Asian Cardiovasc Thorac Ann 2003;11:319-322
© 2003 Asia Publishing EXchange Ltd
Combined Aortic and Mitral Valve Repair
Toshinobu Kazui, MD,
Hajime Kin, MD,
Hiroshi Izumoto, MD,
Takayuki Nakajima, MD,
Kazuaki Ishihara, MD,
Kouhei Kawazoe, MD
Department of Cardiovascular Surgery, Iwate Medical University, Morioka, Iwate, Japan
For reprint information contact: Toshinobu Kazui, MD Tel: 81 019 651 5111 Fax: 81 019 624 8384 email: t-kazui{at}pf6.so-net.ne.jp Department of Cardiovascular Surgery, Memorial Heart Center, Iwate Medical University, 1-2-1 chuoudori Morioka city, Iwate, Japan.
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ABSTRACT
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Six patients, median age 63.3 years (range, 54 to 68 years), underwent concomitant mitral and aortic valve repair from January 2000 to August 2001. Surgical reports and general clinical data were reviewed retrospectively. All patients had degenerative valvular disease, although one patient also had annuloaortic ectasia. There were no surgical complications. The 30 day survival rate was 100%, and the New York Heart Association classification score improved from 2.2 (range, 1 to 2) preoperative, to 1.0 (all patients) postoperatively (p = 0.03) As measured by intraoperative transesophageal echocardiography, the left ventricular end-diastolic diameter decreased from 6.0 cm (range, 5.4 to 6.3 cm) to 4.7 cm (range, 4.0 to 5.2 cm) and the left ventricular end-systolic diameter decreased from 3.7 cm (range, 3.4 to 4.1cm) to 3.1 cm (range, 2.9 to 3.7 cm). No patient developed endocarditis, thromboembolism or hemorrhage. There was no valve related morbidity during a 1 year follow up. Double valve repair is an acceptable alternative to valve replacement in selected patients with some types of valvular disease. Longer term follow up with greater numbers of patients is needed.
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INTRODUCTION
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In many institutions, double valve replacement has been performed for aortic and mitral valve disease.1 Around 9.3 to 13.7% of patients with valvular heart disease have involvement of both the aortic and mitral valves.2,3 Although many groups perform simultaneous aortic and mitral valve replacement for such patients,1 some data suggest a survival advantage for aortic valve replacement combined with mitral valve repair.4 In our institution, we have tried to preserve the patient’s valves by using the aortic and mitral valve repair technique as long as possible,5–7 especially in cases of degenerative disease. However, the efficacy of double valve repair in degenerative disease is undocumented. The aim of this study was to review the surgical outcome of combined aortic and mitral valve repair.
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PATIENTS AND METHODS
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Between January 2000 to August 2001, six male patients underwent simultaneous aortic and mitral valve repair at the Memorial Heart Center, Iwate Medical University (Table 1
). The mean age was 63.3 ± 5.9 (range, 54 to 68 years). All patients had both aortic valve regurgitation (AR) and mitral valve regurgitation (MR), including one patient with annuloaortic ectasia (AAE).
The feasibility of aortic valve repair was assessed by preoperative transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE). Three echocardiographic findings are essential for repairing the regurgitant aortic valve:
- The pathology of the valve is dominant or pure regurgitation.
- The valve leaflet is pliable.
- Leaflet size is fairly well preserved.7
All surgical procedures were performed under cardiopulmonary bypass. We employed subvalvular circular annuloplasty5 (Figure 1), leaflet suspension (Figure 2), leaflet plication (Figure 3), and ST junction tailoring as aortic valve procedures. When subvalvular circular annuloplasty was selected, a row of horizontal mattress pledgetted sutures was placed along the aortic annulus, passing stitches from the aortic side down to the left ventricular outflow tract side. A 0.6 mm thick Gore-Tex membrane (WL Gore & Associates, Arizona, USA) was tailored in the form of a 9 mm wide strip, and its length was adjusted according to the desired post-repair annulus size. In the normal Japanese population, the desired diameter ranges from 20 to 24 mm.5 As the primary goal of this technique was to shorten the commissural annulus, the width of a mattress suture at the commissural annulus was made longer than the width of corresponding bites on the strip. Whenever a cusp(s) had prolapsed, leaflet suspension or cusp plication was performed. Leaflet suspension was performed to correct the prolapsing leaflet by suturing leaflet margin over and over fashion with CV-7 (WL Gore & Associates, Arizona, USA). CV-7 was not tied at this point. When the patients weaned from cardiopulmonary bypass, adequate length of CV-7 was determined by TEE. CV-7 was tied outside tissue of the aorta and fixed with surgical clip. Cusp plication was performed, when the leaflet was redundant.
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Figure 1. Schematic representation of the subvalvular circular annuloplasty technique. A 0.6 mm thick Gore-Tex membrane (WL Gore & Associates, Arizona, USA) was tailored in the form of a 9 mm wide strip. A row of horizontal mattress pledgetted sutures were placed to tighten the annulus.
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Figure 2. Leaflet suspension is performed by suturing the redundant cusp over and over fashion with CV-7 (WL Gore & Associates, Arizona, USA) to suspend the cusp.
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The mitral valve repair procedures included hemi-ring annuloplasty, leaflet resection and suture, Kay’s annuloplasty and chordae reconstruction with artificial chordae.8 Concomitant procedures were Yacoub’s operation (aortic root remodeling),9 the Maze procedure, and replacement of the ascending aorta (Table 1
). Intraoperative TEE was used to assess the success of valve repair in all patients.
Perioperative echocardiographic changes were studied retrospectively. All patients had preoperative and postoperative echocardiography, at discharge, and 3, 6 and 12 months after operation. The mean follow-up period was 1.67 ± 0.37 years (range, 12 to 24 months).
Results are expressed as the mean ± standard deviation. Statistical analyses were performed using Student’s t test for continuous variables and chi-squared test for categorical variables. A p value < 0.05 was considered significant. All analyses were performed using StatView version 4.5 (SAS Institute, Cary, NC, USA). Other statistical analysis was not done, because of the small size of the experience.
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RESULTS
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All patients had degenerative valve disease. At the completion of the repair, the grade of AR and MR were less than or equal to I/IV in all cases. The operative profiles were as follows: mean cardiopulmonary bypass time, 181.1 ± 26.0 min (range, 139 to 210 min), mean aortic clamp time, 143.5 ± 31.8 min (range, 105 to 183 min) and mean intensive care unit stay, 1.83 ± 1.17 days (range, 1 to 4 days).
No patient died within 1 year of surgery. However, a 65-year-old man died of pneumonia 2 years postoperatively. No patient developed endocarditis, thromboembolism, or hemorrhage.
Five patients were in New York Heart Association (NYHA) class II and one patient in NYHA class I before surgery. Six patients were in NYHA class I one year after surgery. One patient was in NYHA class II 14 months after surgery. Mean NYHA class improved from 2.16 ± 1.2 to 1.00 ± 0.0 (p = 0.03) (Figure 4).
All patients had AR and MR preoperatively (AR grade I = 1, grade II = 4, grade IV = 1, MR grade II = 2, grade IV = 4). One patient with AR grade I showed leaflet prolapse preoperatively. Because the lesion seemed to progress in the future, aortic valve repair was performed concomitant with mitral valve repair. Intraoperative TEE and postoperative grades of AR and MR were as follows: AR grade 0 = 3, grade I = 3, MR grade 0 = 5 and grade I = 1 at one year after surgery: AR grade I = 3, grade II = 3, MR grade 0 = 4, grade I = 1, and grade II = 1. Mean AR grade improved from 2.2 ± 1.0 to 1.5 ± 0.5, and mean MR grade improved from 3.3 ± 1.0 to 0.6 ± 0.9 (p = 0.001) (Figure 5, 6). Left ventricle end-diastolic diameter decreased from 6.0 ± 0.4 cm to 4.7 ± 0.5 cm. (p = 0.0004), and the left ventricle end-systolic diameter decreased from 3.7 ± 0.3 cm to 3.1 ± 0.4 cm (p = 0.03).
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DISCUSSION
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Aortic valve repair is not performed commonly, because it is technically demanding and the outcome of aortic valve replacement with a valve prosthesis is reliable. However, aortic valve repair is feasible for some pathologies such as bicuspid valve, some degenerative valve diseases,6,11 and mild rheumatic disease.12 Patients having difficulty with long term anticoagulation therapy may receive benefit from aortic valve repair.
In our institution, patients with bicuspid valve or degenerative aortic valve disease have been treated with aortic valve repair, and surgical techniques have been standardized to some extent.5–7 A number of techniques for mitral valve repair have been developed in an effort to preserve native valve and avoid the complications of mitral valve replacement.10 Double valve replacement has become routine for patients with double valve disease in many centers.2,3 Technically the operation is quite feasible, and the long term results were satisfactory. However, it is our opinion that all conservative efforts on the aortic valve are well justified in order to avoid introducing the specific problems derived from a single prosthesis.
One other report on simultaneous aortic valve replacement and mitral valve repair achieved quite satisfactory long term results.4 Aortic valve replacement combined with mitral valve repair preserved left ventricular function better than aortic valve combined with mitral valve replacement, because the mitral chordae are preserved. Gillinov et al.13 reported that double valve repair yields acceptable late survival with minimal valve-related morbidity, but found limited durability. They recommended that this procedure should be reserved for patients who cannot tolerate anticoagulation. The authors used a variety of procedures for aortic valve repair, including commissuroplasty and cusp debridment, which we do not perform anymore.
In our institution, the most common aortic valve repair procedures were subvalvular circular annuloplasty,5 leaflet suspension, leaflet plication, and ST junction tailoring. In this series, all patients had degenerative valve disease and their valves were not damaged severely. These procedures seemed feasible. Subvalvular circular annuloplasty is effective in aortic valve regurgitation with annular dilatation. It tightens the dilated annulus so that deeper coaptation can be realized. Leaflet suspension is used to correct cusp prolapse. It reinforces the free margin of leaflets, and prevents them from prolapsing. Leaflet plication reduces the redundant free margin of leaflets and adjusts the size of the coaptation area. ST junction tailoring shortens each of the commisures to obtain a deeper coaptation area.
Grinda et al.14 have performed triple valve repair on young patients with rheumatic disease. They use autologous pericardial patch extension of the aortic valve. Although the long-term results of their triple valve repair are uncertain, initial and mid-term results are good as a palliative procedure to young rheumatic patients.
The obvious merits of double-valve repair are low risk of valve-related complications such as endocarditis, thromboembolism, and hemorrhage.13 However, in the case of rheumatic disease, durability is limited. Gillinov et al. reported that surgeons should use the techniques with caution in patients with aortic stenosis, rheumatic valve disease, or mitral valve anterior leaflet pathology.13 In our series, all patients had degenerative disease, and their short-term results were quite acceptable. On the other hand, about half of Dr Grinda’s series were patients with rheumatic disease, yet their results were also good.
There are limitations to this study. This is a very small series of double valve repair and the follow-up period is short. It is difficult to extrapolate the long-term results from our initial results. However, repair offers distinct advantages over replacement. Therefore further study, including longer follow-up with echocardiography, is needed. In conclusion, double-valve repair yields acceptable early outcomes and freedom from valve-related morbidity in the short-term period, while cardiac function improves. Long-term study is needed to determine durability.
A part of this paper was presented at the 10th Annual Meeting of ASCVS April 17–19, 2002, Jeju, Korea.
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REFERENCES
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ABSTRACT
INTRODUCTION
