title: How Does Mitral Valve Repair Fail in Patients With Prolapse?-Insights From Longitudinal Echocardiographic Follow-Up.
abstract: BACKGROUND
  Repair of mitral regurgitation (MR) caused by prolapse has been well validated. Although favorable early and late results after repair have been reported, few data are available that mechanistically describe how a mitral repair fails beyond the mere need for mitral valve reoperation. We therefore sought to determine the modes of valve repair failure in patients who underwent surgical correction of MR caused by prolapse.
  
  
  METHODS
  Between 2001 and 2015, 855 patients underwent repair of MR caused by prolapse. Patients were a mean age of 63.7 ± 12.7 years, and 380 (44%) had bileaflet prolapse. The overall repair rate was 97.2%. These patients were monitored as part of a cohort initiative and underwent serial clinical and echocardiographic assessments at 1, 3 to 6, and 12 months after the operation. Beyond the first year of the MR repair, patients were assessed by echocardiography every 1 to 2 years or when clinically indicated. Clinical and echocardiographic follow-up averaged 4.3 ± 3.5 years.
  
  
  RESULTS
  Freedom from recurrent MR of 2+ or higher was 92.4% ± 1.3% at 5 years and 86.6% ± 2.4% at 10 years. Overall, recurrent MR of 2+ or higher developed in 49 patients (5.7%) at a mean of 3.1 ± 2.5 years after the repair, of whom 14 (1.6%) had recurrent MR of 3+ or 4+. Among patients with bileaflet prolapse, recurrent MR of 2+ or higher was observed in 24, of whom 9 had 3+ or 4+ MR., The development of recurrent MR of 2+ or higher was categorized as prolapse in 6 and nonprolapse in 43. Severe mitral stenosis occurred in 3 patients at 8.2 years after the MR repair. Mitral reoperation was ultimately performed in 21 patients. Patients who had recurrent MR 2+ or higher within the first year after the operation were more likely to undergo a subsequent mitral valve reoperation (incident rate ratio, 5.2 ± 2.9; p = 0.003), although no association between recurrent MR and reoperation was observed after the first year.
  
  
  CONCLUSIONS
  Severe MR after repair is rare, although some may have recurrent moderate MR. Patients who required a subsequent mitral valve reoperation were most likely to have recurrent MR of 2+ or higher within the first year after the operation.
authors.affiliation: Division of Cardiac Surgery, University of Ottawa, Ottawa, Ontario, Canada; School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada. Electronic address: vchan@ottawaheart.ca.
authors.forename: Vincent
authors.initials: V
authors.lastname: Chan
authors.affiliation: Division of Cardiac Surgery, University of Ottawa, Ottawa, Ontario, Canada.
authors.forename: Elsayed
authors.initials: E
authors.lastname: Elmistekawy
authors.affiliation: Division of Cardiac Surgery, University of Ottawa, Ottawa, Ontario, Canada; School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada.
authors.forename: Marc
authors.initials: M
authors.lastname: Ruel
authors.affiliation: Division of Cardiac Anesthesia, University of Ottawa, Ottawa, Ontario, Canada.
authors.forename: Mark
authors.initials: M
authors.lastname: Hynes
authors.affiliation: Division of Cardiac Surgery, University of Ottawa, Ottawa, Ontario, Canada.
authors.forename: Thierry G
authors.initials: TG
authors.lastname: Mesana
mesh_terms: D004452:Echocardiography / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects*; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000000981:diagnostic imaging / Q000601:surgery*; D008944:Mitral Valve Insufficiency / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D009864:Ontario / Q000453:epidemiology; D012086:Reoperation; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D017211:Treatment Failure; D016896:Treatment Outcome