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mitral valve replacement (MVR)

Also see mitral valve surgery Indications: 1) mitral stenosis: a) mitral valve area < 1 cm2/m2 (body surface area) b) severe symptoms c) recurrent systemic thromboembolism d) pulmonary hypertension e) valvuloplasty may be an alternative to mitral valve replacement 2) mitral regurgitation a) symptomatic or progressive increase in LV size - LV end diastolic dimension > 4.5 cm b) decline in LV systolic function Special laboratory: - cardiac catheterization with coronary angiography in patients at risk for coronary artery disease Complications: - operative mortality 5-15% in the elderly [2] - operative mortality is 8.9% for mitral valve replacement vs 3.9% for mitral valve repair [3] - severe mitral annular calcification makes transcatheter MVR more challenging [5] - procedural complications (20%) - left ventricular outflow tract obstruction (9%) - valve embolization (6%) - stroke occurred (7%) - conversion to open surgery (6%) - periprocedural mortality by 30 days (30%) [5] Procedure: - bioprosthetic valve vs mechanical mitral valve replacement - mechanical prosthetic valves are associated with lower risk of reoperation but greater risk of bleeding or stroke [4]* - no significant survival difference at 15 years* - mortality benefit for mechanical valve vs bioprosthetic valve persists until age 70 years [7] * patients aged 50-69 years [4] - transcatheter MVR with a balloon-expandable valve prosthesis for degenerated mitral bioprostheses & failed annuloplasty rings is a less invasive alternative to repeat surgery [5,6] Management: - mitral valve replacement should not be delayed or denied based on age alone [3] - mitral valve repair rather than mitral valve replacement is preferred unless clinically or anatomically contraindicated [3] - prognosis: estimated 10-year survival - 37% for mitral valve replacement - lifetime anticoagulation - rivaroxaban for atrial fibrillation & bioprosthetic mitral valve [8]

Related

mitral valve repair

Specific

transcatheter mitral valve replacement/insertion (TMVR, TMVI)

General

cardiac valve replacement mitral valve surgery

References

  1. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 126
  2. Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
  3. Vassileva CM et al. Long term survival of patients undergoing mitral valve repair and replacement: A longitudinal analysis of Medicare fee-for- service beneficiaries. Circulation 2013 Apr 8 PMID: 23569153 http://circ.ahajournals.org/content/early/2013/04/08/CIRCULATIONAHA.113.002200 - Rao RK and Foster E. Rethinking mitral valve surgery during the golden years. Circulation 2013 Apr 8 PMID: 23569152 http://circ.ahajournals.org/content/early/2013/04/08/CIRCULATIONAHA.113.002574
  4. Chikwe J et al. Survival and outcomes following bioprosthetic vs mechanical mitral valve replacement in patients aged 50 to 69 years. JAMA 2015 Apr 14; 313:1435 PMID: 25871669
  5. Guerrero M et al. Transcatheter mitral valve replacement in native mitral valve disease with severe mitral annular calcification: Results from the first multicenter global registry. JACC Cardiovasc Interv 2016 Jul 11; 9:1361 PMID: 27388824
  6. Yoon SH, Whisenant BK, Bleiziffer S et al. Transcatheter mitral valve replacement for degenerated bioprosthetic valves and failed annuloplasty rings. J Am Coll Cardiol 2017 Aug 29; 70:1121. PMID: 28838360 - Webb JG, Cheung AW, Dvir D. Transcatheter mitral valve replacement when mitral surgery fails: 10 years later. J Am Coll Cardiol 2017 Aug 29; 70:1132. PMID: 28838361
  7. Goldstone AB, Chiu P, Baiocchi M et al Mechanical or Biologic Prostheses for Aortic-Valve and Mitral- Valve Replacement. N Engl J Med 2017; 377:1847-1857. November 9, 2017 PMID: 29117490 http://www.nejm.org/doi/full/10.1056/NEJMoa1613792
  8. Guimaraes HP et al. Rivaroxaban in patients with atrial fibrillation and a bioprosthetic mitral valve. N Engl J Med 2020 Nov 14; [e-pub]. PMID: 33196155 https://www.nejm.org/doi/10.1056/NEJMoa2029603