European Journal of Cardiovascular Medicine

Mitral valve disease continues to be a significant cause of cardiac morbidity and mortality worldwide, with rheumatic heart disease remaining a leading etiology in developing regions despite advances in preventive cardiology and antibiotic prophylaxis.¹ Surgical intervention, particularly mitral valve replacement (MVR), is often indicated in advanced cases with severe valvular dysfunction where repair is not feasible.² MVR has demonstrated consistent survival benefits and symptomatic relief, although postoperative outcomes can vary depending on preoperative cardiac function, ventricular geometry, and comorbid conditions.³

The evaluation of surgical success following MVR extends beyond perioperative mortality, encompassing parameters of functional recovery, reverse ventricular remodeling, and hemodynamic normalization.⁴ Echocardiography plays a pivotal role in quantifying these outcomes, offering detailed insights into left ventricular ejection fraction (LVEF), left atrial (LA) dimensions, and left ventricular end-systolic dimensions (LVESD), which together provide markers of myocardial adaptation and surgical efficacy.⁵ Postoperative improvements in these indices have been linked to enhanced exercise tolerance and quality of life.⁶

Mitral valve disease remains a significant contributor to cardiovascular morbidity, particularly in developing countries where rheumatic heart disease continues to predominate. Mitral valve replacement (MVR) is often the definitive surgical intervention in patients with advanced valvular pathology or non-repairable valves. While operative success is traditionally assessed using mortality and complication rates, these measures do not fully capture postoperative recovery and patient benefit. Clinical improvement, echocardiographic reverse remodeling, and functional capacity together provide a comprehensive assessment of surgical outcomes. This study therefore aims to compare clinical, echocardiographic, and functional outcomes before and after mitral valve replacement, thereby providing holistic evidence of surgical impact.

Aim: To compare clinical, echocardiographic, and functional outcomes in patients before and after mitral valve replacement.

This prospective observational before–after study was conducted in the Department of Cardiothoracic Surgery of a tertiary care teaching hospital over a period of 12–18 months. The study population consisted of adult patients (≥18 years) diagnosed with mitral valve disease who underwent isolated mitral valve replacement during the study period. Patients undergoing concomitant cardiac procedures, those with significant non-cardiac comorbidities such as cerebrovascular disease, chronic renal or liver disease, malignancy, active infection, or those lost to follow-up were excluded. A hospital-based consecutive sampling method was employed, and all eligible and consenting patients were included until the feasible sample size was achieved. Baseline clinical evaluation was performed preoperatively, which included assessment of symptoms, New York Heart Association (NYHA) functional class, and transthoracic echocardiographic parameters such as left ventricular ejection fraction, left ventricular end-systolic dimension, and left atrial size. Mitral valve replacement was carried out according to standard institutional surgical protocols. Postoperative evaluation was conducted at 3 to 6 months follow-up and included repeat clinical assessment, functional evaluation using NYHA classification, and echocardiographic examination to assess postoperative changes. Data was collected using a structured predesigned proforma. Ethical approval was obtained from the Institutional Ethics Committee, and written informed consent was taken from all participants prior to enrollment. Data were entered and analyzed using statistical software. Continuous variables were expressed as mean ± standard deviation and categorical variables as frequencies and percentages. Preoperative and postoperative values were compared using paired t-test or Wilcoxon signed-rank test as appropriate, while categorical variables were analyzed using Chi-square or McNemar test. A p-value of less than 0.05 was considered statistically significant.

Table 1 shows the baseline clinical and echocardiographic characteristics of the study population comprising 50 patients who underwent isolated mitral valve replacement. The mean age of the patients was 56.4 ± 10.8 years, with 22 (44%) males and 28 (56%) females. Mitral stenosis was present in 28 (56%) patients, while mitral regurgitation was observed in 22 (44%). Preoperatively, 18 (36%) patients were classified as NYHA functional class I–II and 32 (64%) as class III–IV. Sinus rhythm was noted in 19 (38%) patients and atrial fibrillation in 31 (62%). The mean preoperative left ventricular ejection fraction was 52.6 ± 9.4%, the mean left ventricular end-systolic dimension was 42.8 ± 6.2 mm, and the mean left atrial diameter was 5.6 ± 0.8 cm. Table 2 shows the comparison of NYHA functional class before and after mitral valve replacement. Preoperatively, NYHA class I was observed in 2 (4%) patients, class II in 16 (32%), class III in 24 (48%), and class IV in 8 (16%) patients. Postoperatively, 18 (36%) patients were in NYHA class I, 22 (44%) in class II, 9 (18%) in class III, and 1 (2%) in class IV. The mean NYHA functional class changed from 3.0 ± 0.7 before surgery to 1.8 ± 0.6 after surgery. The proportion of patients in NYHA class I–II increased from 18 (36%) to 40 (80%), while those in class III–IV decreased from 32 (64%) to 10 (20%).

Table 3 shows the comparison of echocardiographic parameters before and after surgery. The mean left ventricular ejection fraction increased from 52.6 ± 9.4% preoperatively to 58.9 ± 8.7% postoperatively. The mean left ventricular end-systolic dimension decreased from 42.8 ± 6.2 mm to 38.4 ± 5.9 mm. The mean left atrial diameter reduced from 5.6 ± 0.8 cm before surgery to 4.9 ± 0.7 cm at follow-up. Table 4 shows the functional outcome assessment before and after mitral valve replacement. The mean NYHA functional class score was 3.0 ± 0.7 preoperatively and 1.8 ± 0.6 postoperatively. The number of patients in NYHA class III–IV decreased from 32 (64%) before surgery to 10 (20%) after surgery, while those in NYHA class I–II increased from 18 (36%) to 40 (80%).

Table 5 shows the association between preoperative left ventricular ejection fraction and postoperative functional improvement. Among 30 patients with a preoperative ejection fraction of ≥50%, 26 (86.7%) showed improvement in NYHA functional class and 4 (13.3%) showed no improvement. Among 20 patients with a preoperative ejection fraction of <50%, improvement was observed in 12 (60%) patients, while 8 (40%) showed no improvement. Table 6 shows the overall clinical, echocardiographic, and functional outcomes following mitral valve replacement. Clinical improvement was observed in 40 (80%) patients, echocardiographic improvement in 38 (76%) patients, and functional improvement in 42 (84%) patients during the postoperative follow-up period.

Table 1. Baseline Clinical and Echocardiographic Characteristics of Study Participants (n = 50)

Table 2. Comparison of NYHA Functional Class Before and After Mitral Valve Replacement (n = 50)

* McNemar test

Table 3. Comparison of Echocardiographic Parameters Before and After Mitral Valve Replacement (n = 50)

*Paired t-test

Table 4. Functional Outcome Assessment Before and After Surgery (n = 50)

Table 5. Association of Preoperative Left Ventricular Function with Postoperative Functional Improvement (n = 50)

*Chi-square test

Table 6. Overall Clinical, Echocardiographic, and Functional Outcome  After MVR (n = 50)

The present study demonstrated significant improvement in clinical, echocardiographic, and functional outcomes following mitral valve replacement (MVR), aligning with recent literature emphasizing the reversibility of cardiac remodeling and symptomatic recovery post-surgery.⁶ The observed reduction in left ventricular end-systolic dimension (LVESD) and left atrial (LA) diameter, alongside the increase in left ventricular ejection fraction (LVEF), underscores favorable ventricular remodeling after MVR — a key determinant of long-term prognosis.⁷ These changes reflect the restoration of normal left atrial pressure dynamics and regression of chronic volume overload previously imposed by mitral regurgitation or stenosis.

Functional improvement, as evidenced by the shift of 80% of patients to New York Heart Association (NYHA) class I–II, parallels findings from Ayuba et al., who observed comparable improvements in functional class and structural indices after mitral valve interventions, particularly in patients with preserved preoperative ventricular function.⁶ Similar to our results, Giustino et al. demonstrated that improvements in NYHA class strongly correlate with postoperative quality of life and reduced heart failure hospitalization rates, highlighting functional recovery as a robust clinical endpoint.⁸

Our findings that patients with higher preoperative LVEF experienced greater postoperative improvement are consistent with prior evidence indicating that baseline ventricular function significantly modulates surgical benefit.⁹ In a large comparative analysis, Kamioka et al. found that preoperative left ventricular dysfunction independently predicted suboptimal echocardiographic recovery and persistent NYHA III–IV status post-surgery.¹⁰ These results reinforce the importance of early surgical intervention before irreversible myocardial remodeling ensues.

Furthermore, the marked postoperative reduction in LA size suggests regression of chronic atrial dilation, which has implications for rhythm control and long-term reduction of atrial fibrillation burden. Iliadis et al. reported that echocardiographic reverse remodeling directly translates to symptomatic improvement and enhanced exercise tolerance.¹¹ Our findings corroborate this physiological link between hemodynamic correction and functional capacity.

The strong concordance between clinical and echocardiographic recovery in this cohort underscores the integrated nature of postoperative assessment. Improvement in LVEF and LV geometry likely facilitates improved cardiac output and exercise tolerance, translating into better NYHA status. Nunes et al. highlighted the prognostic role of echocardiographic remodeling metrics in predicting postoperative survival, supporting their inclusion in routine postoperative evaluation.¹²

Collectively, these results emphasize that mitral valve replacement not only alleviates symptoms but also promotes structural and functional cardiac restoration. The integration of clinical and echocardiographic indices provides a comprehensive framework for evaluating surgical efficacy and guiding timing of intervention. Future multicentric longitudinal studies are warranted to evaluate whether the magnitude of early echocardiographic recovery predicts long-term survival and durability of symptom improvement.

This study shows that mitral valve replacement leads to clear and meaningful improvement in patients during the early postoperative period. Most patients experienced relief from symptoms, reflected by a shift to lower New York Heart Association functional classes after surgery. Along with clinical improvement, echocardiographic findings also showed better heart function, with improvement in left ventricular performance and reduction in chamber dimensions, suggesting favorable cardiac recovery following surgery. The study also brings out an important clinical view: patients who had better heart function before surgery tended to recover more effectively in terms of functional capacity. This highlights the importance of timely surgical intervention, before significant deterioration of left ventricular function occurs. Overall, the findings enhance practical understanding of patient recovery after mitral valve replacement by linking symptom relief, objective echocardiographic changes, and functional improvement. This integrated approach provides clinicians with clearer expectations of postoperative outcomes and supports early diagnosis, appropriate surgical timing, and structured follow-up to improve patient care and quality of recovery.

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