PII: S0003-4975(99)01371-5

Abstract

The article by Kitamura and colleagues describes an interesting technique for the repair or salvage of rheumatically damaged valves beyond the reaches of percutaneous or surgical commissurotomy. The technique has some characteristics of deja vu in relation to the aortic decalcification rage more than a decade ago that ended in universal aortic regurgitation due to scarring and retraction of the leaflets. In considering this form of cosmesis for valve repair, it must be accompanied with at least a word of caution. The mechanism of valve destruction in rheumatic heart disease is not a superficial shroud over a structurally intact valve. Rheumatic valvular heart disease is a progressive inflammatory process involving all layers of the leaflets with inflammatory cells, scarring, and calcification. Valve replacement removes the valvular inflammatory process from the equation. To cosmetically carve or “rasp” a structure resembling a valve leaflet does not correct or eliminate the process. Rheumatic valve disease is frequently an indolent and progressive disease and will continue to cause tissue reaction, retraction, and inflammation. Although the early results may be acceptable, understanding the inflammatory process will cause these patients to return with progressive valve disease in the future. However, there may be continental differences in this disease process. In rheumatic patients in the United States, the valve seen at the time of operation is in elderly patients and is knarled and retracted such that any repair is not possible. Rheumatic involvement causes a disarray of the basic structural components of the valve, and gross remodeling or rasping will not recreate the intricate and organized layered structure of the native valve leaflets. It will be crucial that these patients are followed diligently before any widespread application of the rasping procedure is performed [1Freeman W.K. Schaff H.V. Orszulak T.A. Tajik A.J. Ultrasonic aortic valve decalcification serial Doppler echocardiographic follow-up.J Am Coll Cardiol. 1990; 16: 623-630Crossref PubMed Scopus (36) Google Scholar, 2Hanson T.P. Edwards B.S. Edwards J.E. Pathology of surgically excised mitral valves.Arch Pathol Lab Med. 1985; 109: 823-828PubMed Google Scholar, 3Waller B. Howard J. Fess S. Pathology of aortic valve stenosis and pure aortic regurgitation. A clinical morphologic assessment—Part I.Clin Cardiol. 1994; 17: 85-92Crossref PubMed Scopus (20) Google Scholar, 4Waller B.F. Howard J. Fess S. Pathology of mitral valve stenosis and pure mitral regurgitation—Part I.Clin Cardiol. 1994; 17: 330-336Crossref PubMed Scopus (46) Google Scholar, 5Waller B.F. Howard J. Fess S. Pathology of mitral valve stenosis and pure mitral regurgitation—Part II.Clin Cardiol. 1994; 17: 395-402Crossref PubMed Scopus (20) Google Scholar, 6Subramanian R. Olson L.J. Edwards W.D. Surgical pathology of combined aortic stenosis and insufficiency. A study of 213 cases.Mayo Clin Proc. 1985; 60: 247-254Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar, 7Subramanian R. Olson L.J. Edwards W.D. Surgical pathology of pure aortic stenosis. A study of 374 cases.Mayo Clin Proc. 1984; 59: 683-690Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar, 8Agozzino L. Falco A. de Vivo F. de Vincentiis C. de Luca L. Esposito S. Cotrufo M. Surgical pathology of the mitral valve gross and histological study of 1288 surgically excised valves.Int J Cardiol. 1992; 37: 79-89Abstract Full Text PDF PubMed Scopus (24) Google Scholar, 9Turri M. Thiene G. Bortolotti U. Milano A. Mazzucco A. Gallucci V. Surgical pathology of aortic valve disease.Eur J Cardiothorac Surg. 1990; 4: 556-560Crossref PubMed Scopus (36) Google Scholar].