Mitral valve replacement in young patients: review and current challenges

Abstract

Mitral valve repair is the ideal intervention for mitral valve disease with excellent long-term survival comparable to the age-matched general population. When the mitral valve is not repairable, mechanical prostheses may be associated with improved survival as compared with biological prostheses. Newer mechanical and biological valve prostheses have the potential to improve outcomes following mitral valve replacement in young patients. Patients presenting for mitral valve surgery after failed transcatheter mitral valve-in-valve have high rates of postoperative mortality and morbidity, exceeding those seen with reoperative mitral valve surgery, which poses issues in young patients who have a higher cumulative incidence of reintervention.

Plain language summary

Patients presenting with mitral valve disease, the most common type of heart valve disease, have a survival advantage when they undergo mitral valve repair as opposed to replacement, and this is particularly true for young patients. When the mitral valve is not repairable, mechanical prostheses (prosthetic implants) may be associated with improved survival as compared with biological prostheses, and this difference is mostly observed until the age of 70 years. Newer techniques of treating mitral valve disease without requiring open heart surgery have not yet been shown to be superior or even equivalent to traditional open heart surgery in the general population. Patients presenting for mitral valve surgery after failure of these newer techniques have high rates of death, exceeding those seen with mitral valve reoperation, which has important implications for young patients with mitral valve disease.

Article highlights

• Patients presenting with mitral valve disease have a survival advantage when they undergo mitral valve repair as opposed to replacement, and this is particularly true for young patients.

• Most young patients with degenerative mitral disease can be successfully repaired but those with nondegenerative etiology pose a greater challenge, including patients with infective endocarditis and advanced rheumatic disease.

• When the mitral valve is not repairable, mechanical prostheses may be associated with improved survival as compared with biological prostheses, and this difference in survival is mostly observed until the age of 70 years.

• Newer mechanical and biological valve prostheses have the potential to improve outcomes following mitral valve replacement in young patients.

• As compared with primary mitral valve surgery, reoperation is associated with significantly higher mortality and morbidity. Patients presenting for redo mitral surgery might benefit from a right mini-thoracotomy approach as opposed to a median resternotomy.

• While transcatheter mitral valve-in-valve is a less invasive and appealing option, there are multiple concerns about exponentially increasing transvalvular gradients with each subsequent valve-in-valve, which may limit its durability and success in young patients.

Keywords: :

• biological mitral prosthesis
• mechanical mitral prosthesis
• mitral valve disease
• mitral valve repair
• mitral valve replacement
• young patients

Supplemental material

Supplemental data for this article can be accessed at https://doi.org/10.1080/14796678.2024.2343592

Financial disclosure

The authors have no financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Competing interests disclosure

MWA Chu has received a speaker's honorarium from Medtronic, Edwards Lifesciences, Terumo Aortic, Abbott Vascular, and Boston Scientific. The authors have no other competing interests or relevant affiliations with any organization or entity with the subject matter or materials discussed in the manuscript apart from those disclosed. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Writing disclosure

No writing assistance was utilized in the production of this manuscript.