The meta-analysis by He and collaborators [has the worth to cover, as
much as possible, a gap of scientific evidence where conducting a
randomized trial appears very complex for ethical and logistical
reasons. The authors concluded that mitral valve repair (MVP) provide
better pooled results, both early and late, with respect to mitral valve
replacement (MVR). However, the superiority of MVP is driven by some
single large cohort-studies where surgeons had wide experience in the
field of MVP for IE. This finding is also confirmed by other studies.
But if mitral repair produces such a better short- and long-term
survival than replacement, why are there no clear indications from
consensus and guidelines pushing surgeons toward the pursuit of a
reconstructive procedure at almost any cost? We wonder but to repair or
not to repair, is that really the question? The AATS consensus suggests
to repair “whenever possible” but without providing more specific
indications. If the two primary goals of surgery are total removal of
infected tissues and reconstruction of cardiac morphology, including
repair or replacement of the affected valve(s), probably MVP as to
perform in case of less extensive tissue detriment by the infection. In
more wide valve involvement, MVP may be the choice but only in very
expert hands and in Centers with very large volume of valve repairing.
This decision cannot therefore be the result of the choice of an
individual but must derive from a careful multidisciplinary discussion
to be held in an EndoTeam.