Currently there is no approved thoracic aortic aneurysm (TAA) screening protocol as exists for the abdominal aorta. However, as a result of the National Lung Screening Trial, the Centers for Medicare and Medicaid Services (CMS) recently began covering annual low-dose computed tomography (LDCT) scans in long-term smokers, a population also at risk for developing aortic aneurysms. We hypothesized that these lung cancer screening scans represent a novel method of identifying TAA. We identified 300 consecutive patients undergoing LDCT for lung cancer screening between the years 2014 and 2015 at a single center. Patient records were reviewed, and demographics and comorbidities were recorded. Each CT scan was reviewed, and the dimensions of the thoracic aorta were measured in three locations: immediately distal to the left subclavian artery, the middescending thoracic aorta, and immediately proximal to the celiac artery. We defined aortic ectasia as having a thoracic aortic diameter measuring between 3.5 and 4.0 cm, and aneurysm as measuring >4.0 cm. In total, 300 patients (157 [52%] men) were examined. The mean age was 61.6 years (range 43-78). There were 298 (99.3%) with a smoking history, with 141 (47%) being active smokers at the time of their initial scan. Common comorbidities included hyperlipidemia in 113 (37%), hypertension in 100 (33.3%), and chronic obstructive pulmonary disease in 37 (12.3%). Four patients (1.3%) had a personal history of abdominal aortic aneurysm (AAA): two had been repaired previously and two did not yet meet criteria for repair. There were 11 patients (4%) with a family history of AAA. Of the patients undergoing lung cancer screening, 166 (55.3%) met CMS criteria for AAA screening duplex. Overall, 11 patients (4%) had thoracic aortic ectasia, and one patient had a small distal TAA measuring 4.01 cm. The mean diameter of the aorta at the left subclavian artery in the population was 2.80 cm, 2.65 cm in the midthorax, and 2.59 cm at the celiac artery. LDCT for lung cancer examines a population similar to that at risk for aortic aneurysm, with over half of the population in this sample meeting CMS criteria for AAA duplex screening. The thoracic aorta can be measured with acceptable accuracy on these scans. Overall, there is a low incidence of TAA in this population. Larger studies will need to be done to determine the impact of these scans on the diagnosis of thoracic aortic pathology.

OBJECTIVE:To determine the relationship between postoperative morbidity and mortality and patients' perspectives of care.BACKGROUND:Priorities in health care quality research are shifting to place greater emphasis on patient-centered outcomes. Whether patients' perspectives of care correlate with surgical outcomes remains unclear.DESIGN:Retrospective cohort study.METHODS:Using data from the Michigan Surgical Quality Collaborative clinical registry (2008-2012), we identified 41,833 patients undergoing major elective general or vascular surgery. Our exposure variables were the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Total and Base Scores derived from the Hospital Value-Based Purchasing Patient Experience of Care Domain. Using multilevel, mixed-effects logistic regression models, we adjusted hospitals' rates of morbidity and mortality for patient comorbidities and case mix. We stratified reporting of outcomes by quintiles of hospitals' Total and Base Scores.RESULTS:Risk-adjusted morbidity (13.6%-28.6%) varied widely across hospitals. There were no significant differences in risk-adjusted morbidity rates between hospitals with the lowest and highest HCAHPS Total Scores (24.5% vs 20.2%, P = 0.312). The HCAHPS Base Score, which quantifies sustained achievement or improvement in patients' perspectives of care, was not associated with a reduction in postoperative morbidity over the study period despite an overall decrease of 2.5% for all centers. We observed a similar relationship between HCAHPS Total and Base Scores and postoperative mortality.CONCLUSIONS AND RELEVANCE:Patients' perspectives of care do not correlate with the incidence of morbidity and mortality after major surgery. Improving patients' perspectives and objective outcomes may require separate initiatives for surgeons in Michigan.

The future is here—quality measures now have teeth. Increasingly used as a measure of surgical quality, hospital readmissions have now been translated into financial penalties for hospitals. The Hospital Readmissions Reduction Program contained within the Affordable Care Act went into effect in October 2012, penalizing hospitals up to 3% of their Medicare payments over the next 3 years.1 This policy is expected to expand to surgical diagnoses by 2015. In the context of this increasing policy emphasis, it is worth questioning whether readmissions actually measure quality or whether they instead capture socioeconomic conditions outside the hospital’s control. Additionally, it is debatable that readmission is always a bad outcome. The financial penalty for readmissions also may have unintended consequences and may not be appropriate in all contexts. Above and beyond these concerns that apply in all of health care, there are issues specific to surgical readmissions. Creative solutions must be reached with careful forethought and consideration of all stakeholders.

Objective: The Center for Medicare and Medicaid Services recently began assessing financial penalties to hospitals with high readmission rates for a narrow set of medical conditions. Because these penalties will be extended to surgical conditions in the near future, we sought to determine whether readmissions are a reliable predictor of hospital performance with vascular surgery.Methods: We examined 4 years of national Medicare claims data from 1576 hospitals on beneficiaries undergoing three common vascular procedures: open or endovascular abdominal aortic aneurysm repair (n = 81,520) or lower extremity arterial bypass (n = 57,190). First, we divided our population into two groups on the basis of operative date (2005-2006 and 2007-2008) and generated hospital risk-and reliability-adjusted readmission rates for each time period. We evaluated reliability through the use of the "test-retest" method; highly reliable measures will show little variation in rates over time. Specifically, we evaluated the year-to-year reliability of readmissions by calculating Spearman rank correlation and weighted kappa tests for readmission rates between the two time periods.Results: The Spearman coefficient between 2005-2006 readmissions rankings and 2007-2008 readmissions rankings was 0.57 (P < .001) and weighted kappa was 0.42 (P < .001), indicating a moderate correlation. However, only 32% of the variation in hospital readmission rates in 2007-2008 was explained by readmissions during the 2 prior years. There were major reclassifications of hospital rankings between years, with 63% of hospitals migrating among performance quintiles between 2005-2006 and 2007-2008.Conclusions: Risk-adjusted readmission rates for vascular surgery vary substantially year to year; this implies that much of the observed variation in readmission rates is either random or caused by unmeasured factors and not caused by changes in hospital quality that may be captured by administrative data.

IMPORTANCEWith the health policy focus on shifting risk to hospitals and physicians, hospital leaders are increasing efforts to reduce excessive resource use, such as patients with extended length of stay (LOS) after surgery. However, the degree to which extended LOS represents complications, patient illness, or inefficient practice style is unclear.OBJECTIVETo examine the influence of complications on the variance in hospitals' extended LOS rates after colorectal resections.DESIGN, SETTING, AND PARTICIPANTSIn this retrospective cohort study performed from January 1 through December 31, 2009, we analyzed data from the 2009 American College of Surgeons National Surgical Quality Improvement Program. Study participants were 22 664 adults undergoing colorectal resections in 199 hospitals.EXPOSURESInpatient complications recorded in the American College of Surgeons National Surgical Quality Improvement Program registry. Inpatient complications were identified by the association of the complication's postoperative date with the patient's surgical discharge date.MAIN OUTCOME AND MEASUREHospitals' risk-adjusted extended LOS rates, defined as the proportion of patients with a hospital stay greater than the 75th percentile for the entire cohort.RESULTSA total of 2177 patients (42.8%) with extended LOSs did not have a documented inpatient complication. Although there was wide variation in risk-adjusted extended LOS (14.5%-35.3%) and risk-adjusted inpatient complication (12.1%-28.5%) rates, there was only a weak correlation (Spearman ρ = 0.56, P < .001) between the two. Only 52.0% of the variation in hospitals' extended LOS rates was attributable to hospitals' inpatient complication rates.CONCLUSIONS AND RELEVANCEMuch of the variation in hospitals' risk-adjusted extended LOS rates is not attributable to patient illness or complications and therefore most likely represents differences in practice style. Efforts to reduce excess resource use should focus on efficiency of care, such as increased adoption of enhanced recovery pathways.

BACKGROUND:Surgical readmissions will be targeted for reimbursement cuts in the near future. We sought to understand differences between hospitals with high and low readmission rates in a statewide surgical collaborative to identify potential quality improvement targets. STUDY DESIGN:We studied 5,181 patients undergoing laparoscopic or open colectomy at 24 hospitals participating in the Michigan Surgical Quality Collaborative between May 2007 and January 2011. We first calculated hospital risk-adjusted 30-day readmission rates. We then compared reasons for readmission, risk-adjusted complication rates, risk-adjusted inpatient length of stay, and composite process compliance across readmission rate quartiles. RESULTS:Hospitals with the lowest 30-day readmission rates averaged 5.1%, compared with 10.3% in hospitals with the highest rates (p < 0.01). Despite wide variability in readmission rates, reasons for readmission were similar between hospitals. Compared with hospitals with low readmission rates, hospitals with high readmission rates had higher risk-adjusted complication rates (29% vs 22%, p = 0.03), but similar median lengths of stay (5.5 days vs 5.6 days, p = 0.61). Although measures to reduce complications were associated with lower surgical site infection rates, they were not associated with reduced overall complication or readmission rates. There was wide variation in complication rates among hospitals with similar readmission rates. CONCLUSIONS:There is wide variation in hospital readmission rates after colectomy that correlates with overall complication rates. However, the wide variation in complication rates among hospitals with similar readmission rates suggests that hospital complication rates explain little about their readmission rates. Preventing readmissions after colectomy in hospitals with high readmission rates will require more attention to different care processes currently unmeasured in many clinical registries as well as complication prevention.

Medicare now levies financial penalties against hospitals for excessive readmissions. Although intensive postdischarge follow-up has been shown to decrease readmissions in medical patients, evidence-based interventions to decrease readmissions in vascular surgery are scant. We sought to examine the effect of a callback program on readmission rates in patients undergoing major vascular surgery. We instituted a predischarge checklist screen and postdischarge callback program in our center for patients undergoing major lower extremity or abdominal vascular surgery. A total of 388 patients were identified in the year prior to (266) and the year after (122) the intervention was initiated. Thirty-day readmission rates, emergency department (ED) visit rates, and early clinic visit rates (defined as a clinic visit less than 14 days postdischarge) were calculated and compared between the pre- and postintervention periods. Major demographic and comorbidities were then used to create a risk-adjusted logistic regression model examining the effect of the interventions on the outcomes. Preintervention 30-day readmission rates were 9.8%, compared to 9.0% after the intervention (P = .81). The most common reason for readmission were infectious/wound-related (40.5%), and the incidence did not differ between pre- and postintervention time periods; additionally, patients with a positive screen for wound concerns at discharge were more likely to be readmitted (P = .04). Postoperative ED visit rates were identical in the postintervention group as compared to the preintervention group, as were the reasons for presentation. Risk-adjusted logistic regression models bore these trends out, though none reached statistical significance. A callback program did not reduce readmissions or direct patients to clinic rather than the ED in a population of patients undergoing major vascular surgery. A focused process for postoperative wound management may yield the highest decrease in readmissions.

Excess hospital length of stay (LOS) is increasingly used to profile hospital performance. It is unclear, however, whether this measure captures technical quality (i.e., postoperative complications and mortality) or is a proxy for hospital efficiency. We sought to investigate whether extended length of stay after a common surgical procedure represents quality or efficiency.

BACKGROUND:Racial disparities have been described in many surgical outcomes. We sought to examine whether these disparities extend to postoperative readmission rates and whether the disparities are associated with differences in patient mix and/or hospital-level differences.STUDY DESIGN:National Medicare beneficiaries undergoing operations in 3 different specialties from 2006 to 2008 were examined: colectomy, hip replacement, and coronary artery bypass grafting (CABG) (n = 798,279). Our outcome measure was risk-adjusted 30-day readmission. We first used logistic regression to adjust for patient factors. We then stratified hospitals into quintiles according to the proportion of black patients treated and examined the differences in readmission rates between blacks and whites. Finally, we used fixed effects regression models that further adjust for the hospital to explore whether the disparity was attenuated after accounting for hospital differences.RESULTS:Black patients were readmitted more often after all 3 operations compared with white patients. The unadjusted odds ratio (OR) for readmission for all 3 operations combined was 1.25 (95% CI 1.22 to 1.28) (colectomy OR 1.17, 95% CI 1.13 to 1.22; hip replacement OR 1.20, 95% CI 1.14 to 1.27; CABG OR 1.25, 95% CI 1.19 to 1.30). Adjusting for patient factors explained 36% of the disparity for all 3 operations (35% for colectomy, 0% for hip replacement, and 32% for CABG), but in analysis that adjusts for hospital differences, we found that the hospitals where care was received also explained 28% of the disparity (35% for colectomy, 70% for hip replacement and 20% for CABG).CONCLUSIONS:Black patients are significantly more likely to be readmitted to the hospital after major surgery compared with white patients. This disparity was attenuated after adjusting for patient factors as well as hospital differences.

Black patients are disadvantaged in many aspects of vascular surgical care compared to non-blacks, such as post-operative mortality and receipt of endovascular procedures. We sought to examine whether these racial disparities extend to rates of post-operative readmission. National Medicare beneficiaries undergoing major vascular surgery (open abdominal aortic aneurysm repair (AAAR) and lower extremity bypass (LEB)) in 2000-2008 were examined (n=387,501). Risk-adjusted 30-day readmission was the primary outcome measure. Logistic regression was used to adjust for patient factors. After ranking hospitals by proportion of black patients served, differences in readmission rates were examined. Finally, the impact of the site of care on the observed disparity was assessed by using modeling techniques that adjust for hospital-specific readmission differences. After adjusting for patient factors, blacks were 20% more likely than non-blacks to be readmitted. Black patients receiving care in predominantly minority-serving hospitals were readmitted more often than black patients in non-minority-serving hospitals (19.9% vs. 14.2%, P=<.001). In models accounting for differences in site of care, the hospitals where black patients receive care accounted for approximately 55% of the residual disparity in readmission rates. This magnitude of this effect was similar for both operations (34% in AAAR, 56% in LEB). Black patients are more likely to be readmitted to the hospital following major vascular surgery compared to non-black patients. Higher readmission rates in minority-serving hospitals play an important role in this observed disparity. Whether patient-level factors or hospital-level processes contribute will require further study.

The escalating cost burden of hospital readmission has prompted recent nationwide efforts aimed at reducing the incidence of this important quality measure. Because patients undergoing vascular surgery account for a significant proportion of readmissions, vascular surgeons may face reduced reimbursements in the near future if these trends continue. However, risk factors associated with readmission remain poorly defined, and further research is needed to identify interventions that will prevent readmission following vascular procedures. Accordingly, this manuscript will (1) propose a conceptual model to explain the driving forces behind readmissions in vascular surgery, (2) review current evidence directed at identifying risk factors and evaluating interventions to reduce readmissions across different medical and surgical specialties, and (3) identify key areas in patient care where targeted research or interventions may be implemented in vascular surgery.

Introduction: Black patients are known to have increased rates of morbidity and mortality following vascular surgery when compared to non-black patients. We sought to examine whether this disparity extends to rates of post-operative readmission. Methods: National Medicare beneficiaries undergoing abdominal aortic aneurysm (AAA) repair in 2007-2008 were examined (n=58, 244). Hospitals were divided into quintiles based on the extent to which they served the black population during the study period. These were termed quintiles 1-5, quintile 1 contained the lowest 20% of black-serving hospitals and quintile 5 contained the highest 20%. the rate of risk-adjusted 30-day post-operative readmission was then compared between quintiles and logistic regression was used to examine the effect of race on this outcome. Risk adjustment included demographic information, patient co-morbidities, socioeconomic factors, and type of aneurysm repair (open versus endovascular). Results: the overall 30-day readmission rate for all patients following AAA repair was 11.8%. Across all hospitals, black patients had a 17% higher risk of 30-day readmission (odds ratio [OR], 1.17; 95% confidence interval [CI] 1.04-1.31) compared to non-blacks. When hospital-level analysis was performed, we found that quintile 1 hospitals treated 35% of the study population but actually treated zero black patients, compared to quintile 5 hospitals, which treated 20% of the study population but 67% of all black patients. We found a significant difference between 30-day readmission rates in non-blacks in quintile 1 compared to blacks in quintile 5 (11.3% versus 14.8%). Overall, blacks treated at the quintile 5 hospitals had a 30% higher risk-adjusted rate of 30-day readmission compared to non-blacks treated at quintile 1 hospitals (OR 1.30; 95% CI 1.12-1.50). Conclusions: Black patients experience a significantly higher risk-adjusted 30-day readmission rate following AAA repair compared to non-black patients. This disparity was even more pronounced at minority-serving hospitals.

IntroductionThe American College of Surgeons National Surgical Quality Improvement Program ranks hospitals according to risk-adjusted rates of postoperative complications. However, this approach does not consider the severity or number of complications that occurred. We sought to determine whether incorporating this information would alter hospital rankings.MethodsThe study examined data for the 39,519 patients who underwent major vascular surgery in 206 National Surgical Quality Improvement Program hospitals during 2008 to 2009. We categorized postoperative complications as minor or severe and evaluated the extent to which minor and severe complications increased a patient's risk of death and prolonged length of stay. We then ranked hospitals on two alternative approaches that included severity or number of complications. We determined the effect of these alternative methods by assessing the proportion of hospitals that moved out of the top and bottom 20% of hospitals compared with standard rankings.ResultsCompared with patients with minor complications, patients with severe complications had a higher mortality rate (16.2% vs 3.6%; P < .001) and prolonged length of stay (66.7% vs 53.3%; P < .001). Patients with two or more complications also had a higher mortality rate (23.7% vs 6.0%; P < .001) and prolonged length of stay (77.0% vs 50.1%; P < .001) than patients with only one complication. Compared with the current approach for assessing morbidity, ranking hospitals by severe complications resulted in 12 hospitals (29%) moving out of the top 20% and 10 hospitals (24%) moving out of the bottom 20%. A similar degree of reclassification was found when the current rankings were compared with an alternative approach that considered the number of different complications.ConclusionsAlthough the severity and number of postoperative complications affect mortality and length of stay, and subsequently, hospital rankings, existing measurement systems do not take this into account. Quality measurement platforms should consider weighting complications according to severity and number.

BACKGROUND Cardiac resynchronization therapy using a left ventricular (LV) lead inserted via the coronary sinus (CS) improves symptoms of congestive heart failure, decreases hospitalizations, and improves survival. An epicardial LV lead is often placed surgically after a failed percutaneous attempt, but whether it offers the same benefits is unknown.OBJECTIVE The purpose of this study was to determine if patients who receive a surgical LV lead after failed CS lead placement for cardiac resynchronization therapy derive the same benefit as do patients with a successfully placed CS lead.METHODS A total of 452 patients underwent attempted CS lead insertion. Forty-five patients who had failed CS lead placement and then had surgical LV lead placement were matched with 135 patients who had successful CS lead placement.RESULTS No major differences in preoperative variables were seen between groups. Postprocedural complications of acute renal injury (26.2% vs 4.9%, P < .001) and infection (11.9% vs 2.4%, P = .03) were more common in the surgical group. Mean long-term follow-up was 32.4 +/- 17.5 months for surgical patients and 39.4 +/- 14.8 months for percutaneous patients. At follow-up, all-cause mortality (30.6% vs 23.8%, P = .22) and readmission for congestive heart failure (26.2% vs 31.5%, P = .53) were similar between surgical and percutaneous groups. Improvement in New York Heart Association functional class (60.1% vs 49.6%, P = .17) was similar between surgical and percutaneous groups.CONCLUSION Surgical LV lead placement offers functional benefits similar to those of percutaneous placement but with greater risk of perioperative complications, including acute renal failure and infection.

BACKGROUND:Dogma suggests optimal myocardial protection in cardiac surgery after prior coronary artery bypass graft surgery (CABG) with patent left internal thoracic artery (LITA) pedicle graft requires clamping the graft. However, we hypothesized that leaving a patent LITA-left anterior descending (LAD) graft unclamped would not affect mortality from reoperative cardiac surgery.METHODS:Data were collected on reoperative cardiac surgery patients with prior LITA-LAD grafts from July 1995 through June 2006 at our institution. With the LITA unclamped, myocardial protection was obtained initially with antegrade cardioplegia followed by regular, retrograde cardioplegia boluses and systemic hypothermia. The Society of Thoracic Surgeons National Database definitions were employed. The primary outcome was perioperative mortality. Variables were evaluated for association with mortality by bivariate and multivariate analyses.RESULTS:In all, 206 reoperations were identified involving patients with a patent LITA-LAD graft. Of these, 118 (57%) did not have their LITA pedicle clamped compared with 88 (43%) who did. There were 15 nonsurvivors (7%): 8 of 188 (6.8%) in the unclamped group and 7 of 88 (8.0%) in the clamped group (p = 0.750). Nonsurvivors had more renal failure (p = 0.007), congestive heart failure (p = 0.017), and longer perfusion times (p = 0.010). When controlling for independently associated variables for mortality, namely, perfusion time (odds ratio 1.014 per minute; 95% confidence interval: 1.004 to 1.023; p = 0.004) and renal failure (odds ratio 4.146; 95% confidence interval: 1.280 to 13.427; p = 0.018), an unclamped LITA did not result in any increased mortality (odds ratio 1.370; 95% confidence interval: 0.448 to 4.191). Importantly, the process of dissecting out the LITA resulted in 7 graft injuries, 2 of which significantly altered the operation.CONCLUSIONS:In cardiac surgery after CABG, leaving the LITA graft unclamped did not change mortality but may reduce the risk of patent graft injury, which may alter an operation.

The ventriculo-gallbladder (VGB) shunt has been reported on several occasions for the alleviation of ventriculo-peritoneal (VP) –shunt-refractory hydrocephalus. There is little data regarding VGB shunts and a need for delineating appropriate surgical therapy when cerebrospinal fluid drainage to the peritoneum becomes infeasible. We report our experience with VGB shunt placement in three patients with chronic hydrocephalus. All three had a history of prior VP-shunt placements and revisions due to distal obstruction or infection, or contraindications to alternative forms of ventricular drainage. In one patient, the VGB shunt functioned well for 9 years but was revised due to contamination during an unrelated operation. Neither of the other two patients have experienced VGB shunt-related complications. VP shunts are presently regarded as the standard of care for uncomplicated hydrocephalus. When VP shunts fail, the most common alternatives have been ventriculo-atrial and ventriculo-pleural shunts. In five case series involving 59 patients with VGB shunts, the long-term success rate was 62.7 per cent. Infection (10.2%) and obstruction (10.2%) were the most common complications. Based on durability and a low incidence of complications, it is the current consensus that VGB shunts are a viable alternative with good outcomes in the case of failed VP shunts.

BACKGROUND:Cardiac injury at the time of resternotomy is a complication faced by all cardiac surgeons, although little is known about its effects on morbidity and mortality. This study was designed to address these questions. STUDY DESIGN:Resternotomies performed at the University of Virginia from 1996 to 2005 were identified. Operative notes were reviewed, and any injury during resternotomy to the heart, great vessels, or bypass grafts was recorded. Perioperative complications and mortality were recorded using the Society of Thoracic Surgeons National Database. RESULTS:In the 11-year period studied, 612 resternotomies were performed out of 7,872 total adult cardiac procedures (7.8%). Fifty-six patients (9.1%) had an injury sustained during resternotomy and initial dissection. Injury to grafts was most common (46.4%), with mammary arteries comprising 21% of the total and vein grafts, 25%. The right ventricle was the second most commonly injured structure (21.4%). There were no significant differences in overall nonadjusted mortality in the injured group compared with that in the noninjured group (8.9% versus 10.2%, p=0.66). Multivariate analysis demonstrated third-time resternotomy to be an independent risk factor for cardiac injury (p=0.04). CONCLUSIONS:Cardiac injury at the time of resternotomy is not associated with an increase in perioperative morbidity or mortality. Third-time resternotomy is an independent risk factor for cardiac injury, so vigilance and adequate preparation are paramount in these patients.

Background. Mitral valve replacement is more frequently performed and perceived to be equivalent to repair in elderly patients, despite the superiority of repair in younger patients. Our objective was to compare mitral repair to replacement in elderly patients age 75 years or older. Patients younger than 75 years undergoing mitral valve surgery served as a reference population.Methods. Consecutive elderly patients undergoing operation for mitral regurgitation at our institution from 1998 to 2006 were reviewed. Elderly patients (mean age, 78.0 +/- 2.8 years) who underwent mitral repair (n = 70) or replacement (n = 47) were compared with cohorts of young patients (mean age, 58.9 +/- 9.3 years) who underwent repair (n = 100) or replacement (n = 98) during the same period. Patient details and outcomes were compared using univariate, multivariate, and Kaplan-Meier analyses.Results. Mitral replacement in elderly patients had higher mortality than repair (23.4%, 11 of 47 versus 7.1%, 5 of 70; p = 0.01) or as compared with either operation in the reference group (p < 0.0001). Postoperative stroke was higher in elderly replacement patients compared with repair (12.8%, 6 of 47 versus 0%; p = 0.003) or compared with either young cohort (p = 0.02). Compared with elderly repair patients, elderly replacement patients had more cerebrovascular disease (21.3%, 10 of 47 versus 4.3%, 3 of 70; p = 0.005) and rheumatic mitral valves (21.3%, 10 of 47 versus 0%; p = 0.0001). In the young group, overall complication and mortality were no different between replacement and repair. Long-term survival favored repair over replacement in elderly patients (p = 0.04). One elderly repair patient experienced late recurrence of persistent mitral regurgitation.Conclusions. In patients age 75 years or older, mitral repair is associated with a lower risk of mortality, postoperative stroke, and prolonged intensive care unit and hospital stay compared with mitral replacement. Mitral repair can be performed in preference over replacement even in patients older than the age of 75.