title: Rheumatic mitral repair versus replacement in a threshold country: the impact of commissural fusion.
abstract: OBJECTIVE
  In developing countries rheumatic heart disease is the predominant indication for cardiac surgery. As the disease tends to progress, reoperation rates for mitral valve repairs are high. Against this background, the predictors of failure were assessed and the overall performance of repairs compared with replacements in a 10-year cohort of rheumatic single mitral valve procedures.
  
  
  METHODS
  Between 2000 and 2010, a total of 646 consecutive adult (aged >15 years) patients underwent primary, single mitral valve procedures. All 87 percutaneous balloon valvuloplasties (100%) were rheumatic, compared to 280 of the 345 primary mitral valve replacements (81%) and 69 of the 215 primary mitral valve repairs (32%). As the study aim was to compare the outcome of mitral valve repair versus replacement in rheumatic patients of a threshold country, all 69 repair patients were propensity-matched with 69 of the replacement patients. Based on propensity score analysis, Kaplan-Meier actuarial analysis with log-rank testing was used to evaluate survival and morbidity.
  
  
  RESULTS
  The follow up was 100% complete (n = 138), and ranged from 0.6 to 132 months (mean 53.3 +/- 36.5 months). Actuarial freedom from valve-related mortality was 96 +/- 3% and 92 +/- 4% at five years, and 96 +/- 3% and 80 +/- 11% at 10 years for repairs and replacements, respectively (p = NS). Actuarial freedom from all valve-related events (deaths, reoperations and morbidity) was 80 +/- 6% and 86 +/- 5% at five years, and 70 +/- 8% and 69 +/- 11% at 10 years (p = NS). Actuarial freedom from all valve-related events was 57 +/- 11% and 96 +/- 3% at five years (p = 0.0008), and 42 +/- 12% and 96 +/- 3% at 10 years (p < 0.001) for those mitral valve repairs with and without commissural fusion, respectively (p = 0.0002 overall).
  
  
  CONCLUSIONS
  The long-term results for mitral valve replacement in an indigent, rheumatic heart disease population of a developing country were better than generally perceived. Notwithstanding, mitral valve repair has a superior long-term outcome in those patients who do not show commissural fusion at operation.
authors.affiliation: Christiaan Barnard Division of Cardiothoracic Surgery, Groote Schuur Hospital, University of Cape Town, South Africa.
authors.forename: Agneta
authors.initials: A
authors.lastname: Geldenhuys
authors.forename: Jithan J
authors.initials: JJ
authors.lastname: Koshy
authors.forename: Paul A
authors.initials: PA
authors.lastname: Human
authors.forename: Juliana F
authors.initials: JF
authors.lastname: Mtwale
authors.forename: Johan G
authors.initials: JG
authors.lastname: Brink
authors.forename: Peter
authors.initials: P
authors.lastname: Zilla
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001281:Atrial Fibrillation / Q000401:mortality; D002648:Child; D003906:Developing Countries / Q000706:statistics & numerical data; D005260:Female; D005500:Follow-Up Studies; D019918:Heart Valve Prosthesis Implantation / Q000379:methods / Q000401:mortality*; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D058386:Mitral Valve Annuloplasty / Q000379:methods / Q000401:mortality*; D008944:Mitral Valve Insufficiency / Q000401:mortality* / Q000601:surgery*; D009017:Morbidity; D012086:Reoperation / Q000401:mortality; D012214:Rheumatic Heart Disease / Q000401:mortality* / Q000601:surgery*; D013019:South Africa / Q000453:epidemiology; D017664:Uncompensated Care / Q000706:statistics & numerical data; D055815:Young Adult