A Systematic Review and Meta-Analysis of Clinical Outcomes After Mitral Valve Repair Versus Replacement in Patients With Rheumatic Heart Disease

Background: The clinical outcomes of rheumatic mitral valve repair (MVP) remain controversial, particularly regarding reoperation rates. Therefore, we conducted a meta-analysis to comprehensively and systematically evaluate clinical outcomes, with a focus on reoperation rates. Methods: PubMed, EMBASE, Web of Science, and the Cochrane Library were searched for articles and abstracts published from 1 January 1990 to 21 September 2023, to compare the clinical outcomes of MVP versus mitral valve replacement (MVR) in patients with rheumatic heart disease (RHD). Results: After screening the titles and abstracts of 2703 articles, a total of 165 articles were reviewed. A total of 20 articles met the inclusion criteria, comprising 4492 MVP and 7913 MVR cases. MVP was associated with lower early mortality (odds ratio (OR): 0.63, 95% confidence interval (CI): 0.50–0.78; p < 0.001) and long-term mortality (OR: 0.57, 95% CI: 0.42–0.77; p < 0.001), as well as reduced rates of thromboembolism (OR: 0.58, 95% CI: 0.46–0.74; p < 0.001), bleeding (OR: 0.70, 95% CI: 0.55–0.89; p = 0.004), and heart failure (OR: 0.28, 95% CI: 0.12–0.67; p = 0.004). There were no significant differences between groups in the incidence of infective endocarditis (p = 0.786), stroke (p = 0.503), or atrial fibrillation (p = 0.180). To analyze reoperation rates more objectively, studies were stratified by surgical era into three subgroups. The risk of reoperation after MVP was high before 2000 (OR: 3.67, 95% CI: 1.98–6.78; p < 0.001). However, from 2000 to 2010, the risk of reoperation decreased but remained high overall, whereas after 2010, the reoperation rate was similar to that observed with MVR. Conclusion: In patients with RHD, MVP is associated with lower early and long-term mortality, as well as reduced thromboembolism, bleeding, and heart failure compared with MVR. Although MVP historically carried a higher reoperation rate than MVR, this rate has gradually declined in recent years, and since 2010, reoperation rates have not differed significantly between MVP and MVR.