CONTEMPORARY OUTCOMES OF AORTIC AND MITRAL VALVE SURGERY FOR RHEUMATIC HEART DISEASE IN SUB-SAHARAN AFRICA

Abstract

There is a paucity of data on outcomes of valvular surgery for end-stage rheumatic heart disease (RHD) in the developing world. The objective of this study was to evaluate the outcomes of aortic and mitral valve surgery for RHD in Ethiopia. From 2009 to 2016, 193 patients with end-stage RHD underwent aortic and/or mitral surgery at a single center in Ethiopia. These surgeries were performed in the context of 22 international humanitarian missions. Median follow-up was 2.6 (IQR: 0.5–3.8) years and 96% complete. The primary outcome was all- cause mortality. The secondary outcome was a composite of major adverse valve-related events (MAVRE): death, reoperation, stroke, major bleeding, endocarditis or structural valve deterioration. Median age was 16 (IQR: 13–22) years and 107 (55%) patients were female. Ten (5%) patients had undergone at least one previous cardiac operation. Surgery consisted of aortic valve (AV) surgery (n=24, 12%), mitral valve (MV) surgery (n=120, 62%), or double valve (aortic and mitral) surgery (n=49, 25%). Concomitant interventions included tricuspid valve repair (n=57, 30%), tricuspid valve replacement (n=3, 2%), and left atrial appendage closure (n=17, 9%). Of the 73 patients who underwent AV surgery, 22 (30%) underwent AV repair, 23 (32%) bioprosthetic AV replacement, and 28 (38%) mechanical AV replacement. Of the 169 patients who underwent MV surgery, 78 (46%) underwent MV repair, 37 (22%) bioprosthetic MV replacement, and 54 (32%) mechanical MV replacement. Mitral repair techniques included annuloplasty (n=63, 80%), commissurotomy (n=46, 58%), papillary muscle splitting (n=36, 46%), leaflet patch enlargement (n=28, 35%), and neo-chordae (n=19, 24%). In-hospital mortality occurred in 5 (2.6%) patients. Other complications included stroke (n=3, 2%), myocardial infarction (n=3, 2%), and re-exploration for bleeding (n=7, 4%). Freedom from all-cause mortality (panel A) and MAVRE (panel B) are presented in the Figure, stratified by the type of prosthesis implanted (no prosthetic valve, n=70; ≥ 1 bioprosthesis, n=55; ≥ 1 mechanical valve, n=68). Patients who received ≥ 1 bioprosthetic valve had a lower 5-year survival compared with those who received ≥ 1 mechanical valve or no prosthetic valve. At 5 years, freedom from MAVRE was significantly better for patients who received ≥ 1 mechanical valve, compared with those who received ≥ 1 bioprosthetic valve or no prosthetic valve. Left-sided valve surgery for end-stage RHD in sub-Saharan Africa is associated with a high incidence of MAVRE at follow-up. The use of bioprosthetic valves is associated with poor outcomes in this population.