Time Of Mitral Valve Repair Research Articles

Is concomitant tricuspid valve repair in patients undergoing robotic mitral valve repair safe and effective?

ObjectivesRobotic-assisted mitral valve repair (MVr) is a well-established procedure for management of degenerative mitral valve disease. Limited data regarding concomitant robotic-assisted tricuspid valve repair (TVr) is available. This review investigates prevalence and outcomes of concomitant robotic-assisted mitral and tricuspid valve repair. MethodsFrom 2014 to 2022, 839 patients underwent robotic-assisted MVr, including 76 patients with moderate or greater tricuspid regurgitation and/or tricuspid annular dilatation ≥40 mm. Among the 76 patients, 19 (25%) underwent isolated MVr and 57 (75%) had concomitant mitral and tricuspid valve repair. Outcome data between the 2 groups were analyzed. ResultsIn the MVr/TVr group, tricuspid regurgitation grades were mild in 4 (7%) patients, moderate in 44 (77%) and severe in 9 (15.7%). Significant tricuspid annular dilatation ≥40 mm was present in all patients. In the isolated MVr group, 3 (15.7%) patients had mild tricuspid regurgitation and 16 (84.2%) had moderate tricuspid regurgitation with significant tricuspid annular dilatation present in only 6 patients. Cardiopulmonary bypass and crossclamp time were 130.6 and 91 minutes versus 85 and 55.4 minutes for robotic MVr/TVr group versus MVr group, respectively (P < .05). The intensive care unit and hospital length of stay were similar: 27.7 versus 27.7 hours and 4.4 versus 4.2 days for MVr/TVr versus MVr (P = .24), respectively. There were no perioperative deaths or heart block in either group. Survival and freedom from reoperation with median follow-up of 16 and 46 months for MVr/TVr and MVr groups, respectively were 100%. ConclusionsConcomitant robotic-assisted tricuspid valve repair for functional regurgitation can be safely and effectively performed at the time of mitral valve repair with excellent short-term morbidity and mortality results.

Repeat crossclamp after failed initial degenerative mitral valve repair is safe and successful

ObjectiveSurgical risk and long-term outcomes when re-crossclamp is required during degenerative mitral valve repair are unknown. We examined the outcomes of patients who required re-crossclamp for mitral valve reintervention. MethodsAdults undergoing mitral valve repair for degenerative mitral valve disease at a single center from 2007 to 2021 who required more than 1 crossclamp for mitral valve reintervention were included. Outcomes including major morbidity and 30-day mortality were collected. Kaplan–Meier analysis characterized survival and freedom from recurrent mitral regurgitation. ResultsA total of 69 patients required re-crossclamp for mitral valve reintervention. Of those, 72% (n = 50) underwent successful re-repair and the remaining underwent mitral valve replacement (28%, n = 19). Major morbidity occurred in 23% (n = 16). There was no 30-day mortality, and median long-term survival was 10.9 years for those undergoing re-repair and 7.2 years for those undergoing replacement (P = .79). Midterm echocardiography follow-up was available for 67% (33/50) of patients who were successfully re-repaired with a median follow-up of 20 (interquartile range, 7-37) months. At late follow-up, 90% of patients had mild or less mitral regurgitation. Of those re-repaired, 2 patients later required mitral valve reintervention. ConclusionsPatients requiring re-crossclamp for residual mitral regurgitation had low perioperative morbidity and no mortality. Most patients underwent successful re-repair (vs mitral valve replacement) with excellent valve function and long-term survival. In the event of unsatisfactory repair at the time of mitral valve repair, attempt at re-repair is safe and successful with the appropriate valvar anatomy.

Query in dealing progressive tricuspid regurgitation with mitral valve disease

Objective: The recommendation to repair progressive tricuspid regurgitation (TR) at the time of mitral valve (MV) surgery is questionable. We assessed the outcomes of tricuspid valve (TV) repair for progressive TR with MV surgery. Patients and Methods: We assigned 611 patients with progressive TR who had MV replacement with or without concomitant TV repair from January 2015 to December 2016. Results: There were no remarkable variation in early mortality or major morbidity rates according to the etiology of the MV disease. Median follow-up was 36 months. After adjustment for baseline characteristics using a propensity score adjustment model, there were no significant differences in the frequency of re-admission for congestive heart failure between the groups. Both groups had similar risk for other late complications affected by valve surgery such as stroke, significant hemorrhage related to anticoagulation, reoperation due to valvular heart lesions other than TV, or infective endocarditis. However, comparing the severity of TR at the last follow-up, patients with greater than progressive TR were significantly less common in the repair group of mitral regurgitation compared with those in the control group. Conclusions: The clinical benefit of simultaneous TV repair for progressive TR with MV surgery for rheumatic mitral regurgitation is certain. Concomitant TV repair cannot be routinely recommended in patients with rheumatic mitral stenosis at the time of MV repair or replacement.

Comparison of the sustainability of mitral annular dynamics between two semi-rigid annuloplasty devices.

The choice of annuloplasty device is fundamental at the time of mitral valve repair, the goal being to optimally restore the physiological 3-dimensional (3D) structure and dynamics of the mitral annulus (MA). This study evaluated MA dynamics after annuloplasty with 2 different semi-rigid devices. Thirty-three patients eligible for mitral valve repair were selected for annuloplasty with the Physio II ring (Edwards Lifesciences, Irving, CA, USA) (n = 17) or the Memo 3D ring (LivaNova, Saluggia, Italy) (n = 16). MA dynamics were assessed with transoesophageal 3D echocardiography intraoperatively and 1 year after repair. The postoperative changes in the anteroposterior diameter {3.7% [standard deviation (SD) 2.7] vs 1.9% [SD 1.3]; P = 0.013} and in the annular height [27.7% (SD 8.7) vs 18.0% (SD 13.9); P = 0.003] were significantly larger with the Memo 3D ring during the cardiac cycle. The restoration of the saddle shape at baseline was superior with the Physio II ring, defined by a larger systolic annular height-to-commissural width ratio [15.1% (SD 2.3) vs 7.1% (SD 2.4); P < 0.001]. These observations of MA dynamics were sustained after 1 year, shown by a greater anteroposterior extension [5.1% (SD 1.0) vs 1.7% (SD 1.6); P = 0.002] and change in annular height-to-commissural width ratio [15.7% (SD 12.7) vs 3.1% (SD 3.0); P = 0.020] for the Memo 3D ring. There were no significant differences in mitral valve function between the 2 devices. The MA dynamics after annuloplasty with the Physio II and Memo 3D rings demonstrated a better systolic 3D restoration of the saddle shape with the Physio II ring, whereas the saddle-shaped geometry improved significantly with the Memo 3D ring, as a dynamic phenomenon. The Memo 3D ring also showed increased anteroposterior annular mobility and folding dynamics throughout the cardiac cycle. Moreover, the observed differences in MA dynamics between both devices appeared to be sustainable 1 year after ring implantation.

A prospective study examining the role of myocardial Fibrosis in outcome following mitral valve repair IN DEgenerative mitral Regurgitation: rationale and design of the mitral FINDER study

BackgroundThe optimal management of chronic severe primary degenerative mitral regurgitation (MR) is to repair the valve but identification of the optimal timing of surgery remains challenging. Current guidelines suggest ‘watchful waiting’ until the onset of symptoms or left ventricular (LV) dysfunction but these have been challenged as promoting ‘rescue surgery’. Better predictors are required to inform decision-making in relation to the necessity and timing of surgery. Chronic volume overload is a stimulus for adverse adaptive LV remodelling. Subclinical reduction in LV strain before mitral repair predicts a fall in LV ejection fraction following surgery and is thought to reflect the development of myocardial fibrosis in response to chronic volume overload. Myocardial fibrosis can be detected non-invasively using cardiac magnetic resonance (CMR) imaging techniques as an expansion of the extracellular volume (ECV).Methods/designThis study investigates whether: 1) patients with above median ECV will have smaller reduction in end-systolic volume index (as a measure of the degree of reverse LV remodelling) on CMR following mitral valve repair, compared to those with below median ECV; and 2) higher ECV on CMR, validated through histology, adversely impacts upon post-operative complications and symptomatic improvement following surgery.This is a multi-centre, prospective, cross-sectional comparison of patients prior to and 9 months following surgery for chronic severe primary degenerative MR. To establish the natural history of ECV in MR, an additional cohort of patients with asymptomatic MR who do not wish to consider early repair will be followed. Investigations include CMR, cardiopulmonary exercise test, stress echocardiography, signal-averaged electrocardiogram, 24-h electrocardiogram monitoring, laboratory tests and patient-reported outcome measures. Patients undergoing surgery will have cardiac biopsies performed at the time of mitral valve repair for histological quantification of fibrosis.DiscussionThis study will advance our understanding of ventricular remodelling in MR, its impact on patient symptoms and ventricular response following surgery. Establishing the link between myocardial fibrosis (measured on CMR and validated through histology), with early ventricular dysfunction, will offer physicians a novel non-invasive biomarker that can further inform the timing of surgery.Trial registrationThis trial was registered at ClinicalTrials.gov (NCT02355418) on 30th November 2015.

Therapeutic strategy for functional tricuspid regurgitation in patients undergoing mitral valve repair for severe mitral regurgitation

BackgroundThe aim of this study was to determine optimal patient selection and selection of a prosthetic ring size for tricuspid valve (TV) repair at the time of mitral valve (MV) repair. MethodsWe prospectively enrolled 167 consecutive patients undergoing MV repair. TV repair was indicated if patients had at least one of the following conditions representing tricuspid annular dilatation: (1) tricuspid regurgitation (TR)≥moderate, (2) history of right heart failure, (3) atrial fibrillation, and (4) pulmonary hypertension. The size of the ring was targeted to a normal-sized systolic tricuspid annuls in relation to the patient's body surface area (BSA). Serial echocardiographic studies were performed preoperatively, at discharge, and at 1, 3, and 5years postoperatively. ResultsOverall, 100 (60%) patients required TV repair, while it was not indicated for 67 (40%) patients. During follow-up, 26 patients showed progression or recurrent TR≥moderate. The TR grade at 5years after MV surgery was 0.8±0.9 in patients with TV repair and 0.9±0.7 in those without TV repair (P=0.69). There were no significant differences between patients with and without TV repair in a composite endpoint of death from any cause, re-do MV or TV surgery, and recurrence or progression of TR≥moderate (P=0.46). ConclusionsPatient selection for TV repair considering not only the grade of TR but clinical signs representing tricuspid annular dilatation is feasible at the time of MV repair. TV repair targeting a normal systolic size in relation to the BSA is a simple and reproducible procedure.

Performing Concomitant Tricuspid Valve Repair at the Time of Mitral Valve Operations Is Not Associated With Increased Operative Mortality

The performance of concomitant tricuspid valve repair (TVr) at the time of mitral valve repair or replacement (MVRR) has previously been associated with elevated short-term risk. Outcomes were assessed at incremental grades of tricuspid regurgitation (TR) to quantify the contemporary risk of concomitant TVr. Between July 2011 and June 2014, 88,473 patients undergoing MVRR were examined using The Society of Thoracic Surgeons database. Outcomes with or without TVr, after isolated MVRR (n= 62,118) and MVRR with coronary artery bypass graft surgery (CABG [n= 26,355]), were independently analyzed at three levels of TR: none-mild, moderate, and severe. Risk-adjusted morbidity and mortality associated with the performance of concomitant TVr were evaluated using multivariable logistic regression. The TR was graded as none-mild in 74.3% of patients (65,769 of 88,473), moderate in 17.2% (15,222 of 88,473), and severe in 8.5% (7,482 of 88,473). The rate ofTVr by TR grade was 3.5% (2,308 of 65,769) for none-mild, 30.6% (4,661 of 15,222) for moderate, and 75.6% (5,654 of 7,482) for severe. Overall risk-adjusted occurrence of any morbidity associated with performance of TVr was increased in both groups (MVRR odds ratio [OR] 1.36, 95% confidence interval [CI]: 1.24 to 1.48; and MVRR plus CABG OR 1.33, 95% CI: 1.19 to 1.49). However, at all grades of TR, TVr was not associated with increased risk-adjusted mortality (MVRR OR 0.99, 95% CI: 0.84 to 1.17; and MVRR plus CABG OR 1.04, 95% CI: 0.85 to 1.27). In contemporary patients, concomitant TVr is not associated with a risk-adjusted increase in mortality, regardless of TR severity. A more liberal approach to TVr at the time of MVRR may be justified when long-term benefits are thought to outweigh incremental short-term morbidity risk. Further investigation of longitudinal TVr outcomes is warranted.

Mitral Valve Repair Without Repair of Moderate Tricuspid Regurgitation

The objective of this study was to assess the fate at long term of mild-to-moderate functional tricuspid regurgitation (TR) left untreated at the time of mitral valve repair in patients with dilated cardiomyopathy. We selected from our prospective hospital database 84 patients (age, 64 ± 9.6 years; ejection fraction, 0.31 ± 0.064) who underwent mitral repair for secondary mitral regurgitation in whom concomitant mild-to-moderate TR (nonlinear scale 1 to 4+) was left untreated. Tricuspid regurgitation was classified as mild in 61 patients (72.6%) and moderate in 23 patients (27.3%). Annular dilatation itself was not systematically measured and was not used as a trigger for tricuspid annuloplasty. Most of the patients were in New York Heart Association functional class III or IV (56 of 84; 66.7%). At a median follow-up of 7.3 years (interquartile range, 4.5 to 9.3), 17 patients (20.2%) had moderate-to-severe TR and 21 patients (25%) showed a progression of at least two grades of their untreated preoperative TR. Freedom from moderate-to-severe TR or from progression of at least two grades of the baseline TR was 77% ± 5% at 5 years and 56.7% ± 8.4% at 10 years. Multivariate analysis identified preoperative right ventricular dysfunction (hazard ratio, 7.2; 95% confidence interval, 2.8 to 23; p = 0.001) and age (hazard ratio, 1; 95% confidence interval, 1.0 1.1; p = 0.03) as independent predictors of TR worsening. A significant number of dilated cardiomyopathy patients with mild-to-moderate TR left untreated at the time of mitral repair show important TR at follow-up. In this setting, a more aggressive policy should be used taking into consideration the degree of annular dilatation and the function of the right ventricle and not simply the grade of TR.

Impact of Concomitant Tricuspid Annuloplasty on Tricuspid Regurgitation, Right Ventricular Function, and Pulmonary Artery Hypertension After Repair of Mitral Valve Prolapse

BackgroundFor patients undergoing mitral valve (MV) repair, the indications for and results of concomitant tricuspid annuloplasty remain controversial. ObjectivesThis study was designed to compare a strategy of routine concomitant tricuspid annuloplasty for moderate tricuspid regurgitation (TR) or tricuspid annular dilation in patients undergoing degenerative MV surgery. MethodsOf 645 consecutive patients (mean age 57 ± 13 years) undergoing primary repair of degenerative mitral regurgitation between 2003 and 2011, 419 (65%) underwent concomitant tricuspid annuloplasty for moderate TR and/or tricuspid annular dilation. These patients were retrospectively analyzed with longitudinal echocardiographic follow-up. ResultsPatients undergoing tricuspid valve repair were older (mean age 59.2 years vs. 52.3 years), had worse right and left ventricular function and higher pulmonary artery pressures, and were more likely to have had atrial fibrillation than patients undergoing isolated MV repair (all p < 0.05). No significant difference in 30-day mortality, morbidity, or permanent pacemaker requirement was seen between treatment groups. Freedom from moderate TR at 7 years was not significantly different in the 2 groups, but multivariate analysis showed that tricuspid annuloplasty was independently associated with freedom from late moderate TR (p = 0.04), and was an independent predictor of recovery of right ventricular function (p = 0.02). ConclusionsIn patients with moderate TR or tricuspid annular dilation who were undergoing degenerative mitral repair, concomitant tricuspid annuloplasty is safe, effective, and associated with improved long-term right-sided remodeling. Routine treatment of moderate TR or tricuspid annular dilation at the time of MV repair appears to be beneficial.

Tricuspid Valve Repair for the Poor Right Ventricle: Tricuspid Valve Repair in Patients with Mild-to-Moderate Tricuspid Regurgitation Undergoing Mitral Valve Repair Improves In-Hospital Outcome.

Background Tricuspid regurgitation (TR) in patients undergoing surgery for mitral valve (MV) increases morbidity and mortality, especially in case of a poor right ventricle. Does repair of mild-to-moderate insufficiency of the tricuspid valve (TV) in patients undergoing MV surgery lead to a benefit in early postoperative outcome? Methods A total of 22 patients with mild-to-moderate TR underwent MV repair and concomitant TV repair with Tri-Ad (Medtronic ATS Medical Inc., Minneapolis, Minnesota, United States) and Edwards Cosgrove (Edwards Lifesciences Irvine, California, United States) rings. The severity of TR was assessed echocardiographically by using color-Doppler flow images. The tricuspid annular plane systolic excursion (TAPSE) was under 1.7 cm. Additional procedures included coronary artery bypass (n = 9) and maze procedure (n = 15). The following parameters were compared: postoperative and peak dose of noradrenaline (NA), pre/postoperative systolic pulmonary pressure (sPAP), extubation time, operation time, cross-clamp time, cardiopulmonary bypass (CPB) time, pre/postoperative ejection fraction (EF), intensive care unit (ICU)-stay, hospital stay, cell saver blood transfusion, intra/postoperative blood transfusion, and postoperative TR. Results The mean age was 67 ± 14.8 years, 45% were male. Mean EF was 47 ± 16.2%, postoperative 52 ± 12.4%. sPAP was 46 ± 20.1 mm Hg preoperatively, sPAP was 40.6 ± 9.4 mm Hg postoperatively, NA postoperatively was 12 ± 10 μg/min, NA peak was 18 ± 11 μg/min, operation time was 275 ± 92 minutes, CPB was 145 ± 49 minutes, ICU stay was 2.4 ± 2.4 days, hospital stay was 10.8 ± 3.5 days, cell saver blood transfusion was 736 ± 346 mL, intraoperative transfusions were 2.5 ± 1.6. Two patients needed postoperative transfusions. A total of 19 patients were extubated at the 1st postoperative day, 2 patients at the 2nd day, and 1 at the 4th postoperative day. Two patients required a pacemaker. No reintubation, no in-hospital mortality, and one reoperation because of bleeding complications. Conclusion Correction of mild-to-moderate TR at the time of MV repair does maintain TV function and avoid right ventricular dysfunction in the early postoperative period improving the clinical outcome.

Functional tricuspid regurgitation at the time of mitral valve repair for degenerative leaflet prolapse: The case for a selective approach

It is not clear whether clinically silent tricuspid valve regurgitation should be addressed at the time of mitral valve repair for severe mitral regurgitation due to leaflet prolapse. We examined the clinical and echocardiographic outcomes of patients with tricuspid regurgitation who underwent only mitral valve repair. We retrospectively analyzed records of patients undergoing mitral valve repair for isolated mitral valve prolapse who had coexistent tricuspid valve regurgitation during an 11-year period at our institution. Echocardiographic data were compared preoperatively, intraoperatively, and postoperatively at less than 1, 1 to 3, 3 to 5, and more than 5 years. In 699 patients who underwent mitral valve repair for severe mitral regurgitation, mean age was 60.4 years and 459 (66%) were male. At the time of mitral valve repair, tricuspid valve regurgitation was grade 3 or more in 115 (16%) patients and less than grade 3 in 584 (84%) patients. After mitral valve repair, overall grade of tricuspid valve regurgitation decreased significantly within the first year (P = .01). In patients with grade 3 regurgitation or more, the grade decreased at dismissal and until the third year (P < .001). Female sex, preoperative atrial fibrillation, and diabetes mellitus were independent risk factors for increased tricuspid valve regurgitation with time; preoperative regurgitation of grade 3 or more independently predicted decreased grade with time. Only 1 patient required tricuspid reoperation 4.5 years after mitral repair. Clinically silent nonsevere tricuspid valve regurgitation in patients with degenerative mitral valve disease is unlikely to progress after mitral valve repair. Tricuspid valve surgery is rarely necessary for most patients undergoing repair of isolated mitral valve prolapse.

Increased Oxidative Stress and Cardiomyocyte Myofibrillar Degeneration in Patients With Chronic Isolated Mitral Regurgitation and Ejection Fraction >60%

This study assessed myocardial damage in patients with chronic isolated mitral regurgitation (MR) and left ventricular ejection fraction (LVEF) >60%. Typically, MR patients have decreased LVEF after mitral valve (MV) repair despite normal pre-operative LVEF. Twenty-seven patients with isolated MR had left ventricular (LV) biopsies taken at time of MV repair. Magnetic resonance imaging with tissue tagging was performed in 40 normal subjects and in MR patients before and 6 months after MV repair. LVEF (66 +/- 5% to 54 +/- 9%, p < 0.0001) and LV end-diastolic volume index (108 +/- 28 ml/m(2) to 78 +/- 24 ml/m(2), p < 0.0001) decreased, whereas left ventricular end-systolic (LVES) volume index was 60% above normal pre- and post-MV repair (p < 0.05). The LV circumferential and longitudinal strain rates decreased below normal following MV repair (6.38 +/- 1.38 vs. 5.11 +/- 1.28, p = 0.0009, and 7.51 +/- 2.58 vs. 5.31 +/- 1.61, percentage of R to R interval, p < 0.0001), as LVES stress/LVES volume index ratio was depressed at baseline and following MV repair versus normal subjects (0.25 +/- 0.10 and 0.28 +/- 0.05 vs. 0.33 +/- 0.12, p < 0.01). LV biopsies demonstrated cardiomyocyte myofibrillar degeneration versus normal subjects (p = 0.035). Immunostaining and immunoblotting demonstrated increased xanthine oxidase in MR versus normal subjects (p < 0.05). Lipofuscin deposition was increased in cardiomyocytes of MR versus normal subjects (0.62 +/- 0.20 vs. 0.33 +/- 0.11, percentage of area: p < 0.01). Decreased LV strain rates and LVES wall stress/LVES volume index following MV repair indicate contractile dysfunction, despite pre-surgical LVEF >60%. Increased oxidative stress could cause myofibrillar degeneration and lipofuscin accumulation resulting in LV contractile dysfunction in MR.

Is the Anterior Intertrigonal Distance Increased in Patients With Mitral Regurgitation Due to Leaflet Prolapse?

Severe mitral regurgitation (MR) leads to progressive enlargement of left ventricular dimensions and, consequently, the mitral valve (MV) annulus. Data from animal and cadaver studies suggest that the mitral annulus may dilate asymmetrically in certain conditions, which may influence the choice of valve repair technique. Although it is generally accepted that the posterior mitral annulus dilates in patients with severe MR due to leaflet prolapse, the stability of the anterior intertrigonal distance has not yet been demonstrated in humans. We obtained real-time, three-dimensional (3D) transesophageal echocardiographic images of the MV in 44 patients: 29 patients scheduled to undergo MV repair for severe MR due to leaflet prolapse (MV disease group) and 15 normal outpatients undergoing evaluation for various reasons (control group). Mitral valve repair was performed by median sternotomy or minimally invasively using thoracoscopic or robotic assistance. All patients underwent implantation of a standard-length flexible 63-mm posterior annuloplasty band at the time of mitral repair and we obtained postoperative 3D images for 11 patients after separation from bypass. Mitral annular dimensions were measured throughout the cardiac cycle using reconstructive analysis software (QLAB MVQ Version 6.0; Phillips, Bothell, WA). The mean patient age was 60 years; 30 were men. The mean ejection fraction was 0.61 and was similar between the two groups (p = 0.16). In patients with MR due to leaflet prolapse, posterior annular length and total annular circumference were significantly larger than in control patients (p < 0.001). In contrast, there was no detectable difference in the anterior intertrigonal distance between patients with MR and normal controls. After mitral valve leaflet repair and posterior annuloplasty there was a significant decrease in both the total annular circumference and posterior annular length (p < 0.0001) while cyclic annular contraction was preserved. Although the posterior mitral annulus is enlarged in patients with significant MR due to degenerative leaflet prolapse, there is no evidence that the intertrigonal distance is abnormal in these patients. Our data support the conclusion that posterior annular reduction with a flexible device at the time of mitral valve repair is important, and that altering the anterior intertrigonal portion of the mitral annulus is unnecessary.

Outcome of mitral valve repair in patients with preoperative atrial fibrillation

To examine late outcome of mitral valve repair in patients with preoperative atrial fibrillation, we reviewed the cases of 323 consecutive patients who underwent mitral valvuloplasty for mitral regurgitation from 1980 to 1991; average age of 215 men and 108 women was 64 years (range 14 to 88 years), and 224 patients (70%) were in New York Heart Association class III or IV before operation. The main indications for operation were severe mitral regurgitation (76%), coronary artery disease with associated mitral regurgitation (15%), and aortic valve disease (6%). At the time of mitral valve repair, coronary artery bypass grafting was done in 35% of patients, aortic valve replacement was done in 7%, and multiple other procedures were done in 10%. For all patients, the 30-day mortality rate was 2.5% (70% confidence limits 1.6% to 3.4%) and survivorships at 3 and 5 years were 81% and 76%, respectively. Before operation, 216 patients were in sinus rhythm and 97 patients had atrial fibrillation; in the latter group, 11 had recent onset of atrial fibrillation within 3 months preceding mitral valve repair. Comparing patients with preoperative atrial fibrillation to those with sinus rhythm, we found no significant difference in operative mortality (3% versus 1.9%) or 5-year survivorship (74.3% +/- 6.3% versus 76.9% +/- 4.0%). At late follow-up, atrial fibrillation was present in 5% of patients with preoperative sinus rhythm, 80% of patients with preoperative chronic atrial fibrillation, and 0% of patients with preoperative recent onset atrial fibrillation (p < 0.01). The left atrial size by echocardiography was larger in patients with preoperative atrial fibrillation compared with that in those with sinus rhythm (59 +/- 1.4 mm versus 50.9 +/- 0.7 mm; p < 0.05). There was, however, only a weak correlation between preoperative left atrial size and late atrial fibrillation. Further, age, gender, and associated coronary artery disease did not correlate with presence of atrial fibrillation at late follow-up. Prevalence of late thromboembolic events was similar in patients with preoperative sinus rhythm compared with that in those with atrial fibrillation. These data suggest that mitral valve repair should be done before or soon after the onset of atrial fibrillation to maximize the chance of postoperative sinus rhythm and avoid long-term anticoagulation with warfarin. However, the early and late results of mitral valve repair in patients with chronic atrial fibrillation are good, and concomitant operation for supraventricular arrhythmia must have negligible morbidity and no adverse effect on operative mortality.