Valve Repair for Rheumatic Mitral Disease llhan Mavioglu1, Orhan V. Dogan, Murat Ozeren, Alp Dolgun, Ertan Yucel
Cardiovascular Surgery Department, Ankara Teaching Hospital, Social 5ecurihJ Organization (S.SK), Ankara, Turkey, lThorax and Cardiovascular Surgery Department, Research Hospital of Faculty of Medicine, Masin University, ,v1ersin, Turkey
Background and aim of study: Mitral valve repair is the standard reparative technique for degenerative mitral disease, but results of valve repair in rheumatic disease are also encouraging. The outcomes after mitral valve repair for rheumatic disease at young age was evaluated for suitability of repair. Methods: A total of 319 patients (246 females, 73 males; mean age 31.3 ± O.S years) underwent mitral valve repair for rheumatic mitral disease at the authors' institution between 1991 and 1998. Mean follow up was Sl.9 ± 1.2 months (range: 9-98 months), and was 88.7% complete. Results: Preoperatively, 47.6% of patients were in NYHA classes III and IV. Mitral stenosis was present in 87.5%, insufficiency in 5.3%, and stenosis/insufficiency in 7.2%. Concomitant procedures were per-
Valve repair principles and techniques for mitral insufficiency (1) have become widely accepted and, following modifications and additions dictated by surgical experience, are now standardized and reproducible procedures. Indeed, today these techniques are regarded as the 'gold standard' and are carried out worldwide in the treatment of degenerative mitral dis
,i I
ease. In the treatment of this condition, mitral valve repair
has a lower mortality and morbidity, better late survival, fewer thromboembolism complications, and slightly increased reoperation rate (though in most series this is statistically not significant) than mitral valve replacement (2-4). Valve repair for rheumatic mitral disease has however been the subject of extensive debate due to the nature of the valve pathology, the difficulties of techniques, and the increased risk of reoperation (3,5,6). Therefore, we have reviewed valve
Address for correspondence: llhan Mavioglu MD, Mersin Universitesi Tip Fakultesi Hastanesi, Zeytinlibahce Caddesi, 33070, Mersin, Turkey
formed in 32% of patients who had associated cardiac lesions. The intraoperative mortality, reoperation and reoperation mortality rates were 0.9%,6.7% and 00/0, respectively. During follow up there were 10 late deaths (3.5%), six of which were cardiac diseaserelated (2.1 %). Postoperatively, 98% of patients were in NYHA classes I and II. Conclusion: Valve repair in mitral disease is a standard technique, with low mortality, complication and reoperation rates, and good cardiac function and late survival. This approach is equally applicable to rheumatic mitral valve repair; hence, rheumatic mitral valves should also be repaired.
The Journal of Heart Valve Disease 2001;10:596-602
repair results for rheumatic mitral disease retrospectively in order to evaluate the suitability of valve repair in this condition.
The authors' institution is the main referral center serving the indigenous community, which has a very low soci.oeconomic status. Consequently, the majority of patients had a history of rheumatic fever in their early life, and before the fourth decade in 83.7% of cases. The patients are generally referred late, with mitral disease which is too complex to be treated with balloon valvotomy. Consequently, most of the mixed lesions and insufficient valves would be replaced it repair would not be feasible.
Clinical material and methods
Patients Between Mav 1991 and March 1998, a total of 319
patients (246 f~males, 73 males; mean age 31.3 ± 0.: years; range: 14 to 63 years) at the authors' institution underwent mitral valve repair, mostly with the use oj
Carpentier's technique (1,7-9), for rheumatic disease Patient demographics, together with intraoperativE
Total associated lesions 102 (32.0) Total 319 (l00) Results
perioperative mortality 3 (0.9) Follow up 283 (88.7) Mean (± SE) follow up (months) 51.9 ± 1.2
and perioperative data, were reviewed retrospectively tionally in suspect cases with mixed or insufficient from the patient files and the repair charts. A preoper valve lesions or left atrial thrombus. Cardiac catheterative diagnosis was made with transthoracic echocar ization and coronary angiography were also used to diography in all cases, with confirmatory evaluate the associated lesions. NYHA functional class transesophageal echocardiography being used addi- (0), the presence of atrial fibrillation, cardiothoracic
Table II: Surgical procedures.
Procedure
Mitral procedure Open mitral commissurotomy Mitral valve repair (complex) Mitral ring annuloplasty
First associated procedure Aortic valve replacement Aortic valve repair Tricuspid valve repair Coronary bypass grafting ASD repair . Tricuspid ring annuloplasty Open tricuspid commissurotomy Left ventricular cystectomy Total
Second associated procedure Tricuspid valve repair Open tricuspid commissurotomy Aortic valve replacement Tricuspid ring annuloplasty Total
598 Rheumatic mitral valve repair I. Mavioglu et al.
ratio and echocardiography findings (including insufficiency grade, mitral valve area (MVA), mitral pressure gradient (MPG) and left atrial diameter (LADx») were recorded prospectively onto the repair study charts.
Preoperatively, 47.6% of the patients were in NYHA classes III and IV, and almost half of these had congestive heart failure. Mitral stenosis was present in 87.5% of patients, insufficiency in 5.3%, and stenosis/insufficiency in 7.2%. One or two concomitant cardiac procedures were performed in 32% of the patients because of the associated cardiac lesions (Table D.
Srugical procedures Different valve repair procedures (commissurotomy,
papillary muscle division, calcification debridement, posterior leaflet quadrangular resection, posterior leaflet patch plasty, chordal shortening, chordal transposition, cleft repair and ring implantation) and concomitant cardiac procedures were applied according to underlying valvular and other cardiac pathology. These are detailed in Table II.
Follow up Questionnaire forms were sent to all survIvmg
patients inviting them to attend a control examination, commencing from the end of 1998. Due to the low socioeconomic status of the patients, follow up was only 88.7% complete at the end of 1999. The mean follow up duration was 51.9 ± 1.2 months (range: 9 to 98 months). At the control investigation, a clinical examination was carried out; in addition, electrocardiography, x-ray and echocardiography were each performed and the data were recorded onto the repair study charts.
Statistical analysis Data were collected and managed as a Microsoft
Excel chart and analyzed with SPSS for Microsoft Windows statistical analysis software.
Preoperative and postoperative categorical parameters were analyzed univariately with a chi-square test. Survival and late morbidity data were evaluated univariately using life-tables (and compared with the Wilcoxon method), and'multivariately using a Cox regression analysis.
Results
The perioperative mortality rate was 0.9% (n = 29). Death occurred only in those patients who underwent concomitant cardiac procedures, the causes being low cardiac output syndrome and myocardial infarction.
Data from the repair study charts were analyzed and showed reductions in NYHA class (Table III), atrial fib-
J Heart Valve Dis Vol. 10. No.5
September 2001
100
90 9~ 84,7%
80
70
60
50
40 1 30
I
20 I1Nom'-"' "",,~" ~ ,;,kI I10
280 240 131 27 o 4
0 24 48 72 96 120
months
Figure 1: Overall survival in 319 patients.
100 --:
90 , - ,,, P=,OO2580 ,,
'----~,
70 5yrs 8yrs Class IV 74,4±11,7% 53,2±19,8%
60 Class ill 96,3±2,6% 96,3±2,6% Class II 98,6±1,4% 91,3±7,2% ,
1____
50
Preop NYEA40 Class IV .............
III ____Class 30
Class II - 20 Number of patients at risk
39 33 18 4 1 10 89 78 42 9 2
152 129 71 14 20
0 24 48 72 96 120
months
Figure 2: Reduction in overall survival in relation to NYHA functional class.
rillation, LADx and MPG, and an increase in MVA (Table IV). Despite no specific procedure being performed to alleviate atrial fibrillation, a significant number of patients returned spontaneously to normal sinus rhythm. This may have been due to the use of superior left atriotomy incision to facilitate better exposure for repair procedures.
01
J Heart Valve Dis Vo!' 10 No.5 September 2001
I II III rv Total
Parameter
CTI >50'hJ (n)
Atrial fibrillation (n) MVA (cm2)
MPG (mmHg) LA diameter (mm)
Table III: Preoperative and postoperative NYHA classification.
Preoperative n (%)
167 (52.4) 103 (32.3) 49 (15.4) 319(100)
Table IV: Comparison of preoperative and postoperative data.
Survival statistics Ten late deaths (four from non-cardiac causes) were
identified among the review of questionnaire forms. The overall five- and eight-year survivals were 94.1 ± 2.4% and 84.7 ± 6.9%, respectively (Fig. 1). The best predictor of late death in patients with rheumatic mitral valve disease was advanced age (p = 0.0001). N'YHA functional class showed a tendency towards being predictive, but not statistically significantly so. However, based on life-table analysis, and when
100 ! 96,0%
90 1 80 j 70 1 60
% 50
40
30
20 ~ I Number of patients at risk
10 oji 280 239 130 26 a o ~
24 48 72 96 120
months
Figure 3: Freedom from cardiac death in patients undergoing mitral valve repair.
Rheumatic mitral valve repair 599 1. Jvfavioglu et al.
NYHA class was compared using the Wilcoxon statistics, NYHA class IV was seen to be a significant factor for reduced survival (p =0.0025) (Fig. 2).
Cardiac-related death The five- and eight-year freedoms from cardiac
death, including valve-related causes, were 96.0 ± 2.1 % and 89.8 ± 6.3%, respectively (Fig. 3). The type of valve pathology, the choice or number of mitral repair procedures applied (simple versus more complex repairs)
100
90 8S, tit:
80
70
60
% SO ~
I40 1 30 i 20 ~
I
I Number of patients at risk 10 1281 240 134
0 l 0 24 48
Postoperative n (%)
218 (77.0) 59 (20.8) 6 (2.1)
283 (100)
p-value
<0.0001 <0.0001 <0.0001 <0.0001 <0.0001
79,,'
27 . 72
I i ~ !
96
I I I
01
120
months
Figure 4: Freedom from reoperation in patients undergoing mitral valve repair.
600 Rheumatic mitral valve repair I. Mavioglu et al.
100
90
80
2-/002270
60
% 5 Y"so MS 89,7±3.0o/a
' MI 6O,4±21,S%40 MS+MI 91,7±8,O%
30
20 Number of patients. at risk Kl. t.r,al Pa thology 245 204 119 26 MS 13 13 4 1 MS+MI
10 23 23 12 1 MI
24 48 72 96 120
months
Figure 5: Freedom from reoperation according to mitral diagnosis at initial operation.
and associated other cardiac lesions (concomitant coronary artery bypass, or aortic or tricuspid valve procedures) did not directly affect late survival. The best predictors of late cardiac death were NYHA class (p = 0.048) and advanced age (p = 0.002).
Reoperation Nineteen patients underwent reoperation, and there
were no mortalities. The mean period to reoperation was 44.S:+; 5.0 months (range: 6 to 85 months) after the initial surgery. Five early reoperations were performed during the first two postoperative years; this was due to restenosis in three patients, to insufficiency in one patient, and to restenosis/insufficiency in one. Fourteen late reoperations were performed after this two-year period. The five- and eight-year freedoms from reoperation were 88.6 ± 2.9% and 79.7 :+; 6.7%, respectively (Fig. 4). The risk of reoperation was predicted by the nature of the mitral pathology at the initial operation, namely mitral insufficiency (p = 0.001), the associated cardiac procedure (p = 0.001) and associated tricuspid disease (p= 0.017). Therefore, the complexity of the repair and the concomitant cardiac procedures (especially tricuspid) were associated with the risk of late reoperation. The five-year_ freedom from reoperation was 89.7 ± 3.0% for mitral stenosis (875% of patients), 91.7 ± 8.0% for mixed stenosis and insufficiency (7.2% of patients), and 60.4 :+; 21.7% for mitral insufficiency (5.3% of patients) (p = 0.0022) (Fig. S).
Discussion
In developing countries, the etiology of mitral valve disease - especially in patients of younger age - is mostly rheumatic fever, mainly because of insufficient prophylaxis. The problems associated with mitral valve replacement have, by necessity, led to the devel-
JHeart Valve Dis , Vol. 10. No.5
September 2001
opment of mitral valve repair in these rheumatic patients. Open mitral commissurotomy (OMC) is a well-known procedure which has a long-term history of success (11), and is especially preferred for calcific or thrombotic valves. In fact, OMC creates a larger MV A and provides better functional recovery and a lower reoperation rate than does percutaneous balloon dilatation for mitral stenosis (12-16). In the present series, OMC was used more often than balloon valvotomy because 32% of the patients had an associated lesion requiring intervention, 11 % (34 of the 40 patients with mixed lesion or myocardial infarction) required a complex mitral repair procedure with a pure mitral disease, and another 30% were unsuitable for balloon valvotomy because of calcification, apparent subvalvular deformation or suspected thrombus in the left atrium. In the 15% of patients who were suitable for balloon valvotomy but could not receive treatment for social reasons and lack of referral, OMC was the technique of choice on the basis of its good longterm results and better cardiac function than would be provided by closed valvotomy.
Many improved and/or additional repair techniques have been successfully introduced for the repair of mitral valve since Carpentier's first repair of mitral insufficiency (1,8-10). In the best-known published series, mitral valve repair procedures - particularly for degenerative disease - have resulted in an increased long-term success rate, lengthened survival, better ventricular function, and lower rates for both reoperation and complications of thromboembolism (4,8,9,17).
When replacement is compared with repair, the latter is seen increasingly to be superior in many respects. Long-term survival, valve-related mortality and morbidity are all worse after replacement with a mechanicalor bioprosthetic valve (2,3,18). In the present study, we reviewed the medium- and long-term results in an attempt to define the suitability of mitral valve repair for rheumatic patients, and in so doing identified fiveand eight-year survival rates of 94% and 85%, respectively. These are ?uperior to the five- and ten-year values of 80-88% and 70-75% achieved after replacement as published in the literature (3,5,18). This difference might in part be due to the younger age of the patients in the present series, although we firmly believe that valve repair patients had a longer survival independent of age.
The major problem associated with valve repair, especially for rheumatic patients, is that of reoperation. In fact, as the typical patient age becomes younger, unlike in the Western world, the requirement for reoperation is increasing accordingly. Among the present patients, 19 survived reoperation, this reduction in mortality being largely attributed to improve
JHeart Valve Dis Vol. 10. No.5 September 2001
ments in technology, together with increased experience of the surgeons. As shown in the present series, reoperation is not considered to be a significant risk factor for mortality.
A thorough analysis of mitral valve structure, leaflet pliability and thickness, loss of leaflet area, length of chordae and papillary muscles, annular dilatation, calcification and degree of associated regurgitation was necessary to prevent early failure of mitral valve repair. Failure to recognize anatomic details may result in procedure-related failure. Most mitral valve repair failures appeared to be valve-related (progressive primary valve disease, endocarditis or leaflet retraction) in rheumatic mitral disease, but were procedure-related (suture dehiscence, rupture of the previously shortened chordae or incomplete initial repair) in degenerative mitral disease in the Cleveland experience (19). Simple commissurotomy versus complex repair did not increase the reoperation risk significantly; however, rheumatic mitral insufficiency as the initial pathology was associated with an increased risk for reoperation in the present series, although the number of patients in this category was small.
Fernandez and colleagues have reported the actuarial freedom from mitral reoperation to be 90% at five years, and 80% at eight years, in patients who had either pure mitral insufficiency or isolated mitral stenosis. This compared with 80% and 72% at five and ten years, respectively, in patients who had mixed mitral stenosis and insufficiency (20). In the present study, there was no increased rate of reoperation for mixed lesions, though the number of patients in this category was small. Other associated valvular lesions increased the risk of reoperation; 13 of the 19 patients who underwent reoperation had associated tricuspid and!or aortic valve disease. In a study conducted to repair mild to moderate aortic valvular involvement during mitral repair until 1997, six patients whose aortic valves were repaired also required reoperation, primarily for aortic disease. The functional results of reparative procedures of non-severe rheumatic aortic valve disease have been inadequate, and conservative operations for rheumatic aortic valve disease do not seem appropriate (21). Szentpetery and colleagues reported a five-year survival of 75%, and a ten-year survival of 67% (all causes) after combined aortic valve replacement and mitral repair in patients whose average age was 57 years, and of whom 50% were originally high risk (22). Aortic valve replacement also had no significant influence on survival and reoperation in the present series.
To conclude, and based on our experience with the technique, our method of choice for all rheumatic mitral disease patients is valve repair whenever the valve pathology is appropriate, irrespective of the
Rheumatic mitral valve repair 601 I. Mavioglu et al.
presence or absence of other concomitant valvular pathologies.
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