Rheumatic mitral valve disease: Comparative outcomes of repair versus replacement

Abstract

Rheumatic mitral valve disease remains a major cause of cardiovascular morbidity and mortality in developing countries, where rheumatic fever is still prevalent. In advanced stages, surgical treatment becomes necessary, with mitral valve repair and mitral valve replacement representing the main strategies. However, evidence comparing their long-term outcomes is heterogeneous and often conflicting. The objective of this study was to map and synthesize the scientific evidence comparing the long-term results of repair versus replacement in rheumatic mitral disease. A scoping review was conducted in accordance with established methodological guidelines. Searches were performed in PubMed, Virtual Health Library, and Cochrane databases. Eligible studies, published between 2016 and April 2025, included adult patients undergoing surgical treatment with follow-up of at least five years. Nine studies met the inclusion criteria, comprising 36,136 patients, with 12,042 undergoing repair and 24,094 undergoing replacement. Repair was associated with lower early mortality (0.96% versus 2.2%), fewer thromboembolic events (114 versus 323), fewer hemorrhagic events (39 versus 252), and better preservation of left ventricular function. However, reoperation rates were higher after repair (7–19%) compared to replacement (<2%). Quality-of-life measures also favored repair, while replacement remained the preferred strategy in cases of extensive calcification, fibrosis, or severe stenosis. In conclusion, repair, when anatomically feasible, provides superior early outcomes and fewer long-term complications. Surgical decisions should be individualized, considering valve anatomy, patient profile, and surgical expertise.