Long-term outcomes of mitral valve replacement in patients with systemic autoimmune disease: a nationwide retrospective cohort study

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Abstract
Background: Late outcomes among patients with systemic autoimmune disease (SAD) who underwent heart valve replacement are not well established. This study aimed to compare the long-term outcomes after an initial, isolated mitral valve replacement (MVR) with either a bioprosthesis or a mechanical prosthesis in patients with SAD. Materials and Methods: In this nationwide retrospective cohort study, we retrieved longitudinal data from the National Health Insurance Research Database for patients with SAD undergoing primary MVR from 1 January 2001, to 31 December 2018. Results: A total of 34 563 patients undergoing heart valve replacement for the first time between January 2001 and December 2018 were identified. After applying exclusion criteria and propensity-score matching, we included 273 bioprosthesis recipients and 273 mechanical prosthesis recipients, and the median duration of follow-up was 5.98 years and 7.44 years, respectively. There was no significant difference between the bioprosthesis group and the mechanical prosthesis group in the incidences of all-cause mortality [hazard ratio (HR): 1.26, 95% confidence interval (CI): 0.97 to 1.64] and the composite outcome of major adverse prosthesis-related events (MAPE) (HR: 0.91, 95% CI: 0.75 to 1.10). The risk of ischemic stroke was lower in the bioprosthesis group (HR: 0.60, 95% CI: 0.42 to 0.87). Subgroup analyses showed that bioprostheses were associated with a lower risk of MAPEs [10-year restricted mean survival time (RMST) difference: 1.25 years, 95% CI: 0.28 to 2.21] and major bleeding (10-year RMST difference: 1.11 years, 95% CI: 0.03 to 2.19) in male patients. Conclusion: Among patients with SAD undergoing MVR, there was no significant difference between bioprostheses and mechanical prostheses in all-cause mortality and the composite outcome of MAPEs. However, bioprostheses showed a lower risk of ischemic stroke. In male patients, bioprostheses were linked to fewer MAPEs and major bleeding.

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