How do we monitor mitral valve annuloplasty rings?
I couldn't find any good guidelines about surgical annuloplasty rings specifically, though there are some about percutaneous annuloplasty rings. The 2020 AHA/ACC valve guidelines have a IIa, LOE C recommendation to monitor bioprosthetic surgical valves at 5 years, 10 years, and then annually, even without clinical changes, which I feel reasonably comfortable extrapolating. These guidelines also say that patients with successful repair + ring have a life expectancy that's similar to matched controls, with low rates of re-op (5%) and recurrent moderate/severe MR (<20%).
I skimmed the first attached article, and you should too, about dehiscence of mitral valve annuloplasty rings. Bottom line, it's rare (1.6%), and tends to happen early, like in the first year; it can often be fixed with repeat operation. Accordingly, these authors suggest getting an echo at six and 12 months after mitral valve repair + ring.
And then definitely read the attached JACC article about long-term outcomes for patients with mitral regurgitation undergoing repair. This is the population I think of when I hear about clinic patients with annuloplasty rings, and indeed, ninety-four percent of these patients had some sort of ring placed with their repair. Here's the graph with long-term outcomes:
Figure 1. Patient Survival and Competing Risk for Mortality and Mitral Valve Reoperation
This study confirms that re-operation rates are low, but interestingly long-term mortality rates are higher than I would have guessed. Apparently cardiac deaths were driven by heart failure. The major outcome I am interested in is recurrent moderate/severe mitral regurgitation, which this study found to be 4% at five years, 6% at ten years, and 13% at twenty years (note this is mostly driven by moderate MR). A good number of patients also developed tricuspid regurgitation: 7% at five years, 10% at ten years, 21% at twenty years. A significant number developed afib: 14% at ten years, 32% at twenty years. And finally, thromboembolism rates were higher than I realized: 7% at ten years, 10% at twenty years.
It's a heterogenous population, with respect to both underlying etiology of MR and type of annuloplasty ring utilized, which makes drawing generalizations hard. PubMed has some nice long-term observational studies for specific types of rings, but alas, I'm not sure which type this particular patient had. I checked with our CT surgeon Dr. Ward who said echo at three months and then it's up to us. I also checked with Dr. Thames who says as long as the initial gradient was fine, monitoring every five years is probably adequate. So, going forward, my practice pattern will be to echo at three months, one year, and then every five years after that.
David TE, David CM, Tsang W, Lafreniere-Roula M, Manlhiot C. Long-Term Results of Mitral Valve Repair for Regurgitation Due to Leaflet Prolapse. Journal of the American College of Cardiology. 2019;74(8):1044-1053. doi:https://doi.org/10.1016/j.jacc.2019.06.052
Noack T, Kiefer P, Vivell N, et al. Annuloplasty ring dehiscence after mitral valve repair: incidence, localization and reoperation. European Journal of Cardio-Thoracic Surgery. Published online August 1, 2019. doi:https://doi.org/10.1093/ejcts/ezz219
Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;143(5). doi:https://doi.org/10.1161/cir.0000000000000923
