Late outcome of unsupported annuloplasty for rheumatic mitral regurgitation

OBJECTIVES

The aim of this study was to evaluate medium- and long-term (range 4 months to 17 years) clinical results in a series of patients treated surgically by unsupported mitral annuloplasty.

BACKGROUND

Mitral valve regurgitation has usually been treated by valve replacement or ring annuloplasty. A few series have reported plastic repair procedures without annular support or remodeling. Furthermore, in rheumatic lesions the results have been inferior to those in degenerative mitral insufficiency, and the majority of previous reports have provided information on short- or medium-term follow-up.

METHODS

One hundred fifty-four patients were operated on (55 male [36%] and 99 female [64%]). The mean age +/- SD was 36 +/- 16 years (range 5 to 73). Associated lesions comprised 47 aortic and 21 tricuspid valve lesions and 2 atrial septal defects. Patients with concomitant mitral stenosis were not included. Preoperative functional class was I or II in 19% and III or IV in 81%. The cardiothoracic ratio was 0.61 +/- 0.10. All patients underwent an unsupported mitral annuloplasty procedure in which the mural portion of the annulus was reduced by applying two buttressed mattress sutures at the commissures without compromising the width of the septal leaflet. When necessary, additional chordal procedures were performed. No patients received ring or posterior annular support.

RESULTS

The early mortality rate was 1.9% (three patients; one of the three died of myocardial failure and two of pulmonary thromboembolism). The late mortality rate was 5.8% (nine patients; three of the nine died of myocardial failure, one each of septicemia, pulmonary thromboembolism and sudden arrhythmic death and three of unknown causes). Twenty-eight patients (18.2%) were reoperated on because of mitral valve dysfunction and 2 (1.3%) because of prosthetic aortic valve dysfunction. A residual late systolic murmur was present in 48% of patients. Late complications were systemic thromboembolism in 5.8% (one third with an aortic valve prosthesis), infective endocarditis in 1.3% and pulmonary thromboembolism in 0.6%. Postoperative functional class was I or II in 84% and III or IV in 16%. Cardiothoracic ratio was 0.58 +/- 0.10. Actuarial probability of late survival was 79.5 +/- 5.3% at 10 years and 71.0 +/- 7.4% at 14 years. Event-free survival was 67.9 +/- 8.9% at 10 years and 56.1 +/- 11.7% at 14 years.

CONCLUSIONS

Rheumatic mitral regurgitation can be effectively treated by annuloplasty without prosthetic annular support, with late results comparable to those obtained with more complicated procedures. This observation is particularly important for treatment of children and young adult patients.

Housing in early life and later mortality

STUDY OBJECTIVES

The aim was to examine the influence of domestic crowding and household amenities in early life on later mortality from all causes and specifically from stomach cancer, chronic obstructive pulmonary disease, and rheumatic heart disease.

DESIGN

This was a retrospective cohort study of people whose houses had been surveyed in 1936 and whose household size was known from the 1939 census. Subjects were followed through the National Health Service Central Register from 1951 to 1989.

SETTING

The housing survey had been carried out in the midland town of Chesterfield.

SUBJECTS

Subjects comprised 8138 men and women born after 1900.

RESULTS

A total of 2929 deaths were observed during the follow up period. All causes mortality in the full cohort was not consistently related to any of the housing variables examined, but among subjects who were still children at the time of the housing survey, death rates were higher in those whose houses were crowded or lacked a hot water tap. No associations could be shown between stomach cancer and domestic crowding or food storage facilities; chronic obstructive pulmonary disease and domestic crowding or use of gas for cooking; or rheumatic heart disease and domestic crowding. There were few deaths from these causes, however, in subjects who were children at the time of housing survey.

CONCLUSIONS

The findings suggest that the housing of young adults in Chesterfield during the 1930s had little effect on their later mortality. Further follow up of the cohort is needed before firm conclusions can be drawn about the influence of housing at younger ages.

Technical considerations and intermediate-term results with modified DeVega tricuspid annuloplasty

Because of unsatisfactory long-term results with current DeVega tricuspid annuloplasty, 43 patients with secondary tricuspid regurgitation associated with mitral disease were treated with a modified DeVega operation. This procedure continues the suture line to the tendon of Todaro, resulting in almost circumferential traction of the tricuspid annulus. The suture is tied securely around a 29-mm or 31-mm (for women and men, respectively) ball-shaped obturator. Atrioventricular block was not observed. One patient died during the early postoperative period. During a mean(s.d.) follow-up of 5.0(2.0) years, one patient died from causes unrelated to tricuspid regurgitation 2 years after surgery. The mean(s.d.) functional class (New York Heart Association) was 3.1(0.5) on admission and improved to 1.2(0.4) at the end of follow-up. The mean(s.d.) cardiothoracic ratio improved from 67(6) to 60(5)% at 1 month after operation and was 59(5)% at the final examination. Preoperative Doppler echocardiography revealed a mean(s.d.) regurgitation grade of 2.7(0.7). (Grades 1-4 are equivalent to mild, moderate, severe and massive regurgitation, respectively.) At 1 month, regurgitation was corrected almost completely in all patients (grade 0.2(0.4)) and remained significantly improved at follow-up (grade 0.5(0.6)). The actuarial freedom rate at 5 years for moderate or severe regurgitation (> grade 2) was 93%. This modification of the DeVega technique substantially improved early and late tricuspid valve competence.

Surgery for organic rheumatic disease of the tricuspid valve

The paucity of reports on the incidence and management of organic involvement of the tricuspid valve in rheumatic disease led us to carry out this retrospective study. Over a four and a half year period, of the 1052 patients undergoing valve surgery at our institution, 253 (24.05%) required tricuspid surgery. Organic involvement was noted in 115 (45.45%) of these patients. Definitive preoperative diagnosis was feasible by echocardiogram in only 48 (41.73%). Tricuspid regurgitation was present in all patients while detectable stenosis was present in 48 (41.7%). Annular dilatation was seen in 52 (45.2%). Primary repair was possible in 107 patients (93.0%). The reduction in tricuspid regurgitation remained stable at the last follow up in all but seven patients. Nine patients underwent reoperation in this study for failure of left-sided valve repairs, of which five needed reoperation on the tricuspid valve. All the five reoperated tricuspid valves had had dilated annuli at primary surgery. The presence or absence of annular dilatation did not cause any significant difference in early or late mortality. The presence of annular dilatation in the presence of left-sided valve lesions superimposed on organically involved tricuspid valves evokes the possibility of the presence of an organo-functional disease.

Cardiac mortality in Alaska's indigenous and non-Native residents

Cardiac disease mortality in Alaska, from both ischaemic and rheumatic heart disease, is of interest given the high consumption of fish and high streptococcal disease rates in the indigenous population. Uniformly coded underlying cause-of-death data for the period 1979-1988, compared with that from 1955-1965, indicated that deaths from all cardiac diseases combined, have been increasing in Alaska Natives over the past 30 years. Recent mortality from all cardiac, ischaemic, and rheumatic heart diseases in Alaska Natives were 80%, 61%, and 202% of those corresponding levels in Alaskan whites, whose cardiac mortality closely profiles US whites. Alaska Native men aged 30-45 years had higher overall mortality rates for cardiac diseases than did whites because of higher mortality rates of rheumatic heart disease and cardiomyopathy. Elderly Alaska Native men had lower rates than whites, reflecting less ischaemic heart disease mortality. The lowest levels of ischaemic heart disease mortality, less than one-third that of US whites, occurred in Alaskan Eskimos who lived in an area with documented patterns of high salmon consumption by individuals with high blood concentrations of omega-3 fatty acids. Elevated mortality from non-ischaemic heart disease and previously documented genetic markers suggest associations deserving further study.

Bacterial intracranial aneurysms

This is a retrospective study of 25 patients with bacterial intracranial aneurysms treated in a single department over a 20-year period. The clinical presentation, investigation and treatment of these patients is discussed. The outcome of the treatment is assessed and is thought to be not as poor as previously reported.

[The PB IMC bovine pericardial prosthesis: 11 years in the mitral position. Instituto de Moléstias Cardiovasculares]

PURPOSE

To evaluate the postoperative results of patients with valvular bovine pericardium prosthesis in mitral position.

METHODS

From 1977 to 1988, 10.812 bovine pericardial valves were produced by IMC Biomédica and implanted. Our group at IMC implanted 1,193. Of the 663 patients with mitral change, 586 were adults and 77 were youngsters (under 21). The rheumatic fever was the most frequent primary cause of valvar disease (76.5%). The stenosis (23.0%) and the insufficiency (20.7%) were the most common of the damages that led to mitral exchange. We studied 602 patients that left the hospital, representing 666 bioprostheses in 11 years. The surgeries were performed with standard cardiopulmonary bypass with crystalloid cardioplegia in the first seven years and hypothermic or normothermic blood cardioplegia enriched with amino acids in the last four years.

RESULTS

Hospital mortality was 9.2%; 13.2% for the first 5.5 years (group I) and 6.3% for the last 5.5 years (group II). Eleven-year follow-up was 98.8% and the mean time was 3.8 years. The actuarial study showed a survival rate of 74.3 +/- 6.5% for the youngsters and 73.0 +/- 3.7% for the adults, with 95.0 +/- 1.0% of the patients free from valve-related fatal complications corresponding to one event % patient-years (endocarditis 0.6%; calcification 0.1%; thromboembolism 0.3%). The actuarial rate of non fatal valve-related late complications was 55.2 +/- 8.6% of patients free from all complications, corresponding an incidence of 2.9%/patient-year (endocarditis 0.5%; calcification 1.8%; thromboembolism 0.3%; periprosthetic leakage 0.2% and rupture 0.08%). In this period 95.8 +/- 1.6% of the patients were free from thromboembolism; 99.1 +/- 0.6% free from rupture; 90.1 +/- 4.08% free from endocarditis in the young group (1.5%/patient-year) and 95.2 +/- 1.03% for adults (1.0%/patient-year). For calcification, the actuarial rate was 43.1 +/- 12.3% for youngsters (7.5/patient-year) and 68.8 +/- 9.3% for adults (1.1%/patient-year).

CONCLUSION

IMC pericardial bioprosthesis performed well in a period of 11 years with low rates of fatal complications; ruptures and thromboembolism without the use of anticoagulants. Calcification was the major complication mainly in youngsters.

Nonconditional logistic regression analysis of risk factors in rheumatic heart disease

The prognostic risk factors in 4323 patients with rheumatic heart disease, admitted from 1970 to 1990, were analysed. The overall mortality was 31.75% in this group of patients. Single factor analysis indicated that cardiac functional classification, time of death, month of death, cardiothoracic ratio, valvular lesions, cardiogenic shock, digitalis-induced arrhythmias, intercurrent pneumonia, pleurorrhea, and hypotension were related to the overall mortality and cardiac death. Multiple factor logistic analysis indicated that for the overall mortality, the independent prognostic factors included presence of cardiac functional classification, cardiothoracic ratio and cardiogenic shock; for cardiac death, the independent factors included cardiac functional classification, cardiothoracic ratio, cardiogenic shock, digitalis-induced arrhythmias and valvular lesions. The data analysis showed that these five factors were contributory to rheumatic heart disease with synergism.

Aortic valve replacement in children under 16 years of age with congenital or rheumatic valvular disease. A study of 64 cases

Sixty-four children have had a single aortic valve replacement under 16 years of age, 50 for rheumatic disease (47) or bacterial endocarditis (3) (group I) and 14 for a congenital aortic valve lesion (group II), 38 were disk prostheses and 26 were ball prostheses. Associated procedures had to be performed 31 times, with widening of a small aortic annulus by a patch in 7 patients. The early mortality was 12.5%. Of 56 survivors, 55 were followed postoperatively for a mean period of 7 years (group I: 44, group II: 11). Forty of the 55 patients were anticoagulated (correctly maintained in only 24 patients), 15 were not anticoagulated. A high rate of late complications was observed. Thrombo-embolic accidents in 5 patients with inefficient anticoagulant treatment, 2 haemorrhagic episodes, 7 prosthetic leaks; specific problems related to this group of young patients were: recurrence of rheumatic fever with increasing severity of mitral valve disease requiring mitral valve replacement in 5 patients and outgrowth of the prosthesis, which affected 7 patients; this complication is the result of either fibrous deposit around the valve annulus or such a small annulus that the surgeon could only implant a small prosthesis. Ten patients required 11 reoperations for various reasons. The main reason for reoperation was mitral valve replacement for worsening of mitral valve disease caused by recurrence of rheumatic fever. A high late mortality 10/55 (18%) was noted. The main cause of death was a perivalvular leak (5); 1 late death was caused by a stenotic number 17 Björk-Shiley valve.(ABSTRACT TRUNCATED AT 250 WORDS)

[Causes of maternal death. A 10-year case analysis]

The causes of maternal deaths in our hospital from 1981 to 1989 were analysed. There were 12,819 live births and 6 maternal deaths during this period, a maternal mortality rate of 46.69/per 100,000. The main cause of maternal deaths was acute fatty liver of pregnancy (50%), and next cardiac disease, acute hemorrhagic necrotic pancreatitis and hemorrhage of subarachnoid space (each 16.67%). There was no death due to obstetric hemorrhage, pregnancy induced hypertension syndrome or ectopic pregnancy. It is suggested that needle biopsy of the liver should be done for pregnant women with jaundice of unknown cause. Pregnant women with cardiac disease should be under the care of both obstetrician and internist in collaboration and cesarean section is indicated when the woman's cardiac function remains at grade 3 or 4.

Cardiac disease in pregnancy

The pregnant patient with normal cardiac function can accommodate many significant alterations in the cardiovascular system without difficulty. Pregnancy in a patient with significant cardiac disease, however, can be extremely hazardous, resulting in decompensation and even death. these conditions account for up to 30% of maternal mortality. This article reviews the interaction between cardiac disease and pregnancy.

[Rheumatic cardiopathy in children younger than 6 years of age]

Most of the published papers on Rheumatic Fever (RF) have not included the younger population. We selected 211 cases of children with RF younger than 6 years of age from 9,471 clinical files from 1944 to 1982. These were followed retrospectively to identify the presence of rheumatic activity, subsequent attacks and penicillin profilaxis. From de 211 cases, 209 had carditis; 57% of them were girls and 43% boys. There were no previous infections of the upper respiratory tract in 36% of the patients. The number of cases with RF increased abruptly after 3 years of age and continued increasing until 5 years of age when 70.5% of the population had there first clinically recognized attack. Lesions were present in the mitral valve in 80% of the cases, in the aortic valve in 12%, in the tricuspid in 5% and in the pulmonary valve in 3%. The death rate during the first attack was 20% being refractory heart failure the main cause of death. Thirteen cases suffered rheumatic pneumonia, 9 of whom died (69.2%).

CONCLUSIONS

1) The incidence of acute rheumatic fever in children under 6 years of age has decreased with time. 2) The death rate as well as the valvular damage decreased with the parents cooperation with the treatment. 3) The changes in the clinical picture and the severity of valve sequelea may be due to penicillin profilaxis and the better understanding of the disease.

[Epidemiological course of rheumatic fever and rheumatic heart disease in Spain (1951-1986)]

A study has been made of the death rate due to Rheumatic Fever (R.F.) and Rheumatic Heart Disease (R.H.D.) in Spain (1951-1985) as well as the disease rate due to Rheumatic Fever (1951-1988). It has been found that the death rate due to R.F. and R.H.D. has clearly decreased over the past 20 years, whilst it is important to note that disease rate due to R.F' has shown a noticeable increase over the past 10 years. And on comparing the death rate due to R.F. in Spain and in the United States, one finds that the U.S. death rate began to drop prior to that in Spain, it currently being minimal in both countries. Stress is placed on the need to increase the control of streptococcus infections, specially throat infections, in our environment.

[Influence of surgical intervention on the course of patients with rheumatic mitral valvular defects]

A retrospective study of 798 patients from Essen University Medical Hospital during the period 1960-1987 with operation performed due to valvular heart disease was undertaken. Among them were 324 suffering from mitral stenosis, 12 from mitral regurgitation, 462 from mixed mitral valvular diseases. The surgical treatment consisted of commissurotomy in 611 patients, and prosthetic valve replacement in 187 patients. Follow-up studies showed: Before and after operation, occurrence of embolism was 16.5 vs 8.7%; status of class of cardiac function (NYHA) from group with commissurotomy was 3.1 vs 2.0; NYHA classification in group of prosthetic replacement was 3.1 vs 1.9; 10 years survival rate after commissurotomy was 95.2%; after valve replacement it was 80.2%; early letality rate after operation (at or within 2 months after operation) depended on 1) the type of operation: commissurotomy 2.8%, valve replacement 10.2%; 2) the state of cardiac function: in class IV it was 12.9%, in class III 4.6%; 3) the number of operations: in only operation it was 4.8%, in reoperations 19.5%. Thus the following fact will lead to false judgement: though the area is the same, the regurgitant volume may vary with the brightness of coloration. Furthermore the left auricle will be enlarged consequently following the increase of regurgitant volume, also causing misinterpretation. It is of practical importance to consider some other factors in quantifying the regurgitant volume.

Clinical course after mitral valve replacement

Two hundred and fifty patients underwent mitral valve replacement for rheumatic valvular disease during a 9-year period from January 1979 to December 1987. A maximum period of follow-up of 10 years and minimum of 1 year was achieved with a mean duration of 4.4 years. The follow-up covered 921 out of a possible 1006 patient-years and was 91.5 per cent complete. Of the patients, 58 (23.2%) were in class II, 145 (58%) were in class III and 47 (18.8%) belonged to class IV. The early mortality for patients in Class II, III and IV was 8.6 per cent, 15.8 per cent and 31.9 per cent respectively and the 3, 5 and 10 years actuarial survival rates for the entire group were 93 per cent, 87 per cent and 70 per cent. The event-free survival rates at the same intervals were 77 per cent, 63 per cent and 57 per cent respectively. Late deaths occurred in 18 (9.5%) of the patients. Twelve of these (66.6%) could be directly ascribed to a valve-related cause.

Valve replacement in the young patient with rheumatic heart disease. Review of a twenty-year experience

During a 20-year period 303 young subjects between 9 and 20 years of age (mean, 16.2 +/- 2.72 years) with rapid and relentlessly progressive valvular disease from rheumatic fever underwent valve replacements. The Starr-Edwards ball valve prosthesis remains the device of choice, although other valves have been implanted. The overall hospital mortality rate was 9.6% in the mitral valve, 3.5% in the aortic valve, and 4.2% in the double valve replacement groups. Actuarial survival at 10, 15, and 20 years was 78.4% (+/- 3.3%), 70.0% (+/- 5.8%), and 59.3% (+/- 11.1%), respectively, for patients with mitral valve replacement. The rates for aortic valve replacement were 85.9% (+/- 4.6%) at 10 and 15 years and 72.7% (12.8%) at 20 years. In the double valve replacement group the survival rates after 5 and 10 years were 79.9% (+/- 5.1%). The incidence of thromboembolism was 0.41, 0.59, and 1.04 per 100 patient-years for the mitral, aortic, and double-valve prostheses, respectively. The prospect of childbearing seems promising in those young women who were subsequently married. Our favorable and gratifying experience in this review bears testimony to the physiologic advantages of the Starr-Edwards valve as the device of choice in the rehabilitation of patients with advanced and severe valvular disease after rheumatic fever.

Mitral valvuloplasty, a better alternative. Comparative study between valve reconstruction and replacement for rheumatic mitral valve disease

Valvuloplasty is now a well accepted alternative method of surgical treatment of mitral valve disease. To analyse its relative performance in rheumatic valvulopathies, three groups of patients who had mitral valvuloplasty (1980-1984; 241 patients) or mitral valve replacement with mechanical (1980-1984; 386 patients) or biological prostheses (1976-1980; 289 patients) were reviewed. The early mortality was 3.3% for valvuloplasty, 7.8% for mechanical valve replacement and 6.6% for bioprostheses (P less than 0.05). Late mortality occurred at the rate of 2.6% per patient year (15 patients) for valvuloplasty, 5.7% per patient year (70 patients) for mechanical valves and 7.4% per patient year (41 patients) for bioprostheses (P less than 0.01), but valve-related mortality was 1.0% per patient year, 2.5% per patient year and 4.2% per patient year, respectively (P less than 0.01). Reoperation was more frequent after valve replacement with bioprostheses (6.7% per patient year) than after valvuloplasty (4.3% per patient year) and after mechanical valve replacement (1.5% per patient year; P less than 0.02), and was necessitated mainly by residual or recurrent valve dysfunction after valvuloplasty, bland or infected periprosthetic leaks in mechanical valves and degradation of bioprostheses. Valve failure occurred at the rate of 6.1% per patient year for valvuloplasty, 5.7% per patient year for mechanical valves and 11.1% per patient year for bioprostheses (P less than 0.05). In actuarial terms, global survival and survival free from valve related complications were 90% +/- 4% and 70% +/- 6% for patients who had valvuloplasty, 76% +/- 3% and 71% +/- 5% for the mechanical prosthetic replacement group and 62% +/- 7% and 30% +/- 7% for bioprosthetic valve replacement.(ABSTRACT TRUNCATED AT 250 WORDS)

Comprehensive review of morbidity and mortality trends for rheumatic fever, streptococcal disease, and scarlet fever: the decline of rheumatic fever

This review of the medical literature reveals that the incidence of rheumatic fever has been declining for at least 150 years, preceding by many decades the use of penicillin as a preventive measure. Simultaneously, the prevalence of rheumatic heart disease has diminished. Streptococcal upper respiratory tract infections remain common but with reduced severity and fewer subsequent cases of rheumatic fever. Scarlet fever has become relatively benign, with low mortality. Whether recent sporadic outbreaks of rheumatic fever due to known rheumatogenic strains of group A streptococci will have a significant effect on morbidity and mortality trends remains to be seen. Relatively high rates of rheumatic fever and rheumatic heart disease in developing countries are difficult to evaluate because of irregularities in reporting and investigative procedures.

Valve replacement in children under 15 years with rheumatic heart disease

From 1967 through 1984, single- or double-valve replacement for rheumatic heart disease (RHD) was undertaken in 184 children (aged 4 to 15 years) in Tunis. At the time of operation most patients were in an advanced state of cardiac disability, but most of them were still in sinus rhythm. A total of 222 valves were inserted. The most commonly used replacement valve was the Starr-Edwards caged-ball prosthesis, with 12 hospital deaths (6.5%). There were no hospital deaths among 19 children who had a (glutaraldehyde-treated porcine) xenograft replacement valve; however, a much higher rate of valve failure occurred later, owing to valve calcification (14 of 19 replacements, 11 requiring reoperation). There were 24 episodes of clinical thrombo-embolism in 21 children after insertion of a prosthetic valve, but only one in a child with a xenograft valve. Two thirds of the patients with prosthetic valves were on anticoagulants, but fewer than half of them had effective levels because of low compliance. For the group with prosthetic valves, the 10-year survival rate was 70%.

The epidemiological transition in an overseas territory: disease mapping in French Polynesia

During the last 200 years in French Polynesia the people have experienced several dramatic changes in the pathological scene. First the discovery of Tahiti and the surrounding islands at the end of the eighteenth century caused the spread of diseases previously unknown, usually in the form of epidemic outbreaks. In contrast, from the 1860s to soon after the end of the Second World War, health amelioration in French Polynesia was slowly occurring. This constituted a first epidemiological transition in which infectious disease mortality was sharply reduced. The distribution of vaccines, hygiene education and legislation stemmed the long period of some 100 years of demographic disaster and at last the population was able to increase. However for a long time infectious or parasitic diseases remained the main causes of morbidity and mortality. Only from the end of the 1950s has the situation evolved to the present state where morbidity and mortality of the circulatory system and cancer are similar in prevalence to industrialized countries. Diachronistic mapping of some of the most noteworthy diseases is presented to illustrate this last and most important phase of the epidemiological transition.