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• W4250749788 abstract "We thank Tavlasoglu and coworkers for the contribution of their letter to the interesting discussion about the decision to replace or repair the mitral valve in double valve surgery (aortic and mitral). Despite the existence of a significant number of reports in the literature dealing with concomitant aortic and mitral valve surgery, few have directly addressed this question. Some would argue that if the aortic valve needs replacement with a prosthesis, an additional mitral prosthesis should not alter the outcome significantly. One landmark study that approached this subject in a methodical way for the first time was published by the Cleveland Clinic group1Gillinov A.M. Blackstone E.H. Cosgrove III, D.M. White J. Kerr P. Marullo A. et al.Mitral valve repair with aortic valve replacement is superior to double valve replacement.J Thorac Cardiovasc Surg. 2003; 125: 1372-1387Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar; however, there were differences between their study population and our own,2Coutinho GF, Correia PM, Antunes MJ. Concomitant aortic and mitral surgery: to replace or repair the mitral valve? J Thorac Cardiovasc Surg. Epub 2014 Jan 2.Google Scholar namely the prevalence of rheumatic disease, which would cause one to expect different results. In the Cleveland Clinic study, 70% of the mitral valves had rheumatic involvement, whereas nearly two-thirds of our patients had secondary (functional) or degenerative mitral disease. Our population is more consistent with the current daily practice in Western countries, because rheumatic etiology is declining. Furthermore, secondary (nonischemic and non–dilated cardiomyopathy) mitral regurgitation in the context of aortic valve disease is gaining importance,3Coutinho G.F. Correia P.M. Pancas R. Antunes M.J. Management of moderate secondary mitral regurgitation at the time of aortic valve surgery.Eur J Cardiothorac Surg. 2013; 44: 32-40Crossref PubMed Scopus (36) Google Scholar because patients are increasingly older, and moderate or moderate-to-severe mitral regurgitation is frequently found. It is thus important to know the outcome (survival and event-free survival) after repair or replacement of the mitral valve. One major limitation of our study was the heterogeneity of the population; the groups (repair vs replacement) were very different with regard to important variables. Naturally, the decision to repair or to replace was influenced by the characteristics of the patient and of the valve, and a repair was preferred whenever possible, which may have created a bias. This was the rationale for performing propensity score matching to obtain more similar groups for comparison, a well-known and accepted statistical method for this type of analysis. Relevant demographic, patient, and echocardiographic characteristics, including mitral valve pathology, were included in the propensity score analysis. We could not demonstrate a clear survival benefit in the repair group, but we can also hypothesize as to reasons for this fact. First all, we recognize that we unfortunately do not yet have a long follow-up time (up to 12.5 years, mean 5.4 years), and we believe that a longer study might have shown evidence of that advantage. Second, the small number of patients subjected to comparison may have also influenced the analysis. We have to acknowledge, however, the possibility that there is simply no survival benefit associated with repairing the mitral valve. Nevertheless, mitral valve repair showed advantage in patients older than 65 years (P = .017) and for nonrheumatic etiology (P = .034). A very recent article from Gaur and colleagues,4Gaur P. Kaneko T. McGurk S. Rawn J.D. Maloney A. Cohn L.H. Mitral valve repair vs. replacement in the elderly: short-term and long-term outcomes.J Thorac Cardiovasc Surg. January 29, 2014; ([Epub ahead of print])PubMed Google Scholar due to be published in this Journal, supports our finding, stating that “elderly patients with mitral regurgitation who undergo MVP [repair] have better postoperative outcomes, lower operative mortality, and improved long-term survival than those undergoing MVR [replacement].” Regarding the latter, we intuitively believe that it is better to repair than to replace a degenerative mitral valve, because there is enough evidence accumulated in the literature favoring that approach.5David T.E. Armstrong S. McCrindle B.W. Manlhiot C. Late outcomes of mitral valve repair for mitral regurgitation due to degenerative disease.Circulation. 2013; 127: 1485-1492Crossref PubMed Scopus (232) Google Scholar Our study implies some important take-home messages. First, double valve surgery can be performed with low mortality (nearly 1%), whether repairing or replacing the mitral valve. Second, major adverse valve events are more common with mitral replacement. Third, there was only a survival advantage in repair for older patients with nonrheumatic valves. Overall, we believe that mitral valve repair is the best option in the setting of concomitant aortic valve replacement. Which subgroup of mitral valve replacement should be compared with mitral valve repair in concomitant aortic and mitral valve surgery?The Journal of Thoracic and Cardiovascular SurgeryVol. 147Issue 6PreviewThe article by Coutinho and colleagues1 draws attention to a classic topic that has not been deeply investigated, whether to replace or repair the mitral valve in double-valve surgery. We congratulate them for keeping our knowledge up to date on this issue. The efforts toward defining the exact solution have great importance. In this regard, we would like to make some contributions and discuss the subject. Full-Text PDF" @default.
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• W4250749788 date "2014-06-01" @default.
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• W4250749788 title "Reply to the Editor" @default.
• W4250749788 doi "https://doi.org/10.1016/j.jtcvs.2014.02.033" @default.
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