Mitral commissurotomy, a technique outdated? Long-term follow-up over a period of 35 years

Rheumatic Heart Disease in the Developing World

Despite recent public policy initiatives, rheumatic heart disease (RHD) remains a major source of morbidity worldwide. Rheumatic heart disease occurs as a sequela of Streptococcus pyogenes (group A streptococcal [GAS]) infection in patients with genetic susceptibility. Strategies for prevention of RHD or progression of RHD include prevention of GAS infection with community initiatives, effective treatment of GAS infection, and secondary prophylaxis with intramuscular penicillin. The cardiac surgical community has attempted to improve the availability of surgery in RHD-endemic areas with some success, and operative techniques and outcomes of valve repair continue to improve, potentially offering patients a safer, more durable operation. Innovation offers hope for a more scalable solution with improved biomaterials and transcatheter delivery technology; however, cost remains a barrier.

Closed Mitral Valvotomy: Celebrating 100 Years of Surgical History

The year 2023 marks the 100th anniversary of the first successful valvotomy for mitral valve stenosis by Elliott C. Cutler in 1923. Closed-chest mitral valve commissurotomy developed further before being replaced by an open procedure after the advent of the heart-lung machine. Currently, because of the almost complete disappearance of rheumatic disease in the Western World, mitral commissurotomies are infrequently performed in those countries, although the procedure-either closed or open-is still performed in developing countries and select patients. This review retraces the 100-year journey from a historic operation to the current era-a milestone in the treatment of patients with mitral stenosis.

Long-Term Prognosis of Patients Who Underwent Percutaneous Transvenous Mitral Commissurotomy for Mitral Stenosis

The long-term prognosis for up to 20 years of patients who have undergone percutaneous transvenous mitral commissurotomy (PTMC) for mitral stenosis (MS) is unknown.We examined 77 of 93 patients (83%) with MS and who underwent PTMC from 1989 to 2002 at our institute, as well as the occurrence of either one of the following clinical endpoints until September 1, 2018: all-cause death or repeat intervention for the mitral valve.The mean follow-up duration was 20.5 ± 7.3 years. The mean age was 51 ± 11 years. Overall, the 20-year survival rate was 71% ± 5%; without any intervention, the 20-year survival rate was 40% ± 6%. In patients who achieved good immediate results (i.e., mitral valve area (MVA) of ≥ 1.5 cm² without mitral regurgitation (MR) of > 2/4 after PTMC), the 20-year survival rate was 80% ± 6%; without any intervention, the 20-year survival rate was 54% ± 7%.In our 20-year observational study, patients who have undergone PTMC for MS had favorable prognosis, especially in those who achieved good immediate results. In those who had poor immediate results, careful follow-up is needed because they might have more clinical event and any intervention for the mitral valve.

Commissuroplasty as a Main Operative Technique in Rheumatic Mitral Valve Repair: Surgical Experiences and Mid-Term Results

AIM

We aimed to evaluate the therapeutic effectiveness of commissuroplasty in mitral valve repair for rheumatic mitral valve disease. For this purpose, we summarise our experience with this technique and analyse the mid-term postoperative outcomes.

METHOD

We retrospectively evaluated the records of patients with rheumatic valve disease who underwent mitral valve repair between January 2011 and January 2018 at our centre. Detailed follow-up data were collected. A Kaplan-Meier survival curve for survival free from reoperation and valve failure was constructed. Multivariate Cox regression analyses were performed to identify predictors of relevant end points (death, reoperation, and valve failure).

RESULTS

A total of 362 patients underwent rheumatic mitral valve repair during the study period. Mitral valve stenosis was the primary pathological feature. Almost all surgeries were accomplished via commissuroplasty. The mean duration of follow-up was 25.57 ± 19.91 months. Twenty-two (22) endpoint events were noted during follow-up. The 2- and 7-year rates of survival free from reoperation and valve failure were 93.9%±1.4% and 91.5%±2.0%, respectively. Multivariate Cox regression analysis revealed that left atrial anteroposterior diameter >60 mm (hazard ratio, 5.2; p < 0.001) was an independent predictor of all endpoints.

CONCLUSIONS

Most Chinese patients with rheumatic valve disease were treated effectively via commissuroplasty combined with other surgical procedures, and the mid-term postoperative outcomes were satisfactory.

Late results of percutaneous mitral commissurotomy up to 20 years: development and validation of a risk score predicting late functional results from a series of 912 patients

BACKGROUND

Long-term follow-up after percutaneous mitral commissurotomy enables predictive factors of late results to be identified.

METHODS AND RESULTS

Late results of percutaneous mitral commissurotomy were assessed in 1024 consecutive patients. Good immediate results, defined as valve area ≥1.5 cm(2) without mitral regurgitation >2/4, were obtained in 912 patients (89%). These 912 patients were randomly split into 2 cohorts comprising 609 and 303 patients that were used to develop and validate, respectively, a scoring system predicting late functional results. The 20-year rate of good functional results (survival without cardiovascular death, mitral surgery, or repeat percutaneous mitral commissurotomy and in New York Heart Association class I or II) was 30.2 ± 2.0%. A multivariable Cox model identified 7 predictive factors of poor late functional results: higher final mean gradient (P<0.0001), interaction between age and final mitral valve area (P<0.0001) showing that the impact of valve area decreases with age, interaction between sex and valve calcification (P<0.0001) showing that the impact of valve anatomy is stronger in men, and interaction between rhythm and New York Heart Association class showing an impact of New York Heart Association class only in patients in atrial fibrillation (P<0.0001). A 13-point score enabled 3 risk groups to be defined, corresponding to predicted good functional results of 55.1%, 29.1%, and 10.5% at 20 years in the validation cohort.

CONCLUSIONS

Twenty years after percutaneous mitral commissurotomy in a population of patients with varied characteristics, 30% still had good functional results. Prediction of late functional results is multifactorial and strongly determined by age and the quality of immediate results. A simple validated scoring system is useful for estimating individual patient outcome.

Mitral valve replacements in redo patients with previous mitral valve procedures: mid-term results and risk factors for survival

OBJECTIVE

We aimed to investigate the risk factors for hospital mortality, short (five years) and mid-term (10 years) survival in patients who underwent mitral valve replacements in redo patients with previous mitral valve procedures.

PATIENTS AND METHODS

Between September 1989 and December 2003, 62 redo patients have undergone mitral valve replacements due to subsequent mitral valve problems. Preoperative, operative, and postoperative data were analyzed retrospectively and evaluated for risk factors affecting hospital mortality, mid- and long-term survival.

RESULTS

The hospital mortality was 6.4%. The one-, five-, and 10-year actuarial survival rates were 94%+/- 2%, 89%+/- 6%, and 81 +/- 9%. New York Heart Association (NYHA) functional class IV, low left ventricular ejection fraction (<35%), increased left ventricular end-diastolic diameter (LVEDD) > 50 mm, female gender, pulmonary edema, and urgent operations were found to be risk factors in short-term survival. NYHA functional class IV, low left ventricular ejection fraction, increased LVEDD, and increased left atrial diameter (LA > 60 mm) were risk factors in mid-term survival.

CONCLUSION

Redo mitral valve surgery with mechanical prosthesis offers encouraging short- and mid-term survival. NYHA functional class IV, low left ventricular ejection fraction, and increased left ventricular diameters were especially associated with increased short- and mid-term mortality. Earlier surgical management before the development of severe heart failure and myocardial dysfunction would improve the results of redo mitral valve surgery.

Mitral valve repair versus replacement in simultaneous mitral and aortic valve surgery for rheumatic disease

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.

Open mitral commissurotomy

Closed mitral commissurotomy for rheumatic mitral valve stenosis was used in many tens of thousands of patients with excellent immediate results and durability, many patients having survived more than 20 years without reoperations. Gradually, this procedure was displaced by the open commissurotomy which has the advantage of direct visualisation of all valve components with immediate assessment of the anatomical and functional result. Open commissurotomy is applicable even in moderately fibrosed and/or calcified valves and in the presence of intra-atrial thrombus. Its results are well established and have not yet been bettered by less invasive procedures, such as percutaneous balloon mitral commissurotomy.

Role of closed mitral commissurotomy for mitral stenosis: mid- and long-term surgical outcome of 36 patients

PURPOSE

To evaluate long-term survival and valve-related complications as well as prognostic factors for mid- and long-term outcome after closed mitral commissurotomy, covering a follow-up period of 14 years.

MATERIAL AND METHODS

Between 1989 and 2003, 36 patients (28 women and 8 men, mean age 28.8 +/- 6.1 years) underwent closed mitral commissurotomy at our institution. The majority of patients were in New York Heart Association (NYHA) functional class IIB, III, or IV. Indication for closed mitral commissurotomy was mitral stenosis. Closed mitral commissurotomy was undertaken with a Tubbs dilator in all cases. Median operating time was 2.5 hours +/- 30 minutes.

RESULTS

After closed mitral commissurotomy, the mitral valve areas of these patients were increased substantially, from 0.9 to 2.11 cm(2). No further operation after initial closed mitral commissurotomy was required in 86% of the patients (n = 31), and NYHA functional classification was improved in 94% (n = 34). Postoperative complications and operative mortality were not seen. Follow-up revealed restenosis in 8.5% (n = 3) of the patients, minimal mitral regurgitation in 22.2% (n = 8), and grade >or=3 mitral regurgitation in 5.5% (n = 2) patients. No early mortality occurred in closed mitral commissurotomy patients. Reoperation was essential for 5 patients following closed mitral commissurotomy; 2 procedures were open mitral commissurotomies and 3 were mitral valve replacements. No mortality occurred in these patients.

CONCLUSIONS

The mitral valve area was significantly increased and the mean mitral valve gradient was reduced in patients after closed mitral commissurotomy. Closed mitral commissurotomy is a safe alternative to open mitral commissurotomy and balloon mitral commissurotomy in selected patients.

Long-term results of reoperative mitral valve surgery in patients with rheumatic disease

BACKGROUND

Reoperative (redo) mitral valve surgery is still a continuing challenge to surgeons. The aim of this study was to detect the factors that affect late mortality or morbidity after redo mitral valve surgery in patients with rheumatic disease.

METHODS

Between May 1983 and February 2003, 92 patients who underwent redo mitral valve surgery for rheumatic disease were enrolled. Risk factors influencing survival or cardiac events were investigated with univariate analysis and a Cox model.

RESULTS

Operative mortality rate was 4.2%. Kaplan-Meier actuarial analysis demonstrated an 84.7% 5-year, a 69.5% 10-year, and a 65.9% 15-year survival. Multivariate analysis demonstrated that age at surgery and preoperative New York Heart Association (NYHA) class were found to be independent predictors of late deaths, and that higher age, advanced NYHA class, and previous mitral valve replacement were independent predictors of cardiac events.

CONCLUSIONS

Redo mitral valve surgery can be achieved with low early mortality. However, long-term results of redo mitral surgery are not necessarily satisfactory in patients with preoperative advanced NYHA class or with a previous mechanical heart valve, and especially in 60 years or older age.

Open mitral commissurotomy in the current era: indications, technique, and results

BACKGROUND

The present retrospective study is focused on indications, techniques, and results of open mitral commisurotomy in the current era.

METHODS

Of the 1,280 patients undergoing open-heart surgical procedures for rheumatic mitral stenosis between January 1990 and July 2000, 276 (21.6%) patients underwent open mitral commissurotomy. Major indications included presence of left atrial thrombus/clot (n = 82, 29.7%), severe subvalvular disease (n = 110, 39.8%), mitral valve calcification (n = 42, 15.2%), mild mitral regurgitation (n = 28, 10.0%), associated aortic valve disease (n = 55, 19.9%), organic tricuspid valve disease (n = 20, 7.2%), and failure or restenosis after closed or balloon mitral valvuloplasty (n = 55, 19.9%). Age of patients ranged from 7 to 67 years (mean, 30.2 +/- 12 years). The majority (76%) were in New York Heart Association class III or IV, and 6.9% were in congestive heart failure. Atrial fibrillation was present in 134 (48.6%) patients. Mitral valve area ranged from 0.3 to 0.7 cm2 (mean, 0.52 +/- 0.12 cm2). Mid-diastolic gradients across the mitral valve ranged from 8 to 34 mm Hg (mean, 14.5 +/- 6.2 mm Hg), and end-diastolic gradients ranged from 8 to 42 mm Hg (mean, 15.2 +/- 5.7 mm Hg). Open mitral commissurotomy was performed using standard cardiopulmonary bypass. Associated aortic valve procedure was performed in 55 patients, and either tricuspid valvotomy or repair was performed in 28 patients.

RESULTS

There were four early deaths. All these patients had associated aortic valve procedure (Ross procedure in 2 and homograft aortic valve replacement in 2). Three patients developed severe mitral regurgitation in early postoperative period (< or = 30 days) and required reoperation. Predischarge echocardiography showed mitral valve area from 1.4 to 3.5 cm2 (mean, 2.6 +/- 0.6cm2) and moderate mitral regurgitation in 4 patients. Follow-up ranged from 1 to 130 months (mean, 64.5 +/- 28.6 months). There was no late death. There were three reoperations for mitral valve failure, and an additional 2 patients developed severe mitral stenosis (mitral valve area < 1.0 cm2). In operative survivors, freedom from mitral valve failure at 10 years was 87.0% +/- 3.5%. In patients with isolated open mitral commissurotomy, the incidence of thromboembolism was 0.5%/patient-year.

CONCLUSIONS

Open mitral commissurotomy provides excellent early and long-term results in a selected group of patients.