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Nwafor IA, Eze JC, Nwafor MN. Surgical Treatment of Valvular Heart Disease in Nigeria: A 6-Year Experience. Tex Heart Inst J 2021; 48:475569. [PMID: 34913972 DOI: 10.14503/thij-19-7080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Surgical treatment of valvular heart disease in Nigeria, the most populous country in sub-Saharan Africa, is adversely affected by socioeconomic factors such as poverty and ignorance. To evaluate our experience in this context, we identified all patients who underwent surgery for acquired or congenital valvular heart disease at our Nigerian center from February 2013 through January 2019. We collected data from their medical records, including patient age and sex, pathophysiologic causes and types of valvular disease, surgical treatment, and outcomes. Ninety-three patients (43 males [46.2%]; mean age, 38.9 ± 10.0 yr [range, 11-80 yr]) underwent surgical treatment of a total of 122 diseased valves, including 72 (59.0%) mitral, 26 (21.3%) aortic, 21 (17.2%) tricuspid, and 3 (2.5%) pulmonary. The most prevalent pathophysiologic cause of disease was rheumatic (87 valves [71.3%]), followed by functional (20 [16.4%]), congenital (8 [6.6%]), degenerative (5 [4.1%]), and endocarditic (2 [1.6%]). All 3 diseased pulmonary valves had annular defects associated with congenital disease. Surgical treatment included mechanical prosthetic replacement of 92 valves (75.4%), surgical repair of 29 (23.8%), and bioprosthetic replacement of 1 (0.8%). We conclude that, in Nigeria, valvular disease is mainly rheumatic, affects mostly younger to middle-aged individuals, and is usually treated with prosthetic replacement.
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Affiliation(s)
- Ikechukwu A Nwafor
- Department of Surgery, National Cardiothoracic Center of Excellence, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - John C Eze
- Department of Surgery, National Cardiothoracic Center of Excellence, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Maureen N Nwafor
- Department of Pharmacy, National Cardiothoracic Center of Excellence, University of Nigeria Teaching Hospital, Enugu, Nigeria
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Hirji SA, Guetter CR, Trager L, Yazdchi F, Landino S, Lee J, Anastasopulos A, Percy E, McGurk S, Pelletier MP, Aranki S, Shekar PS, Kaneko T. Sex-based differences in mitral valve Re-operation after mitral valve repair: Truth or myth? Am J Surg 2020; 220:1344-1350. [PMID: 32788080 DOI: 10.1016/j.amjsurg.2020.06.069] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 04/24/2020] [Accepted: 06/26/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Outcomes after mitral valve (MV) repair are known to be worse in women. Less is known about sex-based differences in MV repair durability. METHODS All adult patients undergoing MV repair from 2002 to 2016 were reviewed. Of 2463 cases, 947 (39%) were women. Re-operation risk was defined as any intervention for repair failure or MV disease progression. Median follow-up was 8.2 years. RESULTS Women were older with higher STS-risk scores and were more likely to have rheumatic disease (RHD). Operative mortality was clinically higher in women (2.7% vs 1.7%; P = 0.09). Although women had significantly higher 10-year re-operation risk (7% vs 4%), adjusted longitudinal analysis showed that this was associated with RHD in women (HR 4.04; P = 0.001). Female sex alone was not a significant predictor (P = 0.21). CONCLUSIONS Re-operation following MV repair was infrequent. Women had increased re-operation risk that was largely attributable to their worse preoperative profiles rather than female sex alone.
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Affiliation(s)
- Sameer A Hirji
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Camila R Guetter
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lena Trager
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Farhang Yazdchi
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samantha Landino
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jiyae Lee
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexandra Anastasopulos
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward Percy
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Siobhan McGurk
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marc P Pelletier
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sary Aranki
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Prem S Shekar
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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De Bonis M, Zancanaro E, Lapenna E, Trumello C, Ascione G, Giambuzzi I, Ruggeri S, Meneghin R, Abboud S, Agricola E, Del Forno B, Buzzatti N, Monaco F, Pappalardo F, Castiglioni A, Alfieri O. Optimal versus suboptimal mitral valve repair: late results in a matched cohort study. Eur J Cardiothorac Surg 2020; 58:328-334. [DOI: 10.1093/ejcts/ezaa103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 01/26/2020] [Accepted: 01/28/2020] [Indexed: 11/14/2022] Open
Abstract
Abstract
OBJECTIVES
After mitral repair for degenerative mitral regurgitation (MR), no or mild (≤1+/4+) residual MR should remain. Occasionally patients are left with more than mild residual MR (>1+/4+) for a number of reasons. The aim of this study was to assess the late implications of such a suboptimal repair in a matched cohort study.
METHODS
From 2006 to 2013, a total of 2158 patients underwent mitral repair for degenerative MR in our institution. Fifty patients (2.3%) with residual MR >1+ at hospital discharge (study group) were matched up to 1:2 with 91 patients operated on during the same period who were discharged with MR ≤1+ (control group). The median follow-up was 8 years (interquartile range 6.3–10.1, longest 12.7 years). A comparative analysis of the outcomes in the 2 groups was performed.
RESULTS
Overall survival at 8 years was 87 ± 8% in the study group and 92 ± 3% in the control group (P = 0.23). There were 3 late deaths (6.0%) in the study group and 6 deaths (6.6%) in the control group. Freedom from reoperation was similar (P = 1.0). At 8 years the prevalence of MR ≥3+ was significantly higher in the study group (15.6% vs 2.1%, P < 0.001) as was the use of diuretics, beta-blockers and angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers. Interestingly, even in the control group, a gradual progression of MR was observed because 13.3% of the patients had MR ≥2+ at 8 years with a significant increase over time (P < 0.001).
CONCLUSIONS
Residual MR more than mild at hospital discharge is associated with lower durability of mitral repair and the need for more medical therapy in the long term. However, even an initial optimal result does not completely arrest the progression of the degenerative process.
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Affiliation(s)
- Michele De Bonis
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Edoardo Zancanaro
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Elisabetta Lapenna
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Cinzia Trumello
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Guido Ascione
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ilaria Giambuzzi
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefania Ruggeri
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Roberta Meneghin
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sabrin Abboud
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Eustachio Agricola
- Division of Cardiology, Echocardiography Laboratory Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Benedetto Del Forno
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nicola Buzzatti
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabrizio Monaco
- Anesthesia and Intensive Care Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Federico Pappalardo
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Anesthesia and Intensive Care Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Castiglioni
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ottavio Alfieri
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Becker TM, Grayburn PA, Roberts WC. Mitral Valve Repair for Pure Mitral Regurgitation Followed Years Later by Mitral Valve Replacement for Mitral Stenosis. Am J Cardiol 2017; 120:160-166. [PMID: 28532769 DOI: 10.1016/j.amjcard.2017.03.242] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 03/20/2017] [Accepted: 03/20/2017] [Indexed: 10/19/2022]
Abstract
We describe herein 2 patients who developed severe mitral stenosis (MS) approximately two decades after a mitral valve repair operation for pure mitral regurgitation (MR) secondary to mitral valve prolapse. This report's purpose is to point out that use of a circumferential mitral annular ring during the repair has the potential to produce a transmitral pressure gradient just like that occurring after mitral valve replacement utilizing a mechanical prosthesis or a bioprosthesis in the mitral position.
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Mvondo CM, Pugliese M, Giamberti A, Chelo D, Kuate LM, Boombhi J, Dailor EM. Surgery for rheumatic mitral valve disease in sub-saharan African countries: why valve repair is still the best surgical option. Pan Afr Med J 2016; 24:307. [PMID: 28154662 PMCID: PMC5267788 DOI: 10.11604/pamj.2016.24.307.7504] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 05/12/2016] [Indexed: 11/11/2022] Open
Abstract
Rheumatic valve disease, a consequence of acute rheumatic fever, remains endemic in developing countries in the sub-Saharan region where it is the leading cause of heart failure and cardiovascular death, involving predominantly a young population. The involvement of the mitral valve is pathognomonic and mitral surgery has become the lone therapeutic option for the majority of these patients. However, controversies exist on the choice between valve repair or prosthetic valve replacement. Although the advantages of mitral valve repair over prosthetic valve replacement in degenerative mitral disease are well established, this has not been the case for rheumatic lesions, where the use of prosthetic valves, specifically mechanical devices, even in poorly compliant populations remains very common. These patients deserve more accurate evaluation in the choice of the surgical strategy which strongly impacts the post-operative outcomes. This report discusses the factors supporting mitral repair surgery in rheumatic disease, according to the patients' characteristics and the effectiveness of the current repair techniques compared to prosthetic valve replacement in developing countries.
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Affiliation(s)
| | - Marta Pugliese
- Divison of Cardiac Surgery, University of Rome Tor Vergata, Rome, Italy
| | | | - David Chelo
- Department of Pediatrics, Chantal Biya Foundation, Yaoundé, Cameroon
| | | | - Jerome Boombhi
- Department of Cardiology, Yaoundé General Hospital, Yaoundé Cameroon
| | - Ellen Marie Dailor
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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Fucci C, Faggiano P, Nardi M, D'Aloia A, Coletti G, De Cicco G, Latini L, Vizzardi E, Lorusso R. Triple-orifice valve repair in severe Barlow disease with multiple-jet mitral regurgitation: Report of mid-term experience. Int J Cardiol 2013; 167:2623-9. [DOI: 10.1016/j.ijcard.2012.06.101] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Revised: 06/22/2012] [Accepted: 06/23/2012] [Indexed: 11/30/2022]
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De Bonis M, Lapenna E, Buzzatti N, Taramasso M, Calabrese MC, Nisi T, Pappalardo F, Alfieri O. Can the edge-to-edge technique provide durable results when used to rescue patients with suboptimal conventional mitral repair? Eur J Cardiothorac Surg 2013; 43:e173-9. [DOI: 10.1093/ejcts/ezt056] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Riegel AK, Busch R, Segal S, Fox JA, Eltzschig HK, Shernan SK. Evaluation of transmitral pressure gradients in the intraoperative echocardiographic diagnosis of mitral stenosis after mitral valve repair. PLoS One 2011; 6:e26559. [PMID: 22087230 PMCID: PMC3210749 DOI: 10.1371/journal.pone.0026559] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Accepted: 09/28/2011] [Indexed: 12/18/2022] Open
Abstract
Objective Acute mitral stenosis (MS) following mitral valve (MV) repair is a rare but severe complication. We hypothesize that intraoperative echocardiography can be utilized to diagnose iatrogenic MS immediately after MV repair. Methods The medical records of 552 consecutive patients undergoing MV repair at a single institution were reviewed. Post-cardiopulmonary bypass peak and mean transmitral pressure gradients (TMPG), and pressure half time (PHT) were obtained from intraoperative transesophageal echocardiographic (TEE) examinations in each patient. Results Nine patients (9/552 = 1.6%) received a reoperation for primary MS, prior to hospital discharge. Interestingly, all of these patients already showed intraoperative post-CPB mean and peak TMPGs that were significantly higher compared to values for those who did not: 10.7±4.8 mmHg vs 2.9±1.6 mmHg; p<0.0001 and 22.9±7.9 mmHg vs 7.6±3.7 mmHg; p<0.0001, respectively. However, PHT varied considerably (87±37 ms; range: 20–439 ms) within the entire population, and only weakly predicted the requirement for reoperation (113±56 vs. 87±37 ms, p = 0.034). Receiver operating characteristic curves showed strong discriminating ability for mean gradients (AUC = 0.993) and peak gradients (area under the curve, AUC = 0.996), but poor performance for PHT (AUC = 0.640). A value of ≥7 mmHg for mean, and ≥17 mmHg for peak TMPG, best separated patients who required reoperation for MS from those who did not. Conclusions Intraoperative TEE diagnosis of a peak TMPG ≥17 mmHg or mean TMPG ≥7 mmHg immediately following CPB are suggestive of clinically relevant MS after MV repair.
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Affiliation(s)
- Ann K. Riegel
- Department of Anesthesiology, University of Colorado Denver, Denver, Colorado, United States of America
| | - Raila Busch
- Department for Cardiology, Angiology, Pneumology and Intensive Care Medicine, University Hospital Greifswald, Greifswald, Germany
| | - Scott Segal
- Department of Anesthesiology, Tufts Medical Center, Boston, Massachusetts, United States of America
| | - John A. Fox
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Holger K. Eltzschig
- Department of Anesthesiology, University of Colorado Denver, Denver, Colorado, United States of America
- * E-mail: (SKS); (HKE)
| | - Stanton K. Shernan
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail: (SKS); (HKE)
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Severino ESBDO, Petrucci O, Vilarinho KADS, Lavagnoli CFR, Silveira Filho LDM, Oliveira PPMD, Vieira RW, Braile DM. Resultados tardios da plastia mitral em pacientes reumáticos. Braz J Cardiovasc Surg 2011; 26:559-64. [DOI: 10.5935/1678-9741.20110045] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Accepted: 10/09/2011] [Indexed: 11/20/2022] Open
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10
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Extending the Scope of Mitral Valve Repair in Rheumatic Disease. Ann Thorac Surg 2009; 87:1735-40. [DOI: 10.1016/j.athoracsur.2009.03.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2009] [Revised: 03/06/2009] [Accepted: 03/06/2009] [Indexed: 11/23/2022]
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Kuwaki K, Kawaharada N, Morishita K, Koyanagi T, Osawa H, Maeda T, Higami T. Mitral valve repair versus replacement in simultaneous mitral and aortic valve surgery for rheumatic disease. Ann Thorac Surg 2007; 83:558-63. [PMID: 17257987 DOI: 10.1016/j.athoracsur.2006.08.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2006] [Revised: 08/05/2006] [Accepted: 08/09/2006] [Indexed: 11/25/2022]
Abstract
BACKGROUND The purpose of this study was to compare the late results of combined mitral valve repair and aortic valve replacement with double valve replacement for patients with rheumatic heart disease. METHODS From 1981 to 2003, 128 patients underwent aortic valve replacement with either mitral valve repair (n = 47) or mitral valve replacement (n = 81) for rheumatic disease. Mean follow-up was 9.1 +/- 4.5 years. RESULTS Rates of actuarial freedom from cardiac-related death (81.4% versus 75.9% at 12 years; p = 0.60), thromboembolism (79.8% versus 85.1% at 12 years; p = 0.78), and bleeding (97.3% versus 95.7% at 12 years; p = 0.77) were similar in both combined mitral valve repair and aortic valve replacement and double valve replacement. However, freedom from mitral valve reoperation was significantly lower in combined mitral valve repair and aortic valve replacement compared with double valve replacement (52.6% versus 76.8% at 12 years; p = 0.002). Mitral valve repair (p = 0.002) and mitral bioprosthesis (p = 0.0001) were independent risk factors for mitral valve reoperation. CONCLUSIONS Potential advantages of preserving, rather than replacing, the native mitral valve, such as better cardiac survival or fewer thromboembolic complications, were not identified in combined mitral valve repair and aortic valve replacement compared with double valve replacement for patients with rheumatic disease. Indeed, combined mitral valve repair and aortic valve replacement was associated with a significantly higher incidence of mitral valve reoperation. Therefore, in double valve surgery for rheumatic disease, mitral valve repair should be limited to the correction of mitral valve lesions only when excellent durability can be expected.
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Affiliation(s)
- Kenji Kuwaki
- Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan.
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12
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Pomerantzeff PMA, de Almeida Brandão CM, Albuquerque JMA, Pomerantzeff PY, Takeda F, Oliveira SA. Mitral valve annuloplasty with a bovine pericardial strip--18-year results. Clinics (Sao Paulo) 2005; 60:305-10. [PMID: 16138237 DOI: 10.1590/s1807-59322005000400008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
PURPOSE Prosthetic annuloplasty rings are currently used in mitral reconstruction. Posterior annuloplasty with a bovine pericardial strip is a technique largely used in the Heart Institute of University of São Paulo Medical School. The purpose of the study was to analyze the late results of mitral valve repair with posterior annuloplasty using a bovine pericardial strip. METHODS Between January 1984 and December 2002, 273 patients underwent mitral valve repair with posterior pericardial annuloplasty in the Heart Institute of University of São Paulo Medical School. One hundred and forty four (52.7%) were women and ages ranged between 1 and 76 years (38.3 +/- 21.1). Rheumatic fever was present in 52.0% of the patients. Associated techniques were employed in 26.0% of the patients, and the most frequent was chordal shortening (9.2%). RESULTS Hospital mortality was 3.3% (9 patients), with the major cause being low cardiac output (6 patients). Actuarial survival was 55.1% +/- 16.8% in 18 years. During the 18-year follow-up: patients were free from the following: reoperation (59.1% +/- 13.9%, (percent +/- Standard Error), thromboembolism (97.4% +/- 2.3%), hemolysis (99.2% +/- 0.2%), and endocarditis (99.6% +/- 1.0%). In the late follow-up period, 83.9% were classified as New York Heart Association functional class I. CONCLUSIONS Late results with mitral valve repair with posterior annuloplasty using a bovine pericardial strip were satisfactory. The technique is feasible, reproducible, and cost effective.
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De Santo LS, Romano G, Della Corte A, Tizzano F, Petraio A, Amarelli C, De Feo M, Dialetto G, Scardone M, Cotrufo M. Mitral mechanical replacement in young rheumatic women: Analysis of long-term survival, valve-related complications, and pregnancy outcomes over a 3707-patient-year follow-up. J Thorac Cardiovasc Surg 2005; 130:13-9. [PMID: 15999035 DOI: 10.1016/j.jtcvs.2004.11.032] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE A follow-up study was performed to assess long-term survival, valve-related complications, and pregnancy outcomes in young rheumatic women undergoing isolated mitral mechanical replacement. The influence of prosthetic type on outcomes was also investigated. METHODS Between 1975 and 2003, 267 isolated mitral mechanical prostheses were implanted. Follow-up reached 3707.8 patient-years. RESULTS Actuarial survival at 1, 5, 10, 15, 20, and 25 years was 97% +/- 0.01%, 90.4% +/- 0.017%, 85.3% +/- 0.023%, 82.3% +/- 0.025%, 71.7% +/- 0.036%, and 70.2% +/- 0.038%, respectively. At multivariate analysis, atrial fibrillation at follow-up was identified as an independent risk factor for late mortality, whereas left ventricular ejection fraction at 12 postoperative months proved to be a protective factor. Freedom from thromboembolism at 1, 5, 10, 15, 20, and 25 years was 98.1% +/- 0.01%, 94.1% +/- 0.015%, 89.1% +/- 0.021%, 85.9% +/- 0.025%, 81.1% +/- 0.031%, and 75.3% +/- 0.063%, respectively. Atrial fibrillation and Carbomedics device were significantly associated with an increase in thromboembolic events. Freedom from reoperation at 1, 5, 10, 15, 20, and 25 years was 99.2% +/- 0.005%, 95% +/- 0.014%, 91.6% +/- 0.018%, 88.6% +/- 0.022%, and 85.7% +/- 0.041%. Type of prosthesis (tilting disc) was identified as a predictor of reoperation. At the end of the study, 208 patients were still alive: 94.7% were in New York Heart Association class I or II. When receiving warfarin therapy, no patient undertaking pregnancy (n = 35) experienced adverse cardiac or valve-related events. Fetal events were significantly less frequent with a daily warfarin dose less than 5 mg. CONCLUSIONS Mechanical devices provided excellent performance, safety, and durability. The prognostic role of left ventricular function and atrial fibrillation overwhelmed any differences that might exist between different prosthetic designs. Pregnancies entail virtually no maternal risk and predictable fetal complications.
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Affiliation(s)
- Luca Salvatore De Santo
- Department of Cardio-Thoracic and Respiratory Sciences, Second University of Naples, V. Monaldi Hospital, Via L. Bianchi, 80131 Naples, Italy.
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DiGregorio V, Zehr KJ, Orszulak TA, Mullany CJ, Daly RC, Dearani JA, Schaff HV. Results of mitral surgery in octogenarians with isolated nonrheumatic mitral regurgitation. Ann Thorac Surg 2004; 78:807-13; discussion 813-4. [PMID: 15336996 DOI: 10.1016/j.athoracsur.2004.03.041] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/15/2004] [Indexed: 11/26/2022]
Abstract
BACKGROUND Increasing numbers of elderly patients are now referred for mitral valve operations. It has been unclear whether the results offset the risk of intervention in this patient population. METHODS We obtained clinical follow-up through May 2002 of 59 patients 80 years or older who underwent first-time isolated mitral valve repair (46 patients) or replacement (13 patients) for nonischemic, nonrheumatic mitral regurgitation from January 1990 to June 2000. The mean duration of follow-up was 68 +/- 33 months. Observed survival was compared with the expected survival of persons of the same age and gender in the general population. RESULTS Preoperatively 79% of patients were in New York Heart Association (NYHA) class III-IV. Operative mortality was 1.7%. Overall 1- and 5-year survival was 89% and 61%. One- and 5-year freedom from thromboembolic complications in hospital survivors was 97% and 84%. One- and 5-year freedom from heart-related hospitalization in hospital survivors was 89% and 78%. There were no reoperations. Twenty-nine patients underwent an echocardiographic follow-up; 31% of them exhibited moderate or more regurgitation. Of 37 surviving patients at follow-up, 78% were in NYHA functional class I-II. No statistically significant difference was noted between the observed survival postoperatively and the expected survival of persons of the same age and gender in the general population. In a univariate analysis, only preoperative left ventricular ejection fraction greater than 40% was significantly associated with freedom from late heart-related mortality (95% confidence interval 62%-92%, p = 0.01) and with freedom from heart-related hospitalization (95% CI 68%-95%, p < 0.01). CONCLUSIONS Native mitral valve surgery for isolated nonischemic, nonrheumatic disease in octogenarians resulted in a survival rate comparable with that of the general population. It also exhibited substantial improvement regarding the functional status of the patient. Reparative techniques did not result in a survival advantage compared with replacement but did prove to be a reliable approach. Surgery performed in an early stage, preceding the development of left ventricular dysfunction, was associated with an improved freedom from late cardiac complications.
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Affiliation(s)
- Vincenzo DiGregorio
- Division of Cardiovascular Surgery, Mayo College of Medicine, Rochester, Minnesota, USA
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15
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Agricola E, Oppizzi M, Maisano F, Bove T, De Bonis M, Toracca L, Alfieri O. Detection of mechanisms of immediate failure by transesophageal echocardiography in quadrangular resection mitral valve repair technique for severe mitral regurgitation. Am J Cardiol 2003; 91:175-9. [PMID: 12521630 DOI: 10.1016/s0002-9149(02)03105-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Residual mitral regurgitation (MR) after repair is a risk factor for late reoperation. The use of intraoperative transesophageal echocardiography (IOTEE) decreases the incidence of immediate repair failure. This study identifies the mechanisms of immediate failure by IOTEE in the quadrangular resection technique, a well-standardized mitral valve repair procedure to guide further repair procedures. Two hundred five consecutive patients underwent quadrangular resection due to prolapse or flail posterior leaflet. Twenty-four patients (11%) had immediate failure. Immediate reinstitution of cardiopulmonary bypass ("second pump run") was needed in 21 patients (10%) for further repair. The identified mechanisms of failure were residual cleft provoking interscallop malcoaptation into the posterior leaflet in 8 patients, residual prolapse of the anterior or posterior leaflets in 1 and 4 patients, respectively, residual annular dilation in 3, left ventricular outflow obstruction in 2, suture dehiscence in 2, and other mechanisms in another 2 patients. In 20 patients (95%), IOTEE guided further repair with resolution of the residual MR, whereas 1 patient underwent valve replacement due to pharmacologically untreatable left ventricular outflow obstruction. In conclusion, even if this type of valve repair technique is well standardized, the incidence of immediate failure is not negligible. IOTEE identified the mechanisms of the immediate failure and guided further repair procedures, thus reducing the incidence of valve replacement (0.5%) without increasing perioperative mortality and morbility.
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Affiliation(s)
- Eustachio Agricola
- Division of Non-Invasive Cardiology, San Raffaele Hospital, Milan, Italy.
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16
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Abstract
BACKGROUND Mitral stenosis after mitral valve repair for non-rheumatic mitral regurgitation is rare. METHODS From 1990 to 1999, 478 patients had mitral valve repair for myxomatous and 40 patients had mitral valve repair for ischemic mitral regurgitation. The Carpentier annuloplasty ring (Edwards Lifesciences, Irvine, CA) was used in 72 patients, the Duran ring (Medtronic, Minneapolis, MN) in 152, a posterior band in 221 and no ring or band in 73 patients. RESULTS Four patients developed mitral stenosis late after mitral valve repair: 2 for myxomatous disease and 2 for ischemic mitral regurgitation. All 4 patients had Duran annuloplasty rings (sizes 25 to 31). The diagnosis of mitral stenosis was made by Doppler echocardiography. The mitral valve area in these 4 patients decreased from 2.7 cm2 (range, 2.3 to 3.2 cm2) early postoperatively to 0.85 cm2 (0.4 to 1.2 cm2) after a mean follow-up of 66 months (range, 38 to 110 months). Three patients had mitral valve replacement and the etiology of the mitral stenosis was the same in all patients (ie, pannus overgrowth on the annuloplasty ring with extension onto both leaflets rendering them stiff and immobile). The fourth patient had a mitral valve area of 1.2 cm2, which was mildly symptomatic with normal pulmonary artery pressure, and this patient has not had reoperation. CONCLUSIONS Mitral stenosis may develop after mitral valve repair for myxomatous disease or ischemic mitral regurgitation when a Duran ring is used for annuloplasty. The stenosis is caused by pannus on the annuloplasty ring with extension onto the leaflets.
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Affiliation(s)
- Mohamed F Ibrahim
- Division of Cardiovascular Surgery, Toronto General Hospital and University of Toronto, Ontario, Canada
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17
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Yau TM, El-Ghoneimi YA, Armstrong S, Ivanov J, David TE. Mitral valve repair and replacement for rheumatic disease. J Thorac Cardiovasc Surg 2000; 119:53-60. [PMID: 10612761 DOI: 10.1016/s0022-5223(00)70217-0] [Citation(s) in RCA: 103] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Mitral valve repair may be technically feasible in patients with suitable anatomy, but the appropriateness of repair for rheumatic disease remains controversial. We evaluated our late outcomes after mitral repair and replacement for rheumatic disease. METHODS Five hundred seventy-three patients underwent mitral valve surgery for rheumatic disease at our institution from 1978-1995. Follow-up was 98% complete (mean, 68 +/- 46 months). Survival and morbidity were evaluated by Kaplan-Meier analysis and Cox regression, including propensity score analysis. RESULTS Mean age was 54 +/- 14 years, 55% of patients had congestive heart failure, 22% were undergoing redo mitral valve surgery, and 9% also underwent coronary bypass. Mitral stenosis was present in 53%, regurgitation in 15%, and both in 32%. Valve repair was performed in 25%, bioprosthetic replacement was performed in 28%, and a mechanical valve was placed in 47%. Patients undergoing repair were younger and less likely to be undergoing reoperation or to have atrial fibrillation than those undergoing replacement (P =.001). The operative mortality rate was 4. 2%. Better late cardiac survival was independently predicted by valve repair rather than replacement (P =.04) after adjustment for baseline differences between patients. Freedom from reoperation was greatest (P =.005) but that from thromboembolic complications was worst (P <.0001) after mechanical valve replacement. Twenty-three patients underwent reoperation after initial repair, with no operative deaths. CONCLUSIONS Mechanical valves minimize reoperation but limit survival and increase thromboembolic complications. Patients undergoing valve repair had improved late cardiac survival independent of their preoperative characteristics. Rheumatic mitral valves should be repaired when technically feasible, accepting a risk of reoperation, to maximize survival and reduce morbidity.
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Affiliation(s)
- T M Yau
- Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
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18
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Gillinov AM, Cosgrove DM, Blackstone EH, Diaz R, Arnold JH, Lytle BW, Smedira NG, Sabik JF, McCarthy PM, Loop FD. Durability of mitral valve repair for degenerative disease. J Thorac Cardiovasc Surg 1998; 116:734-43. [PMID: 9806380 DOI: 10.1016/s0022-5223(98)00450-4] [Citation(s) in RCA: 409] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Degenerative mitral valve disease is the most common cause of mitral regurgitation in the United States. Mitral valve repair is applicable in the majority of these patients and has become the procedure of choice. OBJECTIVE This study was undertaken to identify factors influencing the durability of mitral valve repair. PATIENTS AND METHODS Between 1985 and 1997, 1072 patients underwent primary isolated mitral valve repair for valvular regurgitation caused by degenerative disease. Repair durability was assessed by multivariable risk factor analysis of reoperation. It was supplemented by a search for valve-related risk factors for death before reoperation. Three hospital deaths occurred (0.3%); complete follow-up (4152 patient-years) was available in 1062 of 1069 hospital survivors (99.3%). RESULTS At 10 years, freedom from reoperation was 93%. Among 30 patients who required reoperation for late mitral valve dysfunction, the repair failed in 16 (53%) as a result of progressive degenerative disease. Durability of repair was adversely affected by pathologic conditions other than posterior leaflet prolapse, use of chordal shortening, annuloplasty alone, and posterior leaflet resection without annuloplasty. Durability was greatest after quadrangular resection and annuloplasty for posterior leaflet prolapse and was enhanced by the use of intraoperative echocardiography. Death before reoperation was increased in patients having isolated anterior leaflet prolapse or valvular calcification and by use of chordal shortening or annuloplasty alone. CONCLUSIONS Repair durability is greatest in patients with isolated posterior leaflet prolapse who have posterior leaflet resection and annuloplasty. Chordal shortening, annuloplasty alone, and leaflet resection without annuloplasty jeopardize late results.
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Affiliation(s)
- A M Gillinov
- Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Ohio 44195, USA
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19
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Saiki Y, Kasegawa H, Kawase M, Osada H, Ootaki E. Intraoperative TEE during mitral valve repair: does it predict early and late postoperative mitral valve dysfunction? Ann Thorac Surg 1998; 66:1277-81. [PMID: 9800820 DOI: 10.1016/s0003-4975(98)00756-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Intraoperative transesophageal echocardiography (TEE) using color Doppler flow mapping can accurately measure residual mitral regurgitation (MR), but it is unknown to what extent such measurements correlate with those obtained with postoperative transthoracic echocardiography (TTE). METHODS We used intraoperative TEE (based on direct planimetry of the maximal regurgitant jet area) to measure residual MR in 42 patients who underwent mitral valve reconstruction for MR and compared these measurements with those obtained with early and late postoperative TTE. RESULTS Residual MR as measured by intraoperative TEE correlated significantly with values obtained with both early (r = 0.66; p < 0.0001) and late (r = 0.71; p < 0.0001) postoperative TTE. Forty patients with no or trivial MR (< or =2 cm2) as measured by intraoperative TEE also had no or trivial MR as measured by early (probability of 87.5%) and late (probability of 80.0%) postoperative TEE. Of the 40 patients, 6 had clinically insignificant mild MR (< or =4 cm2) when measured by late postoperative TTE. Two other patients in whom intraoperative TEE showed mild MR developed moderate regurgitation about 3 months later. CONCLUSIONS Intraoperative TEE correlates with early and late postoperative TTE in measurement of residual MR, suggesting it can reliably predict early and late postoperative mitral valve dysfunction.
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Affiliation(s)
- Y Saiki
- Department of Cardiac Surgery, Sakakibara Heart Institute, Tokyo, Japan.
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20
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Abstract
Techniques now exist to correct abnormalities of all components of the mitral valvular apparatus except extensive loss of pliable leaflet area. Thus, paradoxically, myxomatous valves with redundant leaflets represent the ideal candidates for mitral valve repair. Repair for mitral insufficiency can be performed for some rheumatic valves, but patient selection is critical. Loss of leaflet area, leaflet thickening, and extensive calcification of the leaflets or commissures are contraindications to repair. The abnormalities of the subvalvular apparatus are less important because a complete set of new chordae can be reconstructed using PTFE suture material. Some cases of endocarditis are ideal for repair using localized débridement and pericardial patch repair with or without PTFE chordal replacement. True ischemic mitral regurgitation of the Carpentier type I category is still something of a surgical enigma. Because it is a restrictive leaflet motion problem, annuloplasty alone is not always effective, and the outcome of any given repair attempt is less predictable. Repairs in patients with small annuli and multiple leaflet defects requiring complex series of maneuvers have a low probability of success. Furthermore, such patients with small left ventricular cavities are more prone to experience SAM. Several factors contributing to which therapy is chosen for mitral valve disease are summarized in Table 1. Patient selection, accurate evaluation of the cause or causes of mitral regurgitation, and well-executed application of the appropriate techniques for repair are all critical factors in the early and late success of mitral valve repair.
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Affiliation(s)
- G M Lawrie
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
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21
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Gillinov AM, Cosgrove DM, Lytle BW, Taylor PC, Stewart RW, McCarthy PM, Smedira NG, Muehrcke DD, Apperson-Hansen C, Loop FD. Reoperation for failure of mitral valve repair. J Thorac Cardiovasc Surg 1997; 113:467-73; discussion 473-5. [PMID: 9081091 DOI: 10.1016/s0022-5223(97)70359-3] [Citation(s) in RCA: 112] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVE Mitral valve repair is the procedure of choice to correct mitral regurgitation of all types. Up to 10% of patients who undergo mitral valvuloplasty require late reoperation for recurrent mitral valve dysfunction. To determine the causes of failed mitral valve repair, we examined the surgical pathology of patients who underwent reoperation for failed mitral valve repair. PATIENTS AND RESULTS From 1986 to 1994, 81 patients had 86 reoperations for recurrent mitral regurgitation after mitral valve repair. Mean age was 59.2 +/- 1.4 years; 55 were men. Primary valve disease was degenerative in 48 patients (59%), rheumatic in 16 (20%), ischemic in 13 (16%), endocarditic in 3 (4%), and congenital in 1 (1%). Mean time interval between initial mitral valve repair and reoperation was 15.6 +/- 2.5 months. Causes of repair failure were procedure-related (50 cases, 58%), valve-related (33 cases, 38%), or unknown (3 cases, 3%). Procedure-related valve failure was caused by suture dehiscence (21 cases), rupture of previously shortened chordae (19 cases), or incomplete initial correction (10 cases). Valve-related repair failure was caused by progressive primary valve disease (27 cases), endocarditis (5 cases), or extensive leaflet retraction (1 case). Repair failure was procedure-related in 70% of patients with degenerative valvular disease versus only 13% of patients with rheumatic valvular disease (p = 0.0001). At reoperation, mitral valve replacement was performed in 64 patients (79%) and repeat mitral valve repair in 17 (21%). CONCLUSION We conclude that (1) most mitral valve repair failures are procedure-related in degenerative disease and valve-related in rheumatic disease; (2) rupture of previously shortened chordae is a common cause of late failure in patients with degenerative mitral valve disease; and (3) repeat mitral valve repair results in successful treatment for a minority of patients.
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Affiliation(s)
- A M Gillinov
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, OH 44195, USA
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Bernal JM, Rabasa JM, Olalla JJ, Carrión MF, Alonso A, Revuelta JM. Repair of chordae tendineae for rheumatic mitral valve disease. A twenty-year experience. J Thorac Cardiovasc Surg 1996; 111:211-7. [PMID: 8551768 DOI: 10.1016/s0022-5223(96)70418-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Sixty-two patients with rheumatic mitral valve disease (mean age 42.2 +/- 10.2 years) underwent repair of chordae tendineae between June 1974 and May 1994. Chordal shortening was done in 38 patients, fenestration in 17, resection of secondary chordae in 3, replacement in 2, and transposition in 2. In 41 patients, mitral commissurotomy was also done. Ring annuloplasty was done in all patients. The mean follow-up was 10.2 years (range 2 months to 20 years). The completeness of follow-up during the closing interval (January to July 1994) was 100%. Hospital mortality occurred in four patients (6.5%) and nine patients died during the late follow-up. The actuarial survival curve at 20 years was 65.8% +/- 10%. Six patients with mitral valve dysfunction (restenosis 4, insufficiency 2) and one with aortic valve dysfunction (structural deterioration of bioprosthesis) underwent reoperation. The actuarial curve of freedom from reoperation at 20 years for mitral valve dysfunction was 73.1% +/- 10.5%. In the 49 surviving patients, a Doppler echographic study during the closing interval showed a mean mitral valve area of 1.9 +/- 0.3 cm2. In the 43 patients with a repaired native valve, absent or trivial mitral regurgitation was documented in 35 and mild or moderate regurgitation in 8. In conclusion, repair of chordae tendineae in rheumatic mitral valve disease when feasible is a stable and safe procedure with a low prevalence of reoperation. However, the type of reconstructive operation and experience of the surgical team are major considerations in successful repair of the mitral valve.
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Affiliation(s)
- J M Bernal
- Department of Cardiovascular Surgery, Hospital Universitario Valdecilla, Universidad de Cantabria, Santander, Spain
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