Etiology-specific survival and reoperation trends following surgical mitral valve repair and replacement: A meta-analysis of reconstructed time-to-event data.

Current American and European guidelines recommend mitral valve repair (MVr) over replacement (MVR) whenever feasible. However, these recommendations are primarily based on data from patients with degenerative mitral regurgitation (DMR), whereas evidence supporting MVr in other etiologies, such as infective endocarditis (IE) or ischemic mitral regurgitation (IMR), remains less conclusive. We systematically searched for and identified studies published after 2000 that compared MVr and MVR in patients with specific mitral valve disease etiologies, including DMR, IE, IMR, and rheumatic heart disease (RHD). A total of 61 records (10 DMR, 21 IE, 18 IMR, and 12 RHD) of 59 studies published between 2005 and 2024, were included. MVr consistently demonstrated superior survival compared to MVR in DMR and IE patients. Parametric time-varying hazard ratios revealed a sustained survival benefit of MVr in DMR and IE, whereas in IMR and RHD, the survival advantage was transient-lasting only up to six months and 2.7 years postoperatively, respectively-after which survival hazards between MVr and MVR became comparable. This was further corroborated by the results of a two-year landmark and the propensity-matched subgroup analyses. In DMR, MVr was associated with lower reoperation rates compared to MVR; however, in IE, IMR, and RHD, MVr was associated with significantly higher reoperation rates compared to MVR. Our study supports current guidelines favoring MVr over MVR, demonstrating sustained survival benefits in DMR. In IE-specific MR, MVr also showed consistent benefits over MVR, demonstrating that MVr should be prioritized when feasible. However, in IMR and RHD, there was no notable survival advantage of MVr over MVR, with higher reoperation rates observed with MVr. These findings highlight the need for etiology-specific and individualized surgical planning.