Is open surgery or mitral valve replacement (MVR) better for a patient with severe mitral regurgitation due to a Barlow valve and recent atrial fibrillation?

Mitral Valve Repair is Superior to Mitral Valve Replacement for Barlow's Valve with Atrial Fibrillation

For a patient with severe mitral regurgitation due to a Barlow valve and recent atrial fibrillation, mitral valve repair is strongly preferred over mitral valve replacement (MVR) due to better long-term survival, preservation of left ventricular function, and freedom from valve-related complications.

Evidence-Based Rationale for Mitral Valve Repair

Superior Outcomes with Repair

• Current guidelines strongly recommend mitral valve repair over replacement for primary mitral regurgitation, particularly for degenerative pathologies like Barlow's disease 1
• Repair is designated as a Class I recommendation in both American and European guidelines for patients with severe mitral regurgitation 1
• Mitral valve repair preserves the subvalvular apparatus, maintaining left ventricular geometry and function

Specific Benefits for Barlow's Disease

• Barlow's disease (characterized by bileaflet prolapse and excess tissue) is amenable to repair in experienced centers with success rates exceeding 94% 2
• Long-term studies show excellent durability with:
  • 10-year survival of 88.3% after repair
  • Freedom from reoperation of 93.8% at 10 years
  • Freedom from significant mitral regurgitation of 88.4% at 10 years 2

Management of Atrial Fibrillation

• The presence of atrial fibrillation is an indication for earlier intervention rather than a contraindication to repair 1
• Concomitant atrial fibrillation ablation can be performed during mitral valve repair (performed in 28% of patients in one large series) 2
• Early intervention before persistent atrial fibrillation develops improves outcomes, as pre-operative atrial fibrillation is a predictor of excess late postoperative morbidity and mortality 1

Surgical Approaches for Barlow's Disease

Repair Techniques

• Several effective repair techniques exist for Barlow's disease:
  • Neochordal "loop" techniques (used in 72% of cases) 2
  • Ring annuloplasty (essential component in all repairs) 3
  • Posterior leaflet resection (28% of cases) 2
  • Edge-to-edge (Alfieri) technique (17% of cases) 2, 4
  • Simple ring-only approach for cases with mainly central regurgitant jets 3

Conventional vs. Minimally Invasive Approach

• Both conventional sternotomy and minimally invasive approaches show excellent outcomes for Barlow's disease 5
• Minimally invasive approach offers:
  • Comparable safety and efficacy to conventional sternotomy
  • Cosmetic benefits
  • Faster recovery
  • Quicker return to normal activities 5
• However, complex repairs like those needed for Barlow's disease should be performed at centers with extensive experience in mitral valve repair 5, 2

Important Considerations and Caveats

Repair vs. Replacement Decision Factors

• Valve reparability is crucial - repair can be successfully performed in >80% of patients in experienced centers 1
• Surgeon and center experience significantly impact outcomes - referral to high-volume centers is recommended for complex pathologies like Barlow's disease 2
• If repair is not feasible, mitral valve replacement with chordal preservation is preferred to maintain left ventricular function 1

Timing of Intervention

• Early intervention is recommended before development of:
  • Left ventricular dysfunction (LVEF ≤60% or LVESD ≥40 mm)
  • Pulmonary hypertension
  • Persistent atrial fibrillation 1
• Recent atrial fibrillation is actually an indication for earlier surgical intervention (Class IIa recommendation) 1

Postoperative Management

• Anticoagulation management is critical, especially with recent atrial fibrillation
• Long-term monitoring for recurrent mitral regurgitation and atrial fibrillation is essential

Conclusion

For patients with severe mitral regurgitation due to Barlow's valve and recent atrial fibrillation, mitral valve repair offers significant advantages over replacement, including better survival, preserved ventricular function, and freedom from anticoagulation (if sinus rhythm is maintained). The procedure should be performed at experienced centers with high repair rates for complex valve pathologies.