title: Does mitral valve repair offer an advantage over replacement in patients undergoing aortic valve replacement?
abstract: BACKGROUND
  Concomitant aortic and mitral valve (MV) operations have more than doubled over the past decade. We utilized the Society of Thoracic Surgeons Adult Cardiac Surgery Database (ACSD) to evaluate outcomes for patients undergoing combined aortic valve replacement (AVR) and MV repair or replacement.
  
  
  METHODS
  From 1993 to 2007, 23,404 patients undergoing concomitant AVR+MV surgery were identified. Patients with mitral stenosis, emergent or salvage status, and endocarditis were excluded. Outcomes were expressed as unadjusted operative mortality, adjusted odds ratio (OR) for mortality, and a composite of mortality and major complications.
  
  
  RESULTS
  The MV repair was performed in 46.0% and replacement in 54.0% of AVR patients. The rate of MV repair increased from 22.5% in 1993 to 59.1% in 2007 (p<0.0001). Compared with the AVR+MV replacement group, the AVR+MV repair group was older (69.7±11.5 vs 67.2±12.7 years, p<0.0001), had worse ejection fraction (0.449±0.153 vs 0.495±0.139, p<0.0001), and more concomitant coronary artery bypass grafting (CABG) (50.5% vs 40.9%, p<0.0001). Unadjusted operative mortality was lower in the AVR+MV repair group (8.2% vs 11.6%, p<0.0001). Predictors of operative mortality by multivariable analysis included the following: age (OR 1.21, p<0.0001); concomitant CABG (OR 1.49, p<0.0001); diabetes mellitus (OR 1.56, p<0.0001); reoperation (OR 1.53, p<0.0001); and renal failure with dialysis (OR 3.57, p<0.0001). Patients undergoing MV repair had a lower independent risk of operative mortality (OR 0.61, p<0.0001), and mortality also independently improved over time (2003 to 2007 vs 1993 to 1997, OR 0.79, p<0.002).
  
  
  CONCLUSIONS
  When feasible, MV repair remains the most optimal method of correcting mitral regurgitation during concomitant AVR. Continued efforts to improve MV repair rates in this setting seem warranted.
authors.affiliation: Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia. Electronic address: vthoura@emory.edu.
authors.forename: Vinod H
authors.initials: VH
authors.lastname: Thourani
authors.affiliation: Department of Cardiac Surgery, Mayo Clinic, Rochester, Minnesota.
authors.forename: Rakesh M
authors.initials: RM
authors.lastname: Suri
authors.affiliation: Department of Surgery, Vanderbilt University, Nashville, Tennessee.
authors.forename: J Scott
authors.initials: JS
authors.lastname: Rankin
authors.affiliation: Outcomes Research and Assessment Group, Duke Clinical Research Institute, Durham, North Carolina.
authors.forename: Xia
authors.initials: X
authors.lastname: He
authors.affiliation: Outcomes Research and Assessment Group, Duke Clinical Research Institute, Durham, North Carolina.
authors.forename: Sean M
authors.initials: SM
authors.lastname: O'Brien
authors.affiliation: Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
authors.forename: Vinay
authors.initials: V
authors.lastname: Badhwar
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia.
authors.forename: Gorav
authors.initials: G
authors.lastname: Ailawadi
authors.affiliation: Division of Cardiothoracic Surgery, Southern Illinois University, Springfield, Illinois.
authors.forename: Christina M
authors.initials: CM
authors.lastname: Vassileva
authors.affiliation: Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Christian C
authors.initials: CC
authors.lastname: Shults
authors.affiliation: Division of Cardiac Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.
authors.forename: Lars G
authors.initials: LG
authors.lastname: Svensson
authors.affiliation: Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, Maryland.
authors.forename: James S
authors.initials: JS
authors.lastname: Gammie
mesh_terms: D000368:Aged; D001021:Aortic Valve / Q000601:surgery*; D000082882:Bicuspid Aortic Valve Disease; D005260:Female; D006330:Heart Defects, Congenital / Q000150:complications / Q000601:surgery*; D006349:Heart Valve Diseases / Q000150:complications / Q000601:surgery*; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D008297:Male; D008943:Mitral Valve / Q000601:surgery*; D008944:Mitral Valve Insufficiency / Q000150:complications / Q000601:surgery*; D016896:Treatment Outcome