Rheumatic mitral valve disease remains a clinically relevant problem in many countries, particularly among older populations. In these patients, valvular involvement is usually more complex, with more extensive calcification, greater subvalvular involvement, and coexisting comorbidities, all of which influence both the choice of surgical technique and long-term outcomes. Although mitral valve repair is regarded as the preferred treatment whenever technically feasible, its role in older patients remains controversial.

Traditionally, bioprosthetic valve replacement has been the most widely used option in patients older than 60 years because it has been considered a more reproducible strategy with a lower risk of early reintervention. However, improvements in repair techniques and growing surgical expertise have reopened the debate as to whether age alone should continue to be viewed as a limiting factor when considering repair in rheumatic mitral valve disease.

This study retrospectively evaluated 981 patients older than 60 years who underwent mitral valve surgery between 2011 and 2023. Of these, 317 underwent valve repair and 664 received bioprosthetic replacement. To reduce bias related to surgical selection, the investigators performed 1:1 propensity score matching, yielding 2 homogeneous groups of 254 patients each. The primary end point was all-cause mortality, whereas secondary end points included perioperative events, valve reintervention, and adverse events during follow-up. Statistical analysis relied on Kaplan–Meier curves, proportional hazards models, and competing-risk analysis.

After matching, no significant differences were found in mid- or long-term mortality between the 2 groups (p = .130), with a median follow-up of 4.8 years. Valve repair was associated with lower transfusion requirements, a lower rate of perioperative reintervention, and a shorter hospital stay. During follow-up, the incidence of severe mitral regurgitation was higher in the repair group (p = .002), although this did not translate into a higher rate of valve reoperation after statistical adjustment.

The authors conclude that mitral valve repair provides outcomes comparable to those of bioprosthetic replacement in patients older than 60 years with rheumatic mitral valve disease and may therefore be considered a valid surgical option in selected patients.

COMMENTARY:

This study addresses a highly relevant clinical issue that remains unresolved: the true role of mitral valve repair in elderly patients with rheumatic disease. Its main strength lies in the sample size and in the use of propensity score matching, which allows a more balanced comparison between 2 very different surgical strategies that are clearly subject to selection bias.

The findings suggest that, when technically feasible, mitral repair does not compromise mid- or long-term survival in this patient population. In addition, it offers clear perioperative advantages, including lower transfusion requirements and fewer early reinterventions, which are especially relevant in older patients with associated comorbidities.

That said, the study also highlights a higher incidence of severe mitral regurgitation during follow-up in the repair group. Although this did not translate into a significant increase in reoperation, likely influenced by nonmedical factors and by the real limitations surrounding a second intervention in this population, it still raises important questions regarding the durability of rheumatic repair in elderly patients.

Overall, this work supports the idea that age should not be the sole reason to rule out mitral valve repair in rheumatic disease. Rather, it underscores the importance of careful patient selection and the experience of the surgical team. Probably the most relevant message is that mitral repair should continue to be considered whenever feasible, even in patients older than 60 years, instead of defaulting automatically to valve replacement.

REFERENCE:

Zhang W, Luo T, Meng F, Tian B, Fu J, Li F, et al. Mitral valve repair versus bioprosthetic replacement outcomes in patients with rheumatic disease over 60: propensity score–matching results. J Thorac Cardiovasc Surg. 2025;170(6):1536–1545.e5. doi:10.1016/j.jtcvs.2025.03.027