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Deja MA, Malinowski M, Widenka K, Stożyński N, Bartuś K, Kapelak B, Kuśmierczyk M, Hirnle G, Suwalski P, Jasiński M, Gerber W, Tobota Z, Barański K, Maruszewski BJ. Comparison of Repair vs Replacement in Calcific and Rheumatic Mitral Disease. Ann Thorac Surg 2023; 116:954-961. [PMID: 37271445 DOI: 10.1016/j.athoracsur.2023.04.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 04/13/2023] [Accepted: 04/23/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND The benefit of repair over replacement of rheumatic or calcified mitral valve (MV) is debatable. METHODS Patients who underwent MV repair or replacement for rheumatic or calcified MV disease between 2006 and 2020 were identified in the Polish National Registry of Cardiac Surgery Procedures. Patients who underwent additional procedures other than coronary artery bypass grafting or tricuspid valve surgery, as well as redo or emergency cases, were excluded. The long-term survival was verified based on National Health Fund registry data. The survival was compared between MV repair and replacement in the whole cohort and after propensity score matching. RESULTS We included 4338 patients: 1859 (43%) with pure mitral regurgitation and 2479 (57%) with mitral stenosis. MV was repaired in 543 patients (29%) with pure regurgitation and 126 (5.1%) with stenosis (P < .001). In total, 984 (23%) patients underwent concomitant coronary artery bypass grafting and 1358 (32%) tricuspid valve surgery. MV repair improved survival (hazard ratio 0.81; 95% CI 0.68-0.97; P = .022) in patients with no mitral stenosis, and had no effect in mitral stenosis (hazard ratio 1.17; 95% CI 0.85-1.59; P = .332). The results were confirmed in propensity-matched cohorts. The freedom from MV reoperation at 10 years was 95.5% ± 1.2% after repair and 96.0% ± 0.7% after MV replacement (P = .416) in the absence of stenosis and 91.8% ± 3.4% after repair vs 95.9% ± 0.5% after replacement in patients with mitral stenosis (P = .065). CONCLUSIONS Repair of rheumatic/calcified mitral valve should be a preferred option in patients with no mitral stenosis, but confers no benefit if mitral stenosis is present.
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Affiliation(s)
- Marek A Deja
- Department of Cardiac Surgery, Medical University of Silesia, Katowice, Poland.
| | - Marcin Malinowski
- Department of Cardiac Surgery, Medical University of Silesia, Katowice, Poland
| | - Kazimierz Widenka
- Department of Cardiac Surgery, University of Rzeszów, Rzeszów, Poland
| | - Nikodem Stożyński
- Department of Cardiac Surgery, District Hospital No 2, Rzeszów, Poland
| | - Krzysztof Bartuś
- Department of Surgery of Heart, Vessels and Transplantology, Jagiellonian University Medical College, Kraków, Poland
| | - Bogusław Kapelak
- Department of Surgery of Heart, Vessels and Transplantology, Jagiellonian University Medical College, Kraków, Poland
| | | | - Grzegorz Hirnle
- Department of Cardiac Surgery, Transplantology, Vascular and Endovascular Surgery, Silesian Centre for Heart Disease, Zabrze, Poland
| | - Piotr Suwalski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior and Administration, Warszawa, Poland
| | - Marek Jasiński
- Department of Cardiac Surgery, Wroclaw Medical University, Wrocław, Poland
| | - Witold Gerber
- Department of Cardiac Surgery, American Heart of Poland, Bielsko-Biała, Poland
| | - Zdzisław Tobota
- Department of Cardiac Surgery, Children's Memorial Health Institute, Warszawa, Poland
| | - Kamil Barański
- Department of Epidemiology, Medical University of Silesia, Katowice, Poland
| | - Bohdan J Maruszewski
- Department of Cardiac Surgery, Children's Memorial Health Institute, Warszawa, Poland
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Brescia AA, Watt TMF, Murray SL, Rosenbloom LM, Kleeman KC, Allgeyer H, Eid J, Romano MA, Bolling SF. Rheumatic mitral valve repair or replacement in the valve-in-valve era. J Thorac Cardiovasc Surg 2022; 163:591-602.e1. [PMID: 32620398 PMCID: PMC7655552 DOI: 10.1016/j.jtcvs.2020.04.118] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 03/31/2020] [Accepted: 04/15/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE For degenerative mitral disease, repair is superior to replacement; however, the best operative strategy for rheumatic mitral disease remains unclear. We evaluated the association between decision-making in choosing repair versus replacement and outcomes across 2 decades of rheumatic mitral surgery. METHODS Patients undergoing isolated, first-time rheumatic mitral surgery were identified. Era 1 (1997-2008) and Era 2 (2009-2018) were distinguished by intraoperative assessment of anterior leaflet mobility/calcification (Era 2) in deciding between mitral repair versus replacement. Primary outcome was a composite of death, reoperation, and severe valve dysfunction. RESULTS Among 180 patients, age was 59 ± 14 years, and ejection fraction was 58% ± 10%. A higher proportion in Era 1 (n = 56) compared with Era 2 (n = 124) had preoperative atrial fibrillation (68% vs 46%; P = .006); the groups were otherwise similar. Primary indication was mitral stenosis in 69% (124 out of 180; pure = 35, mixed = 89) and did not differ by era (P = .67). During Era 1, 70% (39 out of 56) underwent repair, compared with 33% (41 out of 124) during Era 2 (P < .001). Freedom from death, reoperation, or severe valve dysfunction at 5 years was higher in Era 2 (72% ± 9%) than Era 1 (54% ± 13%; P = .04). Five-year survival was higher in Era 2 than Era 1, but did not differ between repair versus replacement. Five-year cumulative incidence of reoperation with death as a competing risk did not differ by era, but was higher after repair than replacement. CONCLUSIONS Careful assessment of anterior leaflet mobility/calcification to determine mitral repair or replacement was associated with improved outcomes. This decision-making strategy may alter the threshold for rheumatic mitral replacement in the current valve-in-valve era.
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Affiliation(s)
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- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
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Kotit S, Phillips DIW, Afifi A, Yacoub M. The "Cairo Accord"- Towards the Eradication of RHD: An Update. Front Cardiovasc Med 2021; 8:690227. [PMID: 34277735 PMCID: PMC8282907 DOI: 10.3389/fcvm.2021.690227] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 06/07/2021] [Indexed: 01/18/2023] Open
Abstract
Rheumatic heart disease (RHD) is the most common cause of acquired heart disease in children and young adults. It continues to be prevalent in many low- and middle-income countries where it causes significant morbidity and mortality. Following the 2017 Cairo conference "Rheumatic Heart Disease: from Molecules to the Global Community," experts from 21 countries formulated an approach for addressing the problem of RHD: "The Cairo Accord on Rheumatic Heart Disease." The Accord attempts to set policy priorities for the eradication of acute rheumatic fever (ARF) and RHD and builds on a recent series of policy initiatives and calls to action. We present an update on the recommendations of the Cairo Accord and discuss recent progress toward the eradication of RHD, including contributions from our own Aswan Rheumatic Heart Disease Registry (ARGI).
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Affiliation(s)
| | - David I. W. Phillips
- Developmental Origins of Health and Disease Division, University of Southampton, Southampton General Hospital, Southampton, United Kingdom
| | | | - Magdi Yacoub
- Aswan Heart Centre, Aswan, Egypt
- Heart Science Centre, National Heart and Lung Institute, Imperial College London, London, United Kingdom
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Gao Y, Li S, Zhuang X, Gao F, Shi L, Meng X. Comparison of Mitral Valve Repair versus Replacement for the Progression of Functional Tricuspid Regurgitation. Ann Thorac Cardiovasc Surg 2020; 26:72-78. [PMID: 31495812 PMCID: PMC7184033 DOI: 10.5761/atcs.oa.19-00132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: Function tricuspid regurgitation (TR) is frequently observed in patients undergoing mitral valve surgery. It is unclear that mitral valve repair (MVr) or mitral valve replacement (MVR) has influence on the likelihood of late TR progression. Methods: This study included 193 patients with degenerative mitral valve disease who underwent either MVr or MVR. Detailed preoperative materials, follow-up information, and echocardiographic data were collected and statistically analyzed. Results: At 6 and 12 months postoperatively, MVR patients were more likely to have New York Heart Association (NYHA) class III or IV symptoms than MVr patients (6 mo: 15.2% vs 5.0%, 12 mo: 13.0% vs 4.0%, both P <0.05). At 24 months, the incidence of Grade 1+ TR was significantly higher in MVR patients than MVr patients (25.0% vs 12.9%, P <0.05). In univariate analysis, age (odds ratio [OR] = 1.036, P = 0.036), MVR (OR = 2.256, P = 0.033), and preoperative TR area (TRA; OR = 1.541, P = 0.047) were significant predictors for TR progression. In multivariate logistics analysis, only MVR was independently risk factor (P = 0.006). Subsequently, patients were divided into tricuspid valve repair (TVr) group and untreated group. In both subgroups, MVR patients were associated with significantly larger TRA (P <0.01). Conclusion: MVR was an independent risk factor for TR progression, whether tricuspid valve was treated or not.
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Affiliation(s)
- Yang Gao
- Department of Cardiology Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Shubin Li
- Department of Cardiology Surgery, Xinxiang Central Hospital, Xinxiang, China
| | - Xijing Zhuang
- Department of Cardiology Surgery, Dalian Municipal Central Hospital, Dalian, China
| | - Feng Gao
- Department of Cardiology Surgery, Dalian Municipal Central Hospital, Dalian, China
| | - Lei Shi
- Department of Cardiology Surgery, Dalian Municipal Central Hospital, Dalian, China
| | - Xu Meng
- Department of Cardiology Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Chatterjee S, Bansal N, Ghosh R, Sankhyan LK, Chatterjee S, Pandey S, Bose S. Mitral valve repair in children with rheumatic heart disease. Indian J Thorac Cardiovasc Surg 2020; 37:175-182. [PMID: 33642715 DOI: 10.1007/s12055-020-00925-0] [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: 11/27/2019] [Revised: 01/04/2020] [Accepted: 01/07/2020] [Indexed: 11/25/2022] Open
Abstract
Purpose Rheumatic heart disease is the most common acquired heart disease in children in developing countries. The heart valve lesions produce severe hemodynamic changes due to scarring of the valves over time. Around 15.6 million people are affected by rheumatic heart disease (RHD), and 230,000 die around the globe annually. Valve repair should be the primary goal, although it is technically challenging because of the fact that rheumatic process evolves making repair outcomes variable. Methods We reviewed the literature for the various techniques done for mitral valve repair in children with rheumatic heart disease. Early and late results of repair were compared with the results found for mitral valve repair done for such children. Results Prosthetic heart valve implantation in children has major negative impact on their immediate- and long-term survival as well as on quality of their life. Valve repair is associated with improved ventricular function because the normal valve tissue and subvalvular apparatus are preserved, reduced complications related to prosthetic valve, and lower in-hospital and late mortality. Conclusion In children, the results of mitral valve replacement were found to be inferior to those of mitral valve repair. The reoperation rates are similar in patients undergoing initial repair or replacement, which favors repair as an option. In developing world, rheumatic mitral valve disease is more prevalent where adequate facilities for monitoring of prosthetic valve function and management of anticoagulation therapy are not easily available. Valve repair therefore should be the primary goal.
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Lee CH, Laurence DW, Ross CJ, Kramer KE, Babu AR, Johnson EL, Hsu MC, Aggarwal A, Mir A, Burkhart HM, Towner RA, Baumwart R, Wu Y. Mechanics of the Tricuspid Valve-From Clinical Diagnosis/Treatment, In-Vivo and In-Vitro Investigations, to Patient-Specific Biomechanical Modeling. Bioengineering (Basel) 2019; 6:E47. [PMID: 31121881 PMCID: PMC6630695 DOI: 10.3390/bioengineering6020047] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 05/16/2019] [Accepted: 05/17/2019] [Indexed: 12/29/2022] Open
Abstract
Proper tricuspid valve (TV) function is essential to unidirectional blood flow through the right side of the heart. Alterations to the tricuspid valvular components, such as the TV annulus, may lead to functional tricuspid regurgitation (FTR), where the valve is unable to prevent undesired backflow of blood from the right ventricle into the right atrium during systole. Various treatment options are currently available for FTR; however, research for the tricuspid heart valve, functional tricuspid regurgitation, and the relevant treatment methodologies are limited due to the pervasive expectation among cardiac surgeons and cardiologists that FTR will naturally regress after repair of left-sided heart valve lesions. Recent studies have focused on (i) understanding the function of the TV and the initiation or progression of FTR using both in-vivo and in-vitro methods, (ii) quantifying the biomechanical properties of the tricuspid valve apparatus as well as its surrounding heart tissue, and (iii) performing computational modeling of the TV to provide new insight into its biomechanical and physiological function. This review paper focuses on these advances and summarizes recent research relevant to the TV within the scope of FTR. Moreover, this review also provides future perspectives and extensions critical to enhancing the current understanding of the functioning and remodeling tricuspid valve in both the healthy and pathophysiological states.
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Affiliation(s)
- Chung-Hao Lee
- Biomechanics and Biomaterials Design Laboratory, School of Aerospace and Mechanical Engineering, The University of Oklahoma, Norman, OK 73019, USA.
- Institute for Biomedical Engineering, Science and Technology (IBEST), The University of Oklahoma, Norman, OK 73019, USA.
| | - Devin W Laurence
- Biomechanics and Biomaterials Design Laboratory, School of Aerospace and Mechanical Engineering, The University of Oklahoma, Norman, OK 73019, USA.
| | - Colton J Ross
- Biomechanics and Biomaterials Design Laboratory, School of Aerospace and Mechanical Engineering, The University of Oklahoma, Norman, OK 73019, USA.
| | - Katherine E Kramer
- Biomechanics and Biomaterials Design Laboratory, School of Aerospace and Mechanical Engineering, The University of Oklahoma, Norman, OK 73019, USA.
| | - Anju R Babu
- Biomechanics and Biomaterials Design Laboratory, School of Aerospace and Mechanical Engineering, The University of Oklahoma, Norman, OK 73019, USA.
- Department of Biotechnology and Medical Engineering, National Institute of Technology Rourkela, Rourkela, Odisha 769008, India.
| | - Emily L Johnson
- Department of Mechanical Engineering, Iowa State University, Ames, IA 50011, USA.
| | - Ming-Chen Hsu
- Department of Mechanical Engineering, Iowa State University, Ames, IA 50011, USA.
| | - Ankush Aggarwal
- Glasgow Computational Engineering Centre, School of Engineering, University of Glasgow, Scotland G12 8LT, UK.
| | - Arshid Mir
- Division of Pediatric Cardiology, Department of Pediatrics, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA.
| | - Harold M Burkhart
- Division of Cardiothoracic Surgery, Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA.
| | - Rheal A Towner
- Advance Magnetic Resonance Center, MS 60, Oklahoma Medical Research Foundation, Oklahoma City, OK 73104, USA.
| | - Ryan Baumwart
- Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, OK 74078, USA.
| | - Yi Wu
- Biomechanics and Biomaterials Design Laboratory, School of Aerospace and Mechanical Engineering, The University of Oklahoma, Norman, OK 73019, USA.
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