Valve Repair For Rheumatic Disease Research Articles

Early and Midterm Outcomes of Rheumatic Mitral Valve Repair.

Rheumatic heart disease (RHD) is the leading cause of mitral valve disease in the developing world. In general, mitral valve repair is preferred over replacement. Although it is very successful in degenerative disease, its results in the rheumatic valve are not as successful as that for degenerative repair. Our approach has been to repair rheumatic mitral valves when the anatomic substrate appears to permit it, and we aimed by this study to present our immediate and midterm follow-ups of our cohort of rheumatic valve repair patients. From February 2011 to March 2013, 52 consecutive patients underwent mitral valve repair for rheumatic disease with different surgical techniques at the National Heart Institute of Egypt. Patients who had concomitant aortic or coronary artery bypass surgery were excluded. Also, patients needing an emergency operation or redo ones were excluded. On the contrary, patients who had concomitant tricuspid valve surgery were included. Demographic, intraoperative, and perioperative outcome data were recorded prospectively. All patients underwent TTE before hospital discharge. During follow-up, patients were contacted by telephone and invited for follow-up TTE yearly after their operations. Fifty-two patients with rheumatic disease underwent mitral repair. Their mean age was 25.92 ± 9.81 years. The study population was 78.8% female. Forty-nine patients were in New York Heart Association functional class III or IV. Repair procedures included implantation of Carpentier-Edwards Classic mitral annuloplasty ring (100% of the whole study group). Mitral commissurotomy and repair of the subvalvular apparatus were generally performed. Thirteen neochordae were implanted. Anterior leaflet extension with an autologous pericardial patch was used in 4 patients; annular decalcification, in 2 patients; tricuspid repair with De Vega technique, in 18 patients (34.5%); and repair with Carpentier-Edwards Classic tricuspid annuloplasty ring, in 9 (17.3%) patients. There was no operative mortality. The mean follow-up time was 59.9 ± 5 postoperative months (range, 49-60 months). Only 2 patients (3.8%) died. Follow-up echocardiography revealed more-than-or-equal-to-moderate (2+) grade of MR in 5 patients. During the follow-up period, the mean LV end-diastolic diameter decreased significantly from 5.57 ± 1.06 cm to 4.93 ± 0.74 cm (<0.001). The mean pulmonary artery pressure decreased from 44.94 ± 17.01 mmHg to 35.69 ± 7.92 mmHg postoperatively (P < .001). The mean mitral valve area increased from 1.2 ± 0.9 cm2 to 2.3 ± 0.2 cm2 postoperatively (P < .001). The mean mitral valve gradient decreased significantly from 12 ± 4.9 mmHg to 4.3 ± 1.9 mmHg postoperatively (P < .001). The mean MR grade decreased from 3.73 ± 0.45 to 0.96 ± 1.08 postoperatively (P < .001). We conclude that repair is possible in patients with rheumatic mitral valve dysfunction. Current techniques with some modifications can be efficient to restore both the anatomy and physiology (better function) of the mitral valve and can lead to favorable early and midterm outcomes. We, therefore, recommend that the number of rheumatic mitral repair procedures should be increased in developing countries to achieve the best results.

Editorial Comment: Repair of rheumatic mitral valve regurgitation: how far can we go?

In two papers published in this issue of the Journal [1, 2] and presented at the last EACTS Annual Meeting, the group from the National Heart Institute of Kuala Lumpur, Malaysia, discuss their long-term experience of repair for rheumatic mitral valve regurgitation, with the aim of identifying predictors of durability and of comparing them with repairs for degenerative mitral valves, in one of the manuscripts, and to analyse a particular aspect of the technique of repair—leaflet extension, in the other. Mitral valve repair for rheumatic disease is commonly believed to yield poorer results by comparison with other aetiologies, especially degenerative. This is a natural consequence of the evolutive nature of the rheumatic process, which continues to distort the valve apparatus even beyond a successful repair. These rheumatic populations from developing countries are characterized by the low mean age of 20–30 years (32 years in the current series) [3], which renders them susceptible to further bouts of the disease. Hence, antibiotic prophylaxis must be continued until a much older age, at least to 40 years, and the WHO now recommends life-long prophylaxis in patients with severe valve disease or who have had valve surgery [4]. But it is essential to recognize that valve replacement in rheumatic populations also has poorer outcomes, in some reports clearly worse to those of repair, mainly due to deficient socio-economic conditions. My own experience with a similar population in Johannesburg, South Africa, attests to the superiority of repair in these patients [5]. Others have reported similar experiences [6]. It is, however, necessary to distinguish between the rheumatic disease of these patients and that of series originating from developing countries. The latter, now a rarity, represents a different stage of the disease and the mean age of the patients is much higher ( 50 years) [7]. In this case, the histological process has stabilized and most patients only have dilatation of the annulus. Hence, in the absence of significant calcification, the feasibility of repair is higher and the results better. During a 14-year period, the group from Kuala Lumpur repaired the mitral valves of 627 patients, predominantly with regurgitation, a number similar to that done for other aetiologies, and found that the actuarial freedom from valve failure for rheumatics at 5 and 10 years was 85.6 ± 2.3 and 72.8 ± 4.6%, respectively, similar to that for degenerative valves. Although this study has the limitation, acknowledged by the authors, of being a single-centre non-randomized series, it certainly adds to the evidence that contemporary repair of the rheumatic mitral valve is possible in the majority of patients and has excellent results, hence should be the procedure of choice also for this pathology and in these populations. What has changed in recent years that so significantly improved the outcomes? In my opinion, the use of artificial chordae made of polytetrafluoroethylene, to replace ruptured chordae or to re-inforce elongated chordae, has had the most impact. The majority of patients with rheumatic regurgitation have prolapse of the anterior leaflet due to elongated chordae tendineae. In the past, this was treated by one of the techniques of chordal shortening or transfer, as originally described by Carpentier [8]. But with progression of the rheumatic process, the chordae continue to elongate or rupture, causing the repair to fail. For this reason, most surgeons, lately also Carpentier, have turned to the artificial chordae to re-level the free edges of the leaflets to promote adequate coaptation. This can be used even in the younger and smaller patients, and several studies have confirmed the superiority of the results [9]. Another technical alternative which has evolved in the past two decades is leaflet extension, to increase leaflet area and coaptation surface, which is the subject of the second paper authored by the Kuala Lumpur group. The authors treated 62 of 446 rheumatic patients by leaflet extension with glutaraldehydetreated autologous pericardium as part of their mitral repair. The authors analysed prospectively the clinical and echocardiographic data of the patients and found the estimated 5-year freedom from reoperation and valve failure to be 96.8 and 91.6%, respectively, but the follow-up extended for only a little over 3 years, which is much too short to draw definitive conclusions. Leaflet extension is not new. It was used extensively by some of us in the late 1970s and early 1980s, but the results then reported were not very encouraging, most patients developing mixed regurgitation and stenosis due to shrinkage and thickening of the pericardium. But in those days the autologous pericardium was used untreated. The glutaraldehyde-treated pericardium was introduced later as a sequel of the utilization of the similarly treated bovine pericardium, for different uses. The current study of Dillon et al.

Combined Mitral and Tricuspid Valve Repair in Rheumatic Valve Disease

We examined predictors of early and very long-term outcome after combined mitral and tricuspid valve repair for rheumatic disease. Between 1974 and 2002, 153 consecutive patients (mean age, 46.0+/-13.2 years) underwent combined mitral and tricuspid valve repair for rheumatic disease. Mitral disease was predominantly stenosis (82.3%); 100% of patients had organic tricuspid valve disease, predominantly with regurgitation (53.6%) or some degree of tricuspid stenosis (46.4%). Mitral repair included commissurotomy in 132 patients (86.3%) associated with a flexible annuloplasty in 108. Tricuspid valve repair included flexible annuloplasty in 68 patients (44.4%) and suture annuloplasty in 20 patients (13.1%) combined with tricuspid commissurotomy in 62 patients (42.5%). Thirty-day mortality was 5.9%. Late mortality was 60.1%. The median follow-up was 15.8 years (interquartile range, 6 to 19 years). Follow-up was 97.9% complete. Age>65 years was the only predictor of late mortality. Kaplan-Meier survival probability was 74.4% at 10 years and 57.0% at 15 years. Sixty-three patients required valve reoperation (mitral valve, 59; tricuspid valve, 38). Predictors of valve reoperations were either mitral or tricuspid commissurotomy without associated prosthetic ring annuloplasty. At 20 years, Kaplan-Meier freedom from reoperation was 48.5+/-5.1%. Combined mitral and tricuspid valve repair in rheumatic disease showed satisfactory early results. Long-term results were poor because of high mortality and a high number of valve-related reoperations. The use of prosthetic ring annuloplasty was significantly associated with a reduced incidence of both mitral and tricuspid valve reoperations.

Extending the Scope of Mitral Valve Repair in Rheumatic Disease

Extending the Scope of Mitral Valve Repair in Rheumatic Disease

A Mıtral Valve Reconstructıon Case After 16 Years Of Closed Mıtral Commıssurotomy

Mitral stenosis is the most frequently encountered valvular pathology and may require surgical intervention when the lesion is severe in rheumatic etiology.It is now clearly established that restoration of a normal mitral valve function with reconstructive surgery is preferable to replacement with a device,whether bioprosthetic or mechanical. Closed mitral comissurotomy(CMC) was the first effective intervention in valvular heart disease. In this study we're presenting a new valve reconstruction technique used successfully in reoperation of a case who had CMC operation 16 years ago and symptomless up to last 4 months and the first patient repaired successfully after CMC.Mitral valve repair in rheumatic disease is technically difficult.From a purely surgical point of view,a safe myocardial protection,excellent valve exposure,and a direct visual testing method for competence are also essential.However excellent long-term results support flexibility in mitral valve repair.

Extending the Scope of Mitral Valve Repair in Rheumatic Disease

Repair of rheumatic mitral valves has met with limited success because hemodynamic obstruction may persist after repair because of residual diseased leaflet tissue and lack of suppleness. Over the past decade, we have developed and implemented an aggressive approach to rheumatic mitral valve repair with radical excision of the diseased leaflets area, and subvalvular apparatus and subsequent reconstruction, with the objective of removing all diseased valvular tissue. From July 1996 to June 2007, 78 patients underwent mitral valve repair for rheumatic valve disease. Over the same time interval, 54 patients underwent mitral valve replacement. Mean age was 56.4 +/- 16 years. Clinical follow-up (mean 60 +/- 36 months) was complete in 100% of patients, and echocardiographic follow-up (mean 52 +/- 37 months) was 96% complete. There was no hospital mortality or early reoperations. Overall survival was 94% +/- 6% at 8 years, and 95% of patients were in New York Heart Association functional class II or less. Three patients (4%) required reoperation for mitral restenosis and 2 underwent re-repair. At 8 years of follow-up, freedom from cardiac death and mitral valve reoperation were 98% +/- 2% and 94% +/- 5%, respectively. Freedom from valve-related events at 5 and 10 years was 90% +/- 8% and 86% +/- 11%, and freedom from significant mitral regurgitation was 98% +/- 2% at 5 years and 83% +/- 9% at 8 years. A more aggressive approach to resection of diseased valvular tissue with subsequent reconstruction is feasible, with good midterm results, and may extend the scope of valve repair in rheumatic disease patients.

Mitral Valve Repair in Rheumatic Disease with Giant Left Atrium

Mitral Valve Repair in Rheumatic Disease with Giant Left Atrium

Mitral Valve Repair in Rheumatic Disease: Early Results

Mitral valve repair is an accepted method of treating severe mitral valve disease due to rheumatic fever, Valve repair confers fewer complications and better survival as compared to mitral valve replacement. Since commencing open-heart surgery at SGNHC, 49 mitral valve repair operations have been performed here. There were 25 male and 24 female patients. The average age was 28.7 years (5 - 68 years). All were symptomatic with significant dyspnoea and palpitation. Other symptoms were hemoptysis in eight, peripheral embolism in one and CNS embolism in four. Associated lesions included ASD in three, an ASD and constrictive pericarditis in one and a pseudoaneurysm of the left common iliac artery with PDA in the fifth. One patient had undergone CMV nine years before presentation.

Mitral valve repair for rheumatic disease in the young

Mitral valve repair for rheumatic disease in the young

Mitral valve repair in rheumatic disease. The flexible solution.

Mitral valve repair in rheumatic disease is technically more difficult, and there is little information on the long-term stability of this technique. From January 1975 to December 1990, 327 patients underwent mitral valve repair with the Duran flexible ring annuloplasty for rheumatic valve disease. Mean age was 45.4 +/- 12.6 years (range, 23 to 73 years). The techniques used for valve repair include a Duran flexible ring annuloplasty in all cases, commissurotomy in 272 (83.2%), papillary muscle splitting in 171 (52.3%), and subvalvular apparatus repair in 59 patients (18.0%). One hundred one patients required associated tricuspid valve surgery (30.8%). Hospital mortality was 3.36%, being lower for patients with isolated mitral valve repair (2.7%) than those with mitrotricuspid surgery (4.9%). Mean follow-up was 8.6 years (range, 1 to 17 years) and was 96.5% completed. Thirty-four patients required reoperation for severe mitral insufficiency in 12, mitral restenosis in 18, and aortic valve disease in 4. The actuarial curve free from reoperation for mitral cause at 16 years is 89.9 +/- 3.2%. Late mortality occurred in 42 patients (13.2%). Actuarial survival curve at 16 years is 84.0 +/- 3.2% for isolated mitral valve repair and 64.6 +/- 6.7% for mitrotricuspid patients. Mitral valve reconstruction with Duran flexible ring annuloplasty in rheumatic valve disease entails a low hospital mortality with satisfactory long-term clinical results.

Mitral valve repair for rheumatic disease in developing countries: Is India a special case?

Mitral valve repair for rheumatic disease in developing countries: Is India a special case?