Key result
Rheumatic mitral valve repair linked to ~43% lower mid-term mortality and fewer strokes vs replacement.
Why the study?
Patient selection and clinical outcomes of rheumatic mitral valve repair remain controversial.
Does mitral valve repair reduce mid-term mortality and stroke incidence compared to mitral valve replacement in patients with rheumatic heart disease?
Cohort (n=972)
Yes
Does mitral valve repair reduce mid-term mortality and stroke incidence compared to mitral valve replacement in patients with rheumatic heart disease?
Hazard Ratio: 0.429 (95% CI 0.213–0.865)
Absolute Event Rate: 2.7% vs 7.1%
p-value: p=0.018
In patients with rheumatic heart disease, successful mitral valve repair is associated with significantly lower mid-term mortality and stroke compared to replacement, without increasing reoperation rates.
Supports repair preference when feasible in rheumatic mitral disease; extends observational data but should not yet change practice.
Background The patient selection and clinical outcomes of rheumatic mitral valve repair remain controversial. Purpose This study aimed to identify key factors affecting the repairability of rheumatic mitral valves through multimodal imaging and to compare the mid-term clinical outcomes of repair versus replacement using inverse probability of treatment weighting. Methods This multicenter cohort study included 972 patients who underwent rheumatic mitral valve surgery nationwide between 2016 and 2022. Mitral valve repair was attempted first in all patients, and replacement was performed if the surgeon deemed repair unfeasible or suboptimal. Multimodal imaging, including 2D, 3D echocardiography, and cardiac CTA, was used to quantitatively assess factors affecting repairability. Inverse probability of treatment weighting was applied to balance baseline characteristics between groups (SMD <0.1) , and mid-term outcomes were compared. Independent risk factors for prognosis were also explored. Results Among 972 patients, 621 (63.9%) successfully underwent mitral valve repair. BMI, diabetes, left atrial diameter, mitral leaflet calcification, and annular calcification were independent factors affecting repairability. During a median follow-up of 3.51 years, the repair group had significantly lower mid-term mortality (2.7% vs 7.1%, P=0.006) and stroke incidence (0.7% vs 2.4%, P=0.035) compared to the replacement group. The repair group showed a 42.9% reduction in mid-term mortality (HR=0.429 [0.213, 0.865], P=0.018), with consistent survival benefits across subgroups. Reoperation rates did not differ significantly between groups (0.8% vs 0.2%, P=0.185). Previous percutaneous mitral commissurotomy was an independent risk factor for reoperation after repair (HR=7.491 [1.325, 42.358], P=0.023). Cox regression analysis identified age as an independent risk factor for mid-term mortality (HR=1.077 [1.027, 1.128], P=0.002). Restricted cubic spline analysis revealed that surgical mortality risk increased after age 58, primarily in the replacement group (P=0.047), with no significant effect in the repair group (P=0.059). Conclusion In well-selected patients, rheumatic mitral valve repair is superior to replacement in reducing mortality and stroke incidence, with comparable reoperation rates. Patients with a history of percutaneous mitral commissurotomy have a higher risk of reoperation after repair and should be carefully evaluated.Factors to predict repairability Kaplan-Meier curve
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Jia et al. (2025) conducted a cohort in Rheumatic heart disease (n=972). Mitral valve repair vs. Mitral valve replacement was evaluated on Mid-term mortality (HR 0.429, 95% CI 0.213-0.865, p=0.018). Rheumatic mitral valve repair was associated with significantly lower mid-term mortality compared to replacement (2.7% vs 7.1%; HR 0.429; 95% CI 0.213-0.865; P=0.018).
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