Valve characteristics and surgical options for severe rheumatic mitral stenosis with more than mild regurgitation: A dual-center retrospective study

OBJECTIVE The optimal surgical strategy for severe rheumatic mitral stenosis with more than mild regurgitation remains unclear. We aimed to characterize mitral valve pathology in these patients and compare outcomes between repair and replacement. METHODS This dual-center retrospective study analyzed 870 surgically-treated severe rheumatic mitral stenosis patients with complete imaging. Inverse probability weighting balanced baseline characteristics (SMD<0.1). Quantitative assessment combined echocardiography and computed tomography angiography. Primary endpoint was all-cause mortality. RESULTS Of 870 patients, 408 (46.9%) had more than mild regurgitation. Compared to pure stenosis, these patients had larger left atrial diameters (51.0 vs 49.0 mm, P<0.001), higher mean pulmonary artery pressures (42.0 vs 41.0 mmHg, P=0.015), and shorter anterior (33.3 vs 33.7 mm, P=0.026) and posterior (19.2 vs 20.0 mm, P<0.001) leaflets, and a comparable rate of mitral valve repair (65.0% vs 63.0%, P=0.595). Among patients with more than mild regurgitation, early outcomes did not differ between repair (n=265) and replacement (n=143). At 5-year postoperative follow-up, repair was associated with significantly lower mortality (1.4% vs. 7.1%, P=0.009) and comparable reoperation rates (1.4% vs. 1.0%, P=1.000). Survival analysis favored repair (log-rank P=0.005), which independently predicted survival (HR 0.347; P=0.039). CONCLUSIONS Nearly half of severe rheumatic mitral stenosis patients present with more than mild regurgitation. Mitral repair demonstrates improved 5-year survival without increased reoperations, supporting its consideration as a key candidate strategy when feasible.