Closed versus open mitral commissurotomy in pure noncalcific mitral stenosis: Hemodynamic studies before and after operation

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.

Triple valve repair for rheumatic heart disease

The onset of the clinical expression of rheumatic heart disease (RHD) is variable. Exercise or other states that necessitate increased cardiac output often precipitate symptoms. Mitral stenosis (MS) is present in 25% of patients with RHD, and 40% of patients have concomitant MS and mitral regurgitation. About two third of patients with MS have concurrent aortic insufficiency. Pulmonary and tricuspid insufficiency may occur from rheumatic involvement of these valves, or secondary to dilatation of valve annuli from pulmonary hypertension secondary to mitral and/or aortic valve disease. Pregnancy is associated with many hemodynamic changes including expanded intravascular volume, tachycardia, increased intracardiac dimensions, and valvular regurgitation. We report a case of a young female who developed flash pulmonary edema during parturition and was found to have abnormal rheumatic involvement of her aortic, mitral, and tricuspid valves. Successful triple valve repair was performed in a single operation. A review of rheumatic valvular abnormalities, and literature supporting multivalvular repair for rheumatic heart disease is provided.

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.

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.

Mitral commissurotomy, a technique outdated?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

BACKGROUND

The objective of this study was to evaluate long-term survival, valve-related complications as well as prognostic factors for early and late outcome after open and closed mitral commissurotomy covering a follow-up period of 35 years.

METHODS

From 1955 to 1977, 183 patients with mitral stenosis underwent mitral commissurotomy at our institution. Closed valvotomy was performed on 143 patients (group A) and open valvotomy on 40 patients (group B).

RESULTS

Survival rates after 10, 20, and 30 years were 89%, 67.8%, and 49.1% in group A and 91.7%, 66.7%, and 45.9% in group B (p = not significant). The risk of late death increased significantly with an advanced preoperative New York Heart Association functional class, atrial fibrillation, higher age at operation, pre- or postoperative mitral regurgitation, and leaflet calcification. Forty-four patients in group A and 5 patients in group B required reoperation (p < 0.05). Independent predictors for reoperation in a multivariate analysis were a remaining postoperative mitral stenosis or regurgitation. A total of 68 patients showed valve-related complications. The linearized rate of valve-related morbidity and mortality was 2.1% per patient-years in group A versus 1.1% per patient-years in B (p < 0.01).

CONCLUSIONS

Long-term survival for open and closed commissurotomy are excellent, showing no difference between the groups. However, both the incidence of reoperation as well as valve-related morbidity and mortality were significantly lower after open commissurotomy. In well-selected patients with pure mitral stenosis and no leaflet calcification, open commissurotomy still remains a valid surgical option.

Percutaneous mitral commissurotomy versus open mitral commissurotomy: a comparative study

OBJECTIVE

Although many studies in medical literature are comparing percutaneous trans-septal mitral commissurotomy (PTMC) and open mitral commissurotomy (OMC), very few long-term comparative follow-ups are available.

METHODS

Between January 1991 and December 1997, 193 patients with isolated mitral stenosis were assigned either to PTMC (111 cases) or to OMC (82 cases). PTMC was performed in all cases with Inoue Ballon, OMC was performed with standard techniques. Categorical values were compared by chi square analysis, whereas continuous data were compared by Mann-Whitney test. Univariate survival and event free analysis (Kaplan-Meier+/-SE and log rank) were performed. Recurrent stenosis was classified any mitral valve area (MVA) less than 1.2 cm2 and whenever post-op. echo showed a loss more than 50% of the initial gain. Data were reported as mean+/-SD. Data concerning late echocardiographic assessment were studied with linear and logistic regression analysis.

RESULTS

The two groups were homogenous as far preoperative variables as sex, mean age, MVA, echo score and incidence of left atrial thrombosis were concerned. Mean NYHA was preoperatively higher in OMC (2.79+/-0.58) versus PTMC (2.42+/-0.5) (P = 0.001). There was no hospital mortality in both groups. Incidence of hospital complications was similar (4/ 111 after PTMC and 1/82 after OMC; P = 0.3). Seven year survival: 95.41+/-0.02 (PTMC) and 98.05+/-0.01 (OMC) (P = 0.3) and freedom from late complications did not show statistical differences: Embolism 98.78+/-0.01 in PTMC and 98.78+0.01 in OMC (P = 0.8); Recurrent stenosis 71.89+/-0.13 in PTMC versus 82.89+/-0.08 in OMC (P = 0.2); Reoperation 88.43+/-0.08 in PTMC versus 96.25+/-0.02 in OMC (P = 0.4). A larger MVA was found in patients undergone to OMC (2.05+/-0.35) versus PTMC (1.81+/-0.33) (P = 0.001). Furthermore mean NYHA was lower in OMC (1.14+/-0.3) versus PTMC (1.39+/-0.7) (P = 0.001).

CONCLUSIONS

Both techniques achieve with a low operative risk and low incidence of complications a good palliation of rheumatic mitral stenosis. Incidence of complications in the follow-up is similar. OMC allows a larger mitral valve area, a better functional recovery and a lower incidence of late mitral regurgitation.

Less invasive approaches for closed mitral commissurotomy

OBJECTIVE

Recently, closed mitral commissurotomy (CMC) has been reexplored due to the concepts of less invasive valvular surgery. The feasibility of closed mitral commissurotomy via port access or limited thoracotomy by aid transesophageal echocardiography (TEE) was investigated in this clinical study.

METHODS

Between August 1996 and April 1998, 42 patients (32 women, ten men with a mean age of 36.2+/-7.8 years) underwent less invasive CMC at the Kosuyolu Heart and Research Hospital. CMC procedure were done through a limited (12-16 cm) thoracotomy incision in 23 patients, a very limited or mini thoracotomy incision (7-8 cm) in 11 patients and port access by aid TEE in eight patients. Preoperative mean mitral valve area was calculated as 1.19+/-0.13 cm2 and mean mitral valve gradient was measured as 14.8+/-3.2 mmHg. TEE provided information about the mitral valve anatomy and functions during the procedure in all patients.

RESULTS

Commissurotomy was successfully performed in all patients. In eight patients, a Tubbs dilator was inserted via port access at the 6th intercostal space from a 3-cm incision. Incision by guidance of TEE and CMC could be performed without thoracotomy in five patients. In three patients of the port access group, a very limited thoracotomy was required to perform CMC by digital guidance. Postoperative mean MVA was 2.37+/-0.29 cm2, minimal mitral gradient was 5.3+/-1.7 mmHg. In eleven patients, minimal mitral regurgitation was observed. The operations and postoperative period were free of complications in all patients. Following an average 12+/-2.8 h intensive care unit period, all patients were discharged after an average of 3.4+/-0.8 days of hospitalization.

CONCLUSION

Limited thoracotomy has less detrimental structural effects in patients. Port access by aid TEE approach to CMC may offer less invasiveness, lower cost effectiveness and be an alternative to percutaneous balloon mitral valvotomy.

Percutaneous balloon versus surgical closed and open mitral commissurotomy: seven-year follow-up results of a randomized trial

BACKGROUND

Percutaneous balloon mitral commissurotomy (BMC) has been proposed as an alternative to surgical closed mitral commissurotomy (CMC) and open mitral commissurotomy (OMC) for the management of rheumatic mitral valve stenosis (MS).

METHODS AND RESULTS

We conducted a prospective, randomized trial comparing the results of the 3 procedures in 90 patients (30 patients in each group) with severe pliable MS. Cardiac catheterization was performed in all patients before and at 6 months after each procedure. All patients had clinical and echocardiographic evaluation initially and throughout the 7-year follow-up period. Gorlin mitral valve area (MVA) increased much more after BMC (from 0.9+/-0.16 to 2.2+/-0.4 cm2) and OMC (from 0.9+/-0.2 to 2.2+/-0.4 cm2) than after CMC (from 0.9+/-0.2 to 1.6+/-0.4 cm2). Residual MS (MVA <1.5 cm2) was 0% after BMC or OMC and 27% after CMC. There was no early or late mortality or thromboembolism among the three groups. At 7-year follow-up, echocardiographic MVA was similar and greater after BMC and OMC (1.8+/-0.4 cm2) than after CMC (1.3+/-0.3 cm2; P<.00l). Restenosis (MVA <1.5 cm2) rate was 6.6% after BMC or OMC versus 37% after CMC. Residual atrial septal defect was present in 2 patients and severe grade 3 mitral regurgitation was present in 1 patient in the BMC group. Eighty-seven percent of patients after BMC and 90% of patients after OMC were in New York Heart Association functional class I versus 33% (P<.0001) after CMC. Freedom from reintervention was 90% after BMC, 93% after OMC, and 50% after CMC.

CONCLUSIONS

In contrast to surgical CMC, BMC and OMC produce excellent and comparable early hemodynamic improvement and are associated with a lower rate of residual stenosis and restenosis and need for reintervention. However, the good results, lower cost, and elimination of drawbacks of thoracotomy and cardiopulmonary bypass indicate that BMC should be the treatment of choice for patients with tight pliable rheumatic MS.

Closed mitral valvotomy for mitral restenosis: experience in 113 consecutive cases

The costs of heart operations and the problems related to anticoagulation after prosthetic valve replacement are among the limitations faced by patients in nonindustrialized countries with mitral stenosis caused by chronic rheumatic heart disease. The young age at which these patients are seen also compels the surgeon to preserve the native valve. The least costly and optimal way to achieve this objective is by closed mitral valvotomy. After closed mitral valvotomy, mitral restenosis is commonly encountered. We report here our 10-year experience with operation on 113 consecutive patients with mitral restenosis. Closed transventricular revalvotomy was performed with Tubbs dilator in 105 of 113 patients. Mean age was 343 years, with a male to female ratio of 1:1.5. Most patients were in New York Heart Association functional classes III and IV (74.3% and 19.4%, respectively). Mean interval between first and second valvotomy was 9.4 years, Hospital mortality rate was 2.8%, trivial postoperative mitral regurgitation occurred in 16.1%, and moderately severe regurgitation occurred in 1.9%. Early postoperative systemic embolism occurred in 3.8% of the cases. Moderate to excellent symptomatic improvement was noted in 89.4% of the cases and poor results were seen in 10.2%. Late follow-up of 76 patients ranged from 2 to 10 years (mean 3.8 years), with 39.4% patients in New York Heart Association class I and 50% in class II. Close mitral revalvotomy is thus an economical, simple, and safe palliative procedure that carries good long-term results.

Acute changes in left ventricular function after percutaneous transluminal mitral valvuloplasty

Percutaneous balloon mitral valvuloplasty (PBMV) has been shown to induce an immediate increase in the left ventricular end-diastolic volume, which increase, in turn, has been attributed to an increase in left ventricular compliance. We studied 51 patients, 41 women and 10 men, who underwent PBMV, and were in sinus rhythm before and after the procedure. Heart rate did not vary significantly. There were increases in left ventricular end-diastolic volume (97.5 +/- 25.6 vs 112.7 +/- 25.7 ml/m2, P < 0.001), left ventricular end-diastolic pressure (8.7 +/- 3.0 vs 9.7 +/- 4.3 mmHg, P = 0.04), and both left ventricular systolic pressure and stress (118 +/- 20.5 vs 123 +/- 23.2 mmHg and 468 +/- 129 vs 580 +/- 164 mmHg; P = 0.04 and P < 0.001, respectively). The elastic stiffness constant did not vary (16.2 +/- 1.9 vs 15.7 +/- 1.9 (dimensionless units), P = 0.2). The increase in volume seemed to be particularly important when the ventricle appeared to be "shrunken" before PBMV. This increase was still present after a 1 year follow up. Thus, PBMV determines an increase in both end-diastolic volume and pressure, so that the left ventricle appears to move along a single pressure-volume curve. This enlargement evokes the Frank Starling mechanism, and improves systolic performance. Since it is still evident after a 1 year follow up, some concern may arise when a simultaneous volume overload is present, as in aortic insufficiency.

Hemodynamic Evaluation and Exercise Tolerance Comparison before and after Operation in Closed versus Open Mitral Valvotomy in Pure Mitral Stenosis

The relative merits and efficacy of open versus closed mitral valvotomy remains controversial. The purpose of this study was to compare improvement of the hemodynamic parameters and exercise tolerance capacity of the 2 operations in 59 patients with pure mitral stenosis in sinus rhythm. Patients were randomly assigned to 1 of 2 groups: 29 patients in group 1 were operated on with the closed technique and 30 patients in group 2 were operated by the open technique. Preoperatively, the hemodynamic parameters and exercise capacity were similar in the two groups. Cardiac catheterization and exercise treadmill test were performed on all patients before and 3 months after each operation. Hemodynamic parameters as well as exercise tolerance capacity were significantly improved by both open and closed valvotomy ( p < 0.0001). However, postoperatively the improvement in exercise capacity was similar in both groups ( p = NS) and there was no significant difference in hemodynamic parameters in both groups, except for reduction in pulmonary artery pressure and increment in cardiac output. Complication rates were similar in both groups, except for atrial arrhythmias, which were more common in group 2. This study suggested that the closed technique, when performed by experienced surgeons, achieved similar hemodynamic and functional results as the open method. It also has the potential advantage of cost savings in addition to avoiding the complications of cardiopulmonary bypass. It clearly has a place in properly selected patients with mitral stenosis.

Results of percutaneous balloon mitral valvotomy in young adults

The results of percutaneous balloon mitral valvotomy (PBMV) were evaluated in 235 young patients (mean age 29 +/- 11 years) with symptomatic rheumatic mitral stenosis, and the single-balloon Inoue technique was compared with the double-balloon Mansfield technique. PBMV was associated with a significant increase in Gorlin mitral valve area (0.78 +/- 0.23 to 1.61 +/- 0.64 cm2; p < 0.001), and improvement in New York Heart Association functional class (2.78 +/- 0.59 to 1.28 +/- 0.58; p < 0.001). Mitral regurgitation increased significantly (0.4 +/- 0.6 to 1.3 +/- 1.0; p < 0.001), but was significant (> or = 3+) only in 19 patients (8%). Comparison of the Inoue and Mansfield techniques showed a significantly lower Gorlin mitral valve area after PBMV (1.55 +/- 0.56 vs 1.74 +/- 0.74 cm2; p < 0.05), but a lower incidence of mitral regurgitation by color Doppler echocardiography (1.1 +/- 0.7 vs 1.5 +/- 0.8; p < 0.05) in the Inoue group. Patients were divided into those with nonpliable (valve score > 8; group I) and pliable (score < or = 8; group II) valves. Although significant increases in mitral valve area were obtained in both groups, mitral valve area by planimetry was significantly lower in group I (1.49 +/- 0.46 vs 1.86 +/- 0.44 cm2; p < 0.05), whereas there was no difference in the amount of color Doppler mitral regurgitation (1.5 +/- 1.0 vs 1.2 +/- 0.7; p = NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Echocardiographic variables affecting surgical outcome in patients undergoing closed mitral commissurotomy

We studied, by transthoracic cross-sectional echocardiography, the influence of subvalvar pathology on the early hemodynamic result of closed mitral commissurotomy in 132 patients with severe rheumatic mitral stenosis (56 males, 76 females, mean age 25.2 yr, range 10-55) in our tertiary care hospital in North India from July 89 to December 91. The mitral subdistance ratio was calculated by dividing the distance between the papillary muscle tip and mitral valve in systole (apical 4-chamber view) by left ventricular diastolic length (apical long axis view). Nineteen patients with mild subvalvar pathology (mitral subdistance ratio > 0.18) and 71 patients with moderate, achieved a larger valve area (2.26 cm2 SD 0.54) than 42 patients with severe subvalvar pathology (mitral subdistance ratio < 0.12, postoperative valve area 2.09 cm2 SD 0.6, p < 0.05). In addition, 9 of these 42 patients (21%) developed significant mitral regurgitation (4 deaths), in contrast to 1/19 with mild and 6/71 with moderate subvalvar pathology. We conclude that echocardiography identifies patients with severe subvalvar pathology who fare poorly after closed mitral commissurotomy. However, this procedure would still be practised in developing countries like ours due to financial constraints.

Balloon valvuloplasty versus closed commissurotomy for pliable mitral stenosis: a prospective hemodynamic study

Closed surgical mitral valvotomy is the procedure of choice in most patients with symptomatic pliable mitral stenosis in developing countries. The procedure is efficacious and safe. Mitral valvotomy performed with a balloon has shown similar good results, with infrequent complications in selected subjects. Because there is a paucity of studies comparing the two techniques, this study was undertaken to compare the results of percutaneous balloon mitral valvuloplasty with those of closed commissurotomy as determined by catheterization studies. Forty-five patients with tight pliable mitral stenosis were randomly assigned to one of two groups: 23 patients had balloon valvuloplasty by the single catheter technique (group I) and 22 underwent closed surgical valvotomy (group II). The two groups were similar with regard to clinical and hemodynamic findings before intervention. Mitral valve area increased from 0.8 +/- 0.3 to 2.1 +/- 0.7 cm2 in group I (p less than 0.001) and from 0.7 +/- 0.2 to 1.3 +/- 0.3 cm2 in group II (p less than 0.001). Pulmonary artery pressure and pulmonary vascular resistance decreased in both groups, but these changes did not reach statistical significance in group II. Treadmill exercise time increased from 3.8 +/- 2.3 to 7.3 +/- 2.6 min in group I (p less than 0.001) and from 4 +/- 2.6 to 5.6 +/- 2.6 min in group II (p less than 0.001). There were no deaths. One patient in each group developed moderate (3+) mitral regurgitation. A small interatrial shunt (less than 1.5:1) was detected in three patients in group I immediately after the procedure.(ABSTRACT TRUNCATED AT 250 WORDS)