Mitral Valve Repair Failure: Mechanisms, Re-repair Feasibility, and Outcomes of Reintervention. A Systematic Review and Meta-Analysis

Mitral valve repair is the preferred treatment for degenerative mitral regurgitation whenever feasible and durable. Amid the increasing volume of mitral repairs, mitral valve repair failure has emerged as an increasingly recognized clinical entity in contemporary mitral surgery. A systematic literature search was conducted to identify studies reporting intraoperative or interval/postoperatively detected mitral valve repair failure. Evidence synthesis included a systematic summary and analysis of incidence, failure modes, factors favoring re-repair, re-repair techniques and intervention-specific outcomes. Intraoperative mitral valve repair failure was reported across nine unique studies totaling 18,429 patients undergoing initial mitral valve repair, of whom 580 (3.1%) experienced intraoperative failure requiring re-cross-clamping. Re-repair was the primary management strategy in intraoperative failure, with a pooled re-repair rate of 82%. Interval mitral valve repair failure was analyzed from 12 studies including 1,363 patients, occurring at a mean of 6 years following the index repair. Disease progression was the most frequent mechanism of interval failure (44%), followed by technical failure (35%) and new disease (17%). In interval failure, valve replacement remained the most employed strategy, while re-repair was performed in 35% of patients. Re-repair was associated with significantly superior long-term survival (78.3% vs. 58.3%; HR 2.44, 95% CI [1.79-3.33], p < 0.001). Mitral valve re-repair is a safe and feasible option in selected patients with degenerative mitral valve repair failure and is associated with improved long-term survival. Early technical failures and localized, non-calcified defects with preserved leaflet tissue are most likely to benefit from re-repair.