Asian Cardiovasc Thorac Ann 2004;12:341-345
© 2004 Asia Publishing EXchange Ltd
Mitral Valve Repair with Aortic Valve Replacement in Rheumatic Heart Disease
Huynh-Quang Tri Ho, MD,
Van-Phan Nguyen, MD,
Kim-Phuong Phan, MD,
Nguyen-Vinh Pham, PhD
Heart Institute, Ho Chi Minh City, Vietnam
For reprint information contact: Huynh-Quang Tri Ho, MD Tel: 84 8 865 1586 Fax: 84 8 865 1543 Email: hohuynhquangtri{at}yahoo.com 520 Nguyen Tri Phuong Street, 10th District, Ho Chi Minh City, Vietnam.
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ABSTRACT
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From 1992 to 2001, 609 patients with rheumatic heart disease underwent aortic valve replacement with either mitral valve repair (n = 201) or mitral valve replacement (n = 408). Follow-up extended to 10 years. Thirty-day mortality was 1.4% for mitral valve repair and 0.7% for mitral valve replacement ( p = 0.4). Survival at 9 years was 96.5 ± 1.4% after mitral valve repair and 89.7 ± 7.8% after mitral valve replacement ( p = 0.73). Freedom from major bleeding at 9 years was 94.8 ± 2.4% after mitral valve repair and 81 ± 7.2% after mitral valve replacement ( p = 0.03). Freedom from other valve-related complications and from mitral valve re-operation was similar for the two groups. This study showed that in patients with rheumatic heart disease the results of mitral valve repair with aortic valve replacement were comparable to those of double valve replacement. Major bleeding was less frequent after mitral valve repair with aortic valve replacement. Therefore, whenever feasible, mitral valve repair should be attempted in patients with rheumatic heart disease who need concomitant aortic valve replacement.
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INTRODUCTION
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Mitral valve repair is a widely accepted operative method for rheumatic mitral valve lesions requiring surgical treatment. Studies from Georges Pompidou Hospital (Paris, France) and from our institution have documented good results of mitral valve repair using Carpentier’s techniques in patients with rheumatic mitral valve disease.1–3 However, controversy remains regarding whether the mitral valve should be repaired or replaced in patients who need concomitant aortic valve replacement. Some authors have recommended double valve replacement for these patients in order to prevent mitral valve re-operation.4,5
Our approach in patients with multiple valve lesions who need concomitant aortic replacement is to repair the mitral valve if feasible and to replace the mitral valve if the lesions are unsuitable for repair. In this study we evaluated the outcomes after aortic valve replacement with mitral valve repair and double valve replacement in patients with rheumatic heart valve disease over a 9-year follow-up period.
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PATIENTS AND METHODS
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Patients: From 1992 to 2001, 609 patients with rheumatic heart valve disease underwent aortic valve replacement with mitral valve repair (group 1: n = 201) or double valve replacement (group 2: n = 408) at our institution.
Patient characteristics and details of valve lesions are given in Table 1
. Group 1 patients were younger, had a lower frequency of preoperative atrial fibrillation and a lower left ventricular ejection fraction. Pure or predominant mitral stenosis was less common and pure or predominant mitral regurgitation was more common in group 1. Aortic valve stenosis and combined lesion (stenosis and regurgitation) were less common and aortic valve regurgitation was more common in group 1.
Surgical procedures: Repair or replacement of the mitral valve was decided by the surgeon after examination of the lesions. Group 1 patients had mitral valve repair using Carpentier’s techniques with details given in Table 2. Table 3 lists the types of prosthetic heart valves implanted in the two groups. The use of a bioprosthesis for aortic valve replacement was significantly more frequent in group 1 compared to group 2 (12.4% versus 1.2%, p < 0.001).
Fifty-eight (28.9%) patients in group 1 and 132 (32.4%) patients in group 2 had concomitant tricuspid annuloplasty (no statistically significant difference between the two groups).
Postoperative anticoagulation: Oral acenocoumarol was commenced 24 hours after the operation. Patients with bioprostheses were anticoagulated for 3 months with a target international normalized ratio (INR) range of 2–3. Patients who underwent aortic valve replacement with mechanical valves and mitral valve repair received lifelong anticoagulation with a target INR range of 2–3. Patients who underwent double valve replacement with mechanical valves received lifelong anticoagulation with a target INR range of 2.5–3.5.
Follow-up: Follow-up data were collected and categorized according to the 1996 guidelines for reporting morbidity and mortality after cardiac valvular operations.6 Patients were invited for clinical examination and echocardiographic study at our institution. For patients living far away, information was obtained by mailed questionnaire. Data for the deceased patients were collected from the family. Forty-four (7.2%) patients were lost to follow-up including 13 patients in group 1 and 31 patients in group 2 (6.5% versus 7.6%, p = 0.74). The cumulative follow-up was 963 patient-years (pty) for group 1 (median: 62 months; maximal: 120 months) and 1241 pty for group 2 (median: 37.5 months; maximal: 108 months).
Statistical analysis: Statistical comparison of the two groups was performed using the Pearson chi-square test with Yates’ correction or Fisher exact test for categorical variables and Mann-Whitney U-test for continuous variables. Kaplan-Meier survival analysis was used to estimate the survival and freedom from events. The log-rank test was used for comparison of unadjusted survival and freedom from events between the two groups. The events were also expressed in linearized form (percent per pty). In cases when the log-rank test showed a statistically significant difference in freedom from events between the two groups and the events occurred frequently, we used the Cox proportional hazards model to look for the independent predictive value of the mitral valve operation (repair versus replacement). Besides mitral valve operation, variable candidates for multivariable analysis were patient characteristics (Table 1
) and type of aortic prosthetic valve (mechanical valve versus bioprosthesis). A p-value < 0.05 was considered statistically significant. All analyses were performed using SPSS 10.0 for Windows.
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RESULTS
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Survival: Six patients (3 patients in each group) died from irreversible heart failure within 1 month of the operation, yielding a 30-day mortality of 1.4% for group 1 and 0.7% for group 2 ( p = 0.4).
There were 8 late deaths, including 3 in group 1 (2 sudden deaths and 1 death from irreversible heart failure) and 5 in group 2 (2 sudden deaths, 2 deaths from irreversible heart failure and 1 death from cerebral bleeding). Actuarial survival at 9 years was 96.5 ± 1.4% for group 1 and 89.7 ± 7.8% for group 2 (log-rank test: p = 0.73) (Figure 1).
Valve-related complications: In group 1 there were 2 cases of paravalvular leak in the aortic position (linearized rate 0.2%/pty), 2 cases of structural deterioration of aortic bioprosthesis (0.2%/pty), 2 cases of residual mitral regurgitation with important hemolysis after mitral valve repair (0.2%/pty), 1 case of thromboembolic stroke (0.1%/pty), 6 cases of severe bleeding requiring hospitalization (0.62%/pty) and 1 case of prosthetic valve endocarditis in the aortic position (0.1%/pty).
In group 2 there were 3 cases of paravalvular leak, 2 in the aortic position and 1 in the mitral position (linearized rate 0.24%/pty), 1 case of structural deterioration of mitral bioprosthesis (0.08%/pty), 2 cases of mechanical valve thrombosis in the mitral position successfully treated with streptokinase (0.16%/pty), 1 case of thromboembolic stroke (0.08%/pty) and 19 cases of severe bleeding requiring hospitalization (1.53%/pty).
Table 4 lists the 9-year freedom from valve thrombosis, thromboembolism, severe bleeding and prosthetic valve endocarditis of the two groups.
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Table 4. Freedom from Valve Thrombosis, Thromboembolism, Severe Bleeding, and Prosthetic Valve Endocarditis at 9 Years
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Actuarial freedom from severe bleeding in group 1 was significantly greater than in group 2 (Figure 2). The Cox proportional hazards model showed that mitral valve replacement (versus repair) was the only predictor of severe bleeding: HR=2.74; 95% CI=1.02–7.35.
Re-operation: Seven patients in group 1 underwent re-operation (2 for paravalvular leak in the aortic position, 1 for structural deterioration of aortic bioprosthesis, 2 for residual mitral regurgitation with important hemolysis after mitral valve repair, and 2 for progressive mitral regurgitation after mitral valve repair). The 4 patients in group 1 who underwent mitral valve re-operation had mitral valve replacement with mechanical valves. Four patients in group 2 underwent re-operation (2 for paravalvular leak in the aortic position, 1 for paravalvular leak in the mitral position with important hemolysis, and 1 for structural deterioration of the mitral bioprosthesis). The patient with paravalvular leak in the mitral position had refixation of the valve, and the patient with structural deterioration of the mitral bioprosthesis had a further mitral valve replacement with a mechanical valve at re-operation. Freedom from re-operation at 9 years was 81.8 ± 12.8% for group 1 and 89.7 ± 7.9% for group 2 (log-rank test: p = 0.3). Freedom from mitral valve re-operation at 9 years was 84.2 ± 13% for group 1 and 92 ± 7.4% for group 2 (log-rank test: p = 0.42) (Figure 3).
Functional status: At the time of last follow-up the survivors of the two groups showed similar functional status according to the New York HeartAssociation (NYHA) classification (Table 5).
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DISCUSSION
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Based on the results of their studies, some authors recommended mitral valve replacement with mechanical valve for patients with multiple valve disease undergoing mitral valve procedures plus aortic valve replacement.4,5 According to these studies, the freedom from mitral valve re-operation after mitral valve repair, especially in the subgroup of patients with rheumatic heart disease, was significantly lower than after mitral valve replacement. However, it should be noted that the number of patients with rheumatic heart disease undergoing mitral valve repair in those series was small (46 in one series4 and 43 in the other5).
In a series of 72 consecutive patients undergoing aortic valve replacement with concomitant open mitral valvotomy, Kaul et al 7 reported a re-operation rate of only 1.04% after a mean follow-up period of 9 years. More recently, in a study evaluating the long-term results after mitral valve repair with aortic valve replacement, Gillinov et al 8 documented a freedom from mitral valve replacement at 15 years of up to 75% in 169 patients with rheumatic mitral valve disease. In addition, they found that late survival was increased by mitral valve repair rather than replacement in all subsets of patients. They concluded that in patients with double valve disease, aortic valve replacement and mitral valve repair are the preferred strategies when mitral valve repair is possible.
The present study comprised the largest number of patients with rheumatic heart disease undergoing aortic valve replacement and mitral valve repair. In these 201 patients, we documented a 9-year freedom from mitral valve re-operation of 84.2%, which was not significantly lower compared to patients who had double valve replacement. For almost all patients who had mitral regurgitation with or without associated mitral stenosis we performed annuloplasty with a Carpentier-Edwards ring. In one previously mentioned study which documented a surprisingly low freedom from mitral valve re-operation (5 ± 5% at 15 years) after mitral valve repair for rheumatic lesions, annuloplasty with a Carpentier-Edwards or Duran ring was used in only 6.3% of patients.5 In our opinion, the use of a Carpentier-Edwards ring is a very important component of mitral valve repair for mitral regurgitation since it restores the size of the dilated annulus to normal, reinstates the normal shape of the annulus and prevents recurrent deformation and dilatation of the annulus.
Besides the classical procedures such as annuloplasty with a Carpentier-Edwards ring, commissurotomy, chordal transfer and chordal shortening, we also performed leaflet extension with autologous pericardium. In rheumatic lesions of the mitral valve, the leaflets are sometimes retracted due to a lack of valvular tissue. Valve extension with glutaraldehyde-preserved autologous pericardium, a relatively new technique, was very useful in such cases, particularly for children.2 With this technique a larger ring could be used than would otherwise have been possible.2,3,9 All techniques of mitral valve repair used in our series have been shown to be efficacious in cases of rheumatic mitral valve lesions.1–3,9 The durability of mitral valve repair in the present series once again confirmed the value of these techniques.
An important finding of our study was the fact that severe bleeding was significantly less frequent in patients undergoing aortic valve replacement and mitral valve repair compared to patients who had double valve replacement. In multivariant analysis mitral valve replacement (rather than repair) was the only predictor of severe bleeding. This finding reflects the natural advantage of mitral valve repair over replacement. Patients who had double valve replacement were at increased risk of thromboembolism compared to patients who had single aortic valve replacement (the 2 cases of valve thrombosis in group 2 were examples of such a complication), so they needed more intense anticoagulation, and, as a result, were exposed to a greater risk of bleeding.
With current techniques of mitral valve repair and in the hands of experienced surgeons, a large proportion of patients with rheumatic mitral valve lesions can now benefit from valve repair. However, one should not hesitate to replace the mitral valve if its lesions are too complex and unsuitable for repair. As a general rule, we perform valve replacement for patients with severe calcification and/or severe chordal fusion and retraction.
In conclusion, our study showed that in patients with rheumatic heart valve disease the results of aortic valve replacement with mitral valve repair were comparable to those of double valve replacement with regard to survival, mitral valve re-operation and almost all valve-related complications. Severe bleeding occurred significantly less frequently in patients who had aortic valve replacement with mitral valve repair. Therefore, in patients with double valve disease of rheumatic etiology, aortic valve replacement with mitral valve repair should be attempted when the mitral valve lesions are suitable for repair. Double valve replacement should be reserved for patients with complex mitral valve lesions.
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REFERENCES
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INTRODUCTION
