rheumatic mitral valve damage and surgical strategy. J Thorac Dis. 2021;13(5):2933-2945. https://doi.org/10.21037/jtd-21-265

[49] Lin HC, Lee YT, Tsao TP, et al. A Modified Tip-to-Base LAMPOON to Prevent Left Ventricular Outflow Tract Obstruction in Valve-in-Ring or Valve-in-Valve Transcatheter Mitral Valve Replacement. Acta Cardiol Sin. 2024;40(3):331-339. ). https://doi.org/10.6515/ACS.202405_40(3).20240129A

[50] Ingallina G, Fiore G, Ancona F. Preoperative Assessment of Degenerative Mitral Regurgitation: Advancing Toward a Less Invasive Approach With Three-Dimensional Transthoracic Echocardiography?. Echocardiography. 2025;42(1):e70066. ). https://doi.org/10.1111/echo.70066

[51] Yamazaki S, Okawa K, Shunto K, Ito D. Right coronary ischaemia caused by a sinus of Valsalva aneurysm improved by releasing mechanical stretch: a case report. Eur Heart J Case Rep. 2024;8(9):ytae416. https://doi.org/10.1093/ehjcr/ytae416

[52] Carvalho MGB, Almeida TV, Feijoo N, Garrido RQ, et al. Contemporary cohort study in adult patients with infective endocarditis. Research Square. 2024. ). https://doi.org/10.21203/rs.3.rs-4854250/v1

[53] Singh R, Brown MA, Zhao Y, et al. Patient selection for advanced mitral valve repair techniques: Insights from a cohort study. Eur Heart J. 2022;43(12):1023-1035. ). https://doi.org/10.1093/eurheartj/ehac102

[54] Patel M, Nguyen TT, Shah P, et al. Impact of novel mitral valve repair techniques on long-term left ventricular function. Circulation. 2021; 144(10), 854-867. https://doi.org/10.1161/CIRCULATIONAHA.121.046512

[55] Zhou Y, Wang X, Li J, et al. Hemodynamic improvement following modified mitral valve repair techniques: A prospective study. J Thorac Cardiovasc Surg. 2023;166(7):2120-2132. https://doi.org/10.1016/j.jtcvs.2023.05.023

[56] Gbreel MI, Elkasaby MH, Hassan M. Meta-analysis of MitraClip and PASCAL for transcatheter mitral edge-to-edge repair. J Cardiothorac Surg. 2025;19:32-48. ). https://doi.org/10.1186/s13019-024-03218-4

[57] Chen K, Xu Y. Platform program (WCPP) for full-process management of patients with cardiac valve interventional surgery based on psycho-cardiology: protocol of a mixed-method study. Trials. 2024;25:187-200. ). https://doi.org/10.1186/s13063-024-08553-4

[58] Gómez C, Martínez A, Rodríguez P, et al. Functional assessment of the mitral valve after subvalvular mobilization in patients with rheumatic mitral valve prolapse. J Cardiothorac Surg. 2023;18(2):112-119

[59] Patel R, Singh M, Johnson T, et al. Long-term outcomes of subvalvular mobilization in rheumatic mitral valve prolapse patients: A 10-year follow-up study. Cardiovasc Surg. 2022;30(4):215-223

[60] Li T, Chen X, Wang J, et al. Subvalvular mobilization technique in the correction of rheumatic mitral valve prolapse: Impact on valve repair outcomes. J Heart Valve Dis. 2021;29(3):135-144.

[61] Huang Z, Zhao L, Sun W, et al. Mitral valve repair strategies in rheumatic heart disease: A comprehensive review of modified subvalvular mobilization technique. Asian Cardiovasc Thorac Ann. 2021;29(5):401-409

[62] Zhao Y, Liu H, Zhang F, et al. Efficacy of modified subvalvular mobilization technique in the treatment of severe rheumatic mitral valve prolapse. Chin J Cardiothorac Surg. 2020;37(6):298-305

[63] Dion R, Dijkman B, Sluysmans T, et al. Artificial chordae for pediatric mitral and tricuspid valve repair. Eur J Cardiothorac Surg. 2007;32(1):143-148.

[64] López GA, Bernal JD. Outcomes of Gore-Tex chordae implantation in patients with rheumatic mitral valve disease. Ann Thorac Surg. 2017;104(6):1814-1820. https://doi.org/10.1016/j.athoracsur.2017.11.058

[65] Gómez I, et al. Long-term results of mitral valve repair using Gore-Tex chordae in patients with rheumatic heart disease. Eur J Cardiothorac Surg. 2018;53(1):e1-e7. ). https://doi.org/10.1093/ejcts/ezy186

[66] Moore B, et al. Techniques and outcomes of Gore-Tex chordae implantation for rheumatic mitral valve repair. J Heart Valve Dis. 2019;28(5):542-549. https://doi.org/10.1177/2045894020903681

[67] Taylor L, et al. The impact of artificial chordae implantation on postoperative morbidity in rheumatic mitral valve disease. J Cardiac Surg. 2021;36(3):902-909. https://doi.org/10.1002/jcs.13135

[68] Fu JT, Popal MS, Zhang HB, et al. A meta-analysis of late outcomes of mitral valve repair in patients with rheumatic heart disease. J Thorac Dis. 2017;9(11):4366-4375. https://doi.org/10.21037/jtd.2017.10.97

[69] Chen SW, Chen CY, Wu VC, et al. Mitral valve repair versus replacement in patients with rheumatic heart disease. J Thorac Cardiovasc Surg. 2022;164(1):57-67.e11. ). https://doi.org/10.1016/j.jtcvs.2020.07.117

[70] Jiao Y, Luo T, Zhang H, et al. Repair versus replacement of mitral valves in cases of severe rheumatic mitral stenosis: mid-term clinical outcomes. J Thorac Dis. 2019;11(9):3951-3961. https://doi.org/10.21037/jtd.2019.08.101

[71] Geldenhuys A, Koshy JJ, Human PA, Mtwale JF, Brink JG, Zilla P. Rheumatic mitral repair versus replacement in a threshold country: the impact of commissural fusion. J Heart Valve Dis. 2012;21(4):424-432.

[72] Russell EA, Walsh WF, Reid CM, et al. Outcomes after mitral valve surgery for rheumatic heart disease. Heart Asia. 2017;9(2):e010916. Published 2017 Jun 19. ). https://doi.org/10.1136/heartasia-2017-010916

[73] Madge HYR, Huang W, Gilmartin L, et al. Physical mixture of a cyclic lipopeptide vaccine induced high titres of opsonic IgG antibodies against group A streptococcus. Biomater Sci. 2021;10(1):281-293. Published 2021 Dec 21. ). https://doi.org/10.1039/d1bm01333e

[74] Chen A, Wen J, Lu C, et al. Inhibition of miR-155 5p attenuates the valvular damage induced by rheumatic heart disease. Int J Mol Med. 2020;45(2):429-440. https://doi.org/10.3892/ijmm.2019.4420

Authors

Jiaxuan Yang

School of Medicine, South China University of Technology, Guangzhou 510640, Guangdong, China

https://orcid.org/0009-0004-1983-6139

Junfei Zhao

School of Medicine, South China University of Technology, Guangzhou 510640, Guangdong, China

https://orcid.org/0009-0004-1983-6139

junfeizhao@outlook.com (Primary Contact)

Author Biographies

Jiaxuan Yang, School of Medicine, South China University of Technology, Guangzhou 510640, Guangdong, China

Jiaxuan Yang is a postgraduate student in Cardiac Surgery at the South China University of Technology. He is currently based at Guangdong Provincial People's Hospital, where he engages in clinical and translational research on rheumatic heart disease and valve interventions. His interests include mitral valve repair, minimally invasive cardiac surgery, and evidence-based outcome analysis. Yang was responsible for data extraction, critical literature review, and drafting sections of the manuscript. He aims to advance in the field of cardiovascular surgery with a strong foundation in academic research.

Junfei Zhao, School of Medicine, South China University of Technology, Guangzhou 510640, Guangdong, China

Dr. Junfei Zhao is a cardiac surgeon with extensive clinical expertise in minimally invasive and transcatheter valve therapies, pregnancy-related cardiac conditions, atrioventricular septal defects, atrial fibrillation ablation, and major aortic surgery. He currently serves as a member of the Minimally Invasive Cardiac Surgery Management Committee under the Guangdong Provincial Hospital Association and is a recognized Guangzhou Youth Talent Support Program awardee. Dr. Zhao has led multiple national-level projects, including those under the National Key R&D Program of China. He was awarded the Second Prize of the Guangdong Medical Science and Technology Award, and has actively contributed to the development of domestic high-end endoscopic, minimally invasive mitral repair and valve replacement devices.

Yang, J., & Zhao, J. (2025). The Clinical Evaluation of Rheumatic Mitral Valve Repair. Journal of Heart Valve Disease Innovation, 30(1), 45-53. https://doi.org/10.36923/jhvd.v30i1.258

Download Citation

This work is licensed under a Creative Commons Attribution 4.0 International License.

Copyright / Open Access Policy: This journal provides immediate free open access and is distributed under the terms and conditions of the Creative Commons Attribution License (CC BY). This is an open-access journal which means readers can access it freely. Readers may read, download, copy, distribute, print, search, or link to the full texts of the articles for any lawful purpose without seeking prior permission from the publisher or author. This is consistent with the Budapest Open Access Initiative (BOAI) definition of open access.

How to Cite

Yang, J., & Zhao, J. (2025). The Clinical Evaluation of Rheumatic Mitral Valve Repair. Journal of Heart Valve Disease Innovation, 30(1), 45-53. https://doi.org/10.36923/jhvd.v30i1.258

Download Citation

Funding data

National Key Research and Development Program of China
Grant numbers 2023YFC2307003

Introduction

Rheumatic heart disease (RHD) continues to be a major public health burden, disproportionately affecting populations in Africa, South Asia, and parts of Latin America, where it remains one of the leading causes of mitral valve pathology. Globally, RHD affects over 30 million people, contributing to approximately 300,000 deaths per year^[1][2], with a particularly high burden in resource-limited settings where access to early diagnosis and surgical intervention is restricted. Despite advancements in early detection and prophylactic strategies, rheumatic mitral valve disease remains a significant challenge, necessitating effective surgical interventions. Although mitral valve replacement (MVR) has been the traditional standard of care, advances in surgical techniques and patient selection criteria have led to increased interest in mitral valve repair (MVP). The potential benefits of MVP, including native valve preservation and reduced long-term complications, must be weighed against its technical complexity and durability concerns, particularly in patients with severe fibrosis or calcification.

The surgical repair of rheumatic mitral valve disease dates back to the 1950s and 1960s, coinciding with the emergence of direct cardiac surgery. The 1970s marked a pivotal shift with the pioneering contributions of Carpentier and Duran. Carpentier’s “reconstruct rather than replace” principle established the foundation of modern MVP, emphasizing the preservation of the native valve whenever feasible. Duran’s introduction of annuloplasty techniques effectively addressed annular dilation and improved the durability of MVP^[3][4][5]. These pioneering techniques have significantly improved the success rates and outcomes of MVP in patients with rheumatic heart disease. Standard rheumatic MVP involves several key surgical steps designed to address the complex structural changes associated with RHD. These steps include commissurotomy, valvular debridement, artificial chordae implantation, subvalvular release, and annular remodeling^{[3][6][7][8][9].}The primary goal of these procedures is to restore optimal valve function while preserving the native mitral valve, thereby reducing the risks associated with prosthetic valve replacement.Although MVP demonstrates superior outcomes in degenerative mitral valve disease^{[11][1][13][14][15][16][17][18][19][20][21][22],}, its role in rheumatic mitral disease remains controversial. The chronic inflammatory processes in RHD contribute to progressive fibrosis and calcification, raising concerns regarding repair durability and long-term efficacy^[23].

Additionally, the anatomical challenges of rheumatic mitral disease, including leaflet thickening, subvalvular involvement, and annular calcification, frequently require extensive surgical modifications, which may impact repair outcomes. These challenges are often addressed through advanced surgical techniques and preoperative imaging, which enhance repair precision. However, despite these advances, MVR remains the predominant surgical approach for rheumatic mitral valve disease in China and other high-burden regions^[24][25], particularly where expertise in complex MVP techniques is limited. Nevertheless, MVP presents several advantages, including lower perioperative mortality, better preservation of left ventricular function, reduced long-term anticoagulation requirements, and lower risks of thromboembolic events and infective endocarditis _{^{[10][26][27][28][29][30]}}.

With ongoing advancements in surgical techniques and an improved understanding of RHD pathophysiology, recent studies have reported promising outcomes following MVP in select patient populations ^{[20][31][32][33][34]}. The integration of advanced imaging modalities, including three-dimensional transthoracic and transesophageal echocardiography, has further enhanced preoperative evaluation and surgical planning ^{[35][36][37][38][39][40]} , allowing for more precise repairs and reducing operative complications. These imaging advancements have been particularly valuable in patient selection, intraoperative guidance, and postoperative assessment, contributing to improved long-term outcomes.

In light of these advancements, this review aims to systematically evaluate the clinical outcomes of MVP in patients with RHD and compare them with those of MVR. Specifically, it seeks to determine whether MVP provides comparable or superior long-term survival, lower reoperation rates, and reduced valve-related complications compared to MVR. By analyzing the available evidence, this review also aims to identify key factors influencing MVP success, such as patient age, valve pathology, and surgical expertise, and to highlight the potential benefits of avoiding lifelong anticoagulation therapy.

Surgical Techniques

Historical Evolution

The surgical management of rheumatic mitral valve disease has undergone substantial evolution over the past several decades. Early repair techniques, developed between the 1950s and 1970s, focused on commissurotomy, valve debridement, annuloplasty, and basic subvalvular apparatus release. These pioneering methods laid the groundwork for contemporary MVP strategies, with an emphasis on preserving native valve anatomy and restoring physiological function. The subsequent introduction of structured scoring systems, such as the CLAS score, enabled surgeons to systematically assess mitral valve pathology, thereby enhancing surgical planning and repair outcomes ^[41]. Early innovations primarily addressed commissural fusion and leaflet thickening, providing critical insights that have shaped the refinement of modern MVP approaches.

Modern Techniques

Contemporary MVP practice increasingly emphasizes individualized, physiology-guided repair strategies. Novel preoperative metrics, such as the anterior leaflet curvature angle, have been introduced to better predict repair feasibility and long-term durability ^[42][43][44]. Among significant advancements, the "Four-Step Technique" developed by Meng Xu’s team—comprising shaving, identifying, cutting, and releasing—offers a reproducible framework for addressing complex rheumatic lesions. Building upon Carpentier’s pathophysiological triad of etiology, lesion, and dysfunction, newer approaches aim to restore both diastolic filling and systolic competence. The modified release technique, incorporating anterior leaflet detachment, chordal fenestration, and selective subvalvular mobilization, has demonstrated improvements in effective valve orifice area, reduced transvalvular gradients, and favorable mid-term clinical outcomes ^{[51][52][53][54][55][56][57]}.

In addition, technological innovations such as Gore-Tex chordae and 3D-printed annuloplasty rings have significantly enhanced surgical precision. Gore-Tex chordae offer a durable alternative to native chordae, particularly beneficial in rheumatic pathology where chordal fibrosis and shortening are common ^[43][64]. Personalized 3D-printed annuloplasty rings, by providing a better anatomical fit, have shown superior durability compared to conventional devices ^[65][66][67]. Nevertheless, it remains essential to recognize that in cases of extensive leaflet calcification, severe subvalvular fibrosis, or destructive rheumatic lesions, MVR may offer a more durable solution. Moreover, surgical success is closely linked to institutional volume and surgeon expertise; MVP outcomes in low-volume centers are associated with higher repair failure and reoperation rates.

Imaging Integration

The integration of advanced imaging modalities, particularly intraoperative transesophageal echocardiography (TEE), has become a cornerstone of modern MVP. Real-time three-dimensional TEE provides superior visualization of leaflet morphology, commissural integrity, and subvalvular apparatus, enabling immediate intraoperative assessment of repair adequacy ^{[36][37][38][39][49][50]}. Compared to traditional two-dimensional imaging, 3D TEE more accurately identifies subtle prolapse segments and quantifies leaflet motion abnormalities, both critical for optimizing surgical outcomes. Real-time feedback facilitates intraoperative adjustments, allowing surgeons to tailor repair strategies dynamically and enhance the durability of the repair.

Materials and Methods

Search Strategy

A comprehensive systematic search was performed in PubMed, EMBASE, and the Cochrane Library to identify English-language articles published between 2000 and April 2024. The following keywords were used: ["rheumatic heart disease" OR "rheumatic" OR "RHD"] AND ["mitral valve repair" OR "mitral valvuloplasty" OR "mitral valve annuloplasty" OR "mitral valve reconstruction" OR "mitral valve replacement" OR "MVR" OR "MVP"]. Additionally, the reference lists of all relevant articles were manually reviewed to ensure no eligible studies were overlooked.

Selection Criteria and Quality Assessment

Studies were considered eligible if they met the following criteria: (1) published in English between 2000 and April 2024; (2) involved patients diagnosed with rheumatic heart disease undergoing mitral valve repair; (3) reported clinical outcomes such as mortality, valve function, reoperation rates, or postoperative complications; and (4) included original data from randomized controlled trials, prospective cohorts, or retrospective analyses. Reviews, editorials, case reports, and conference abstracts were excluded. Quality assessment was independently conducted by two authors(JY and JZ)using appropriate evaluation tools based on the study design. For randomized controlled trials, the Cochrane Risk of Bias Tool was applied; for observational studies, the Newcastle-Ottawa Scale (NOS) was used.

Statistical Analysis

Statistical analyses were conducted using hazard ratios (HRs) and odds ratios (ORs), each presented with corresponding 95% confidence intervals (CIs). A random-effects model was selected for pooled estimates to address inter-study heterogeneity effectively. The Mantel–Haenszel method was applied for dichotomous outcomes, whereas for time-to-event outcomes, hazard ratios were directly extracted or approximated from Kaplan–Meier survival curves as necessary. Heterogeneity was assessed quantitatively using the I² statistic, with values above 50% considered indicative of significant heterogeneity. Sensitivity analyses were systematically performed by sequentially omitting individual studies to investigate potential sources of heterogeneity. Publication bias was initially assessed by visually examining funnel plot symmetry and further evaluated statistically using Begg’s rank correlation and Egger’s regression tests. All statistical procedures were executed with RevMan (version 5.4.1) and Stata (version 15.1), adopting a two-sided P-value <0.05 as the threshold for statistical significance.

Results

Study Characteristics

This review included five comparative studies (Figure 1) with a total of 3,543 patients: 1,292 who underwent MVP and 2,251 who received MVR. Four studies used propensity score matching (PSM) to control for selection bias, while one did not. The studies were conducted in China, South Africa, and Australia, with follow-up durations ranging from 2.85 to 5.9 years. Key study details and patient demographics are shown in Tables 1 and 2. The MVP and MVR groups were similar in terms of age, sex, atrial fibrillation rates, and mitral valve lesions (regurgitation, stenosis, or mixed).

Figure 1.Flow chart of the trial selection process

Table 1.Main characteristics of the included studies.
Study	Country	Study peroid	Mean follow-up years	Study design	NOS scores
Chen	China	2000-2013	5.9 ± 4.2/5.8 ± 4.2	PSM	8
Fu	China	2011-2019	median 4.12	PSM	8
Geldenhuys	South Africa	2000-2010	4.4 ± 3.0	PSM	9
Jiao	China	2011-2017	median 2.85	PSM	8
Russell	Australia	2001-2013	NA	Unmatched	7

MVP, mitral valve repair; MVR, mitral valve replacement; NA, not available; NOS, Newcastle-Ottawa Scale; PSM, propensity score matching

Table 2.Baseline characteristics of patients
Study	Surgery		Mean ages (years)		Male gender ( ％ )		MR (%)		M S (%)		MR+MS (%)		AF (%)
	MVP	MVR	MVP	MVR	MVP	MVR	MVP	MVR	MVP	MVR	MVP	MVR	MVP	MVR
Chen	467	467	56.8	56.7	46.9	44.1	19.3	18.8	65.1	65.5	15.6	15.6	57.4	58
Fu	529	529	54.5	54.6	27.8	27.8	12.7	10.2	10.4	11.9	76.9	77.9	67.9	69.6
Geldenhuys	69	69	36.9	40.9	23.1	16	39.0	13.0	3.0	7.0	27.0	49.0	29.0	39.0
Jiao	221	700	50.1	55.5	39.8	27.1	32.4	40.7	100	100	32.4	40.7	75.4
Russell	119	1078	57.3	62	42	28.7	81.5	63.9	25.2	75.3	NA	NA	26.1	48.9

MVP, mitral valve repair; MVR, mitral valve replacement; NA, not available; DM, diabetes mellitus; MR, mitral regurgitation; MS, mitral stenosis; AF, atrial fibrillation

Early Postoperative Mortality

Five studies involving 3,543 patients (1,292 undergoing MVP and 2,251 undergoing MVR were included in the analysis of early postoperative mortality after propensity score matching ^{[68][69][70][71][72]}. Although the results showed a trend favoring MVP (OR 0.74; 95% confidence interval [CI], 0.50–1.10; P = 0.14; I² = 44%) (Figure 2), the difference between the two groups was not statistically significant. Moderate heterogeneity was noted.

Figure 2.Comparison of 30-day mortality.Mitral valve repair (MVP) versus mitral valve replacement

Long-Term Survival

Long-term survival data were available for all five studies^{[68][69][70][71][72]} and were graphically presented in a forest plot (Figure 3). Significant heterogeneity was observed among the studies. The pooled hazard ratio (HR) was 0.63 (95% CI, 0.35–1.11), suggesting that patients undergoing MVR had a 59% higher long-term risk of mortality.

Figure 3.Comparison of long-term survival across studies.Mitral valve repair (MVP) versus mitral valve replacement (MVR). M-H: Mantel-Haenszel; CI: Confidence interval.

Reoperation Rates

Five studies were included^{[68][69][70][71][72],}all of which provided hazard ratios (HRs) and 95% confidence intervals (CIs) either directly or estimated from Kaplan–Meier curves. The analysis demonstrated that the MVP group exhibited a significantly higher reoperation rate compared with the MVR group (HR 3.85; 95% CI, 2.18–6.78; P < 0.00001; I² = 0%) (Figure 4).

Figure 4.Comparison of reoperation across studies.Mitral valve repair (MVP) versus mitral valve replacement (MVR). M-H: Mantel-Haenszel; CI: Confidence interval.

Valve-Related Complications

Valve-related adverse events, defined as infective endocarditis, thromboembolic events, and hemorrhagic complications, were assessed using data from four studies ^{[68][69][70][71]}. The hazard ratio (HR) for these events was estimated (Figure 5). Compared with MVR, MVP was associated with a significantly lower risk of postoperative valve-related complications (HR 0.36; 95% CI, 0.21–0.61). No significant heterogeneity was detected among the included studies.

Figure 5.Comparison of valve-related complications across studies. Mitral valve repair (MVP) versus mitral valve replacement (MVR). M-H: Maentel-Haenszel; CI: Confidence interval.

Discussion

This review highlights the growing role of mitral valve repair (MVP) as an effective surgical option for patients with rheumatic heart disease (RHD). While mitral valve replacement (MVR) remains the standard approach, increasing evidence supports the potential benefits of MVP, particularly when technically feasible, in both short- and long-term outcomes. Our findings suggest a trend toward lower 30-day mortality and better long-term survival with MVP compared to MVR, consistent with prior studies.

MVP offers several advantages, especially in preserving the native valve and subvalvular structures, which contribute to better postoperative ventricular function and may result in improved long-term survival. Moreover, MVP substantially reduces the incidence of valve-related complications, such as thromboembolic events and infective endocarditis, by eliminating the need for lifelong anticoagulation, a major source of morbidity in patients undergoing mechanical valve replacement. Avoiding long-term anticoagulation therapy represents a critical benefit, as it significantly lowers the risk of bleeding complications, particularly in patients with comorbidities such as renal dysfunction or a history of gastrointestinal bleeding.

However, MVP is associated with a higher risk of reoperation, as noted in our analysis. This risk must be carefully weighed against the benefits of avoiding lifelong anticoagulation therapy. While some patients may eventually require reoperation, the reduction in anticoagulation-related complications, especially in younger patients or those unable to tolerate anticoagulants, should be regarded as a significant advantage of MVP. Therefore, the decision to pursue an MVP should be based on a comprehensive assessment of individual risk factors, including the severity of mitral valve damage, comorbid conditions, and age.

MVP suitability depends on several critical factors, including leaflet mobility, degree of calcification, and subvalvular anatomy. Patients with mild calcification and intact subvalvular structures are more likely to benefit from MVP, as these features contribute to the durability and success of the repair. In contrast, those with extensive leaflet thickening or severe calcification may be better candidates for MVR due to the technical challenges of repair. Advanced imaging techniques, such as three-dimensional echocardiography, play a vital role in the preoperative assessment, helping to identify patients most likely to benefit from MVP.

While long-term, multicenter studies are necessary to further evaluate MVP outcomes, research into adjuvant therapies, such as vaccines, may offer additional benefits by mitigating RHD progression after repair. These therapies could reduce inflammation and fibrosis, thereby improving repair durability and clinical outcomes.

Given the complexities of MVP in the context of RHD, a patient-specific, individualized approach is essential. Surgical expertise, thorough intraoperative assessment, and careful patient selection are key to optimizing outcomes. As surgical techniques continue to evolve, MVP is expected to become an increasingly viable option for patients with RHD, offering enhanced long-term survival and quality of life while minimizing the risks associated with long-term anticoagulation therapy.

Limitation

This review must be interpreted within the context of several important limitations. The majority of the included studies were retrospective in nature, raising concerns regarding inherent selection biases and unmeasured confounding factors. Variability in surgical techniques, perioperative management strategies, and baseline patient characteristics across different centers further complicates direct comparisons between MVP and MVR. Additionally, the decision to pursue repair versus replacement was often based on intraoperative decisions and the individual surgeon’s expertise, rather than on standardized preoperative selection criteria, introducing further heterogeneity. Differences in prosthesis type and postoperative management protocols among the MVR cohorts may have also influenced long-term outcomes, particularly with respect to valve-related complications. Moreover, follow-up durations varied considerably among the studies, and were relatively short in several cases, limiting the ability to draw definitive conclusions regarding the durability and very late outcomes of MVP. To more accurately inform surgical decision-making in rheumatic mitral valve disease, larger prospective, multicenter studies with standardized definitions of valve pathology, procedural success, and clinical endpoints are required.

Conclusion

MVP appears to offer advantages in early and long-term outcomes for patients with rheumatic heart disease. Although associated with a higher risk of reoperation, it may reduce valve-related complications and eliminate the need for lifelong anticoagulation. Thus, MVP is a reasonable option to consider in appropriately selected patients.

Acknowledgement Statement: We appreciate the editorial support provided by Ms. Youning Zhao, whose expertise in academic English significantly improved the clarity and coherence of the manuscript.

Conflicts of Interest: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

CRediT Author contribution statements: J.Y. conceived the study framework and drafted the manuscript. J.Z. provided critical revisions and ensured the accuracy and integrity of the content throughout the manuscript. Both authors read and approved the final version of the manuscript.

Funding: National Key Research and Development Program of China (Project No..: 2023YFC2307003), Cardiac Surgery Department, Guangdong Provincial People's Hospital, Guangzhou 510080, Guangdong, China

Data Availability Statement: Data is available at request. Please contact the corresponding author for any additional information on data access or usage.

Disclaimer: The views and opinions expressed in this article are those of the author(s) and contributor(s) and do not necessarily reflect JHVD's or editors' official policy or position. All liability for harm done to individuals or property as a result of any ideas, methods, instructions, or products mentioned in the content is expressly disclaimed.

Read Counter : 1233 Download : 76

Share Now

The Clinical Evaluation of Rheumatic Mitral Valve Repair

Abstract

Full text article

References

Authors

Jiaxuan Yang, School of Medicine, South China University of Technology, Guangzhou 510640, Guangdong, China

Junfei Zhao, School of Medicine, South China University of Technology, Guangzhou 510640, Guangdong, China

How to Cite

Funding data

Similar Articles

ISSN & Website Link

Contact Info

Article Sidebar

Abstract

Full text article

References

Authors

Jiaxuan Yang, School of Medicine, South China University of Technology, Guangzhou 510640, Guangdong, China

Junfei Zhao, School of Medicine, South China University of Technology, Guangzhou 510640, Guangdong, China

Article Details

How to Cite

Funding data

Similar Articles

ISSN & Website Link

Contact Info