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Original Article
Mitral valve repair for rheumatic mitral regurgitation: Mid-term results
Asian Cardiovascular & Thoracic Annals 0(0) 1–7 ß The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492315576282 aan.sagepub.com
Somchai Waikittipong
Abstract Aim: This retrospective study was undertaken to evaluate the midterm results of mitral valve repair for rheumatic mitral regurgitation, in term of survival rate and late valve failure. Methods: From January 2003 to January 2014, 97 patients underwent mitral valve repair in our hospital. Age ranged from 8 to 74 years, mean 24 1.4 years; 74 (76%) patients were female. Mean preoperative functional class was 2.47 0.07. Mean preoperative ejection fraction was 59.9% 2%. The lesions were pure mitral regurgitation in 79 (81.4%) patients, predominant mitral regurgitation with stenosis in 9 (9.3%), and predominant mitral stenosis with regurgitation in 9 (9.3%). Seventy-one (73%) patients were in normal sinus rhythm. Results: One patient died in the postoperative period, and 8 were lost during follow-up. Follow-up time ranged from 6 to 137 months, mean 58.8 4.2 months. There were 6 late deaths. Actuarial survival at 5 and 10 years was 95.5% and 89.2%, respectively. Twenty-seven (27.8%) patients had mitral regurgitation during follow-up, and 7 underwent reoperation with no hospital mortality. Freedom from reoperation at 5 and 10 years was 94.5% and 82.7%, respectively. Freedom from reoperation or progression of mitral regurgitation at 5 and 10 years was 70.4% and 61.8%, respectively. Freedom from all late events at 5 and 10 years was 68 % and 56.4%, respectively. Conclusions: Mitral valve repair for rheumatic mitral regurgitation is associated with a significant rate of valve failure and reoperation. However, it has a satisfactory survival rate and is a good alternative to valve replacement, especially for young patients, to avoid the life-long risks of a prosthetic valve.
Keywords Mitral valve, mitral valve insufficiency, postoperative complications, rheumatic heart disease, treatment outcome
Introduction
Patients and methods
Mitral valve repair is the procedure of choice for degenerative mitral valve disease because it has lower rates of thromboembolism, reoperation, and endocarditis compared to mitral valve replacement.1,2 It also preserves left ventricular function better than mitral valve replacement. Rheumatic heart disease is still a common cause of mitral valve disease in developing countries, including Thailand.3 However, mitral valve repair in rheumatic heart disease is more technically demanding,4 and the risk of reoperation is higher than in degenerative valvular heart disease.5 The aim of this study was to evaluate the midterm results of mitral valve repair in rheumatic mitral regurgitation (MR), in terms of survival rate, effectiveness and durability of the procedure, and reoperation rate.
This study was approved by the committee on ethical research of Yala Hospital. From January 2003 through January 2014, 116 consecutive patients with rheumatic MR underwent mitral valve repair in our hospital. Patients with aortic valve operations were excluded from this retrospective study; there were 97 patients eligible for inclusion in the analysis. Age ranged from 8 to 74 years, mean 24 1.4 years, median 19 years. Thirty-three (34%) patients were 15-years old or
Department of Surgery, Yala Hospital, Yala, Thailand Corresponding author: Somchai Waikittipong, MD, Department of Surgery, Yala Hospital, Maung, Yala, Thailand 95000. Email: [email protected]
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Figure 1. Age and sex distribution of 97 patients with rheumatic valve disease.
younger, and 13 (13.4%) were aged 12 years or younger. There were 74 females and 23 males. The distribution of patients according to age and sex is shown in Figure 1. The preoperative New York Heart Association (NYHA) functional class was III-IV in 45 (46.4%) cases; the mean NYHA class was 2.47 0.07, median 2.0. Twenty-six (26.8%) patients were in atrial fibrillation. The mitral valve lesion consisted of pure regurgitation in 79 (81.4%) patients, predominant regurgitation with stenosis in 9 (9.3%), and predominant stenosis with regurgitation in 9 (9.3%). The mean left ventricular ejection fraction on echocardiography was 59.9% 2%. Ten patients had associated lesions: atrial septal defect in 8 and ventricular septal defect in 2. The type of leaflet motion according to the classification of Carpentier6 was assessed by preoperative echocardiography and confirmed during surgery (Table 1). Restricted leaflet motion of the posterior leaflet was the most common functional finding. The combination of restricted posterior leaflet with prolapsed anterior leaflet was found in 6 patients. The surgical procedures are listed in Table 2. Ninety-four patients (97%) were treated by ring annuloplasty. Restriction of the leaflet was treated by leaflet mobilization techniques such as resection of secondary and tertiary chordae, splitting of the papillary muscle, and commissurotomy if there was commissural fusion. Prolapse of the leaflet was treated by various techniques depending on the lesion, such as chordal replacement with PTFE suture (WL Gore & Associates, Inc., USA), chordal transfer, or chordal shortening at the valve level. Since 2010, leaflet enlargement with autologous
Table 1. Intraoperative findings according to leaflet function classification in 97 patients with rheumatic valve disease. Mitral leaflet function
No. of patients
Type I: normal leaflet motion Annular dilatation Type II: leaflet prolapse Anterior leaflet Posterior leaflet Anterior þ posterior leaflets Type III: restricted leaflet motion Posterior Posterior þ anterior
9 (9.3%) 9 26 (26.8%) 10 14 2 62 (63.9%) 44 18
glutaraldehyde-treated pericardium was used in 3 patients with a too-small retracted anterior leaflet. Tricuspid annuloplasty was performed in 33 (34%) patients: flexible band implantation in 5, rigid ring implantation in 8, De Vega annuloplasty in 7, and posterior plication in 13. Associated operations were performed in 10 patients: closure of atrial septal defect in 8, and closure of a ventricular septal defect in 2. All patients were seen at 3- or 4-monthly intervals by a surgeon in the outpatient department. Echocardiography was performed annually or whenever an abnormal murmur was found. Eight (8.2%) patients were lost during follow-up. Follow-up time ranged from 6 to 137 months, mean 58.8 4.2 months, median 49 months. All patients under 35 years of age were given
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Table 2. Surgical techniques in 97 patients with rheumatic mitral valve disease. Surgery
No. of patients
Annuloplasty Flexible ring* Rigid ringy Semi-rigid ringz Pericardium Leaflet mobilization Commissurotomy Chordal replacement Chordal transfer Chordal shortening Leaflet resection Leaflet augmentation
49 24 21 1 60 19 21 9 5 4 3
(50.5%) (21.6%) (21.6%) (1%) (61.9%) (19.6%) (21.6%) (9.3%) (5.2%) (4.1%) (3.1%)
*Cosgrove-Edwards. yCarpentier-Edwards Classic. z Carpentier-Edwards Physio.
oral penicillin. Patients in normal sinus rhythm were given warfarin for 2 months, and those in atrial fibrillation were given lifelong warfarin. Mean standard deviation and median values were calculated for continuous variables. Simple percentages were used to express categorical variables. Late survival and the occurrence of clinical outcomes during the follow-up period were calculated by Kaplan-Meier analysis.
Results One (1%) patient died in the postoperative period. The cause of death was postoperative low cardiac output. There were 6 (6.1%) late deaths due to endocarditis in 1 case and sudden unexplained death in 5. All patients with sudden unexplained death had no residual MR before discharge. The actuarial survival at 5 and 10 years was 95.5% and 89.2%, respectively (Figure 2). One patient developed a cerebral embolism. This patient had predominant mitral stenosis with regurgitation. She had preoperative atrial fibrillation and continued receiving anticoagulants. However, she developed a cerebral embolism 10 years after the operation. No patient had anticoagulant-related complications. There were 27 (27.8%) patients who had MR during follow-up: grade 1 in 12, grade 2 in 13, and grade 3 in 2. Seven patients underwent reoperation with no hospital mortality. The interval between the first operation and reoperation ranged from 4 to 99 months. Findings at reoperation revealed that the causes of MR were progression of residual MR in 5 patients and recurrence of MR from disease progression in 2. One patient is awaiting reoperation. The
remaining patients are in NYHA functional class I or II. Freedom from reoperation at 5 and 10 years was 94.5% and 82.7%, respectively (Figure 3). The causes of late MR in all patients were residual MR in 9 patients and progression of the valve lesion in 18. The freedom from reoperation or progression of MR at 5 and 10 years was 70.4% and 61.8%, respectively (Figure 4). The remaining patients were in NYHA functional class I. There were 61 patients free from all events including late death, reoperation, and progression of MR. Freedom from all late events at 5 and 10 years was 68% and 56.4%, respectively (Figure 5).
Discussion The long-term result of mitral valve repair for rheumatic valvular heart disease varies in the literature; the actuarial survival rate at 10 years ranges from 89% to 92% (Table 3), and the freedom from reoperation at 10 years ranges from 81% to 89%. The actuarial survival rate and freedom from reoperation in our study were comparable to those in other studies. Many factors are reported to be associated with late valve failure, including age, status of rheumatic carditis at the time of operation, mitral valve pathology, surgical techniques, and progression of the valvular disease itself. Antunes and colleagues7 demonstrated that patients under 12-years old have significantly worse rates of survival and complication-free survival. They reported a 27% reoperation rate for very young rheumatic patients (mean age 16 years). Duran and colleagues8 reported that the incidence of reoperation was 26.8% in patients less than 20 years of age and 4.5% in those over 20 years of age. However, Chauvaud and colleagues11 found that young age was not a predisposing factor for reoperation. The overall freedom from reoperation at 10 years in their study was 82%, while the freedom from reoperation at 10 years in patients younger than 19 years was 81%. In fact, the exact predisposing factor might be the higher incidence of acute rheumatic carditis in younger patients. Many studies have shown that the presence of acute rheumatic carditis at the time of operation is associated with a higher rate of late valve failure. In a study by Skoularigis and colleagues,10 32% of patients had acute rheumatic carditis at the time of operation, and the actuarial freedom from reoperation at 5 years was only 74.9%. They showed that only active rheumatic carditis was an independent predictor of reoperation. In the study of Antunes and colleagues,7 16.6% of patients had acute rheumatic carditis at the time of surgery, actuarial freedom from reoperation at 5-years was only 78%. Duran and colleagues8 also showed that among the reoperated patients, 4 had active rheumatic carditis at the time of their first surgery, and 4 more had
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Figure 2. Actuarial survival (number in parenthesis is number of patients at risk).
Figure 3. Freedom from reoperation (number in parenthesis is number of patients at risk).
a reactivation after surgery. In the study of Chauvaud and colleagues,11 freedom from reoperation in patients operated on in the acute phase of rheumatic fever was only 71% at 10 years, while freedom from reoperation
in all patients was 82% at 10 years. The occurrence of mixed mitral stenosis and regurgitation was also reported to be associated with a higher rate of late valve failure. Antunes and colleagues7 showed that
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Figure 4. Freedom from reoperation or progression of mitral regurgitation.
Figure 5. Freedom from all late events (number in parenthesis is number of patients at risk).
the best results were obtained in their mitral stenosis group and the worst in the mixed mitral valve disease group. Kumar and colleagues12 also demonstrated that patients with isolated MR were likely to have better
long-term results than those with mixed lesions. The majority of their patients in whom significant MR developed, had mixed lesions, and this was an independent predictor of late valve failure. However, this
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Table 3. Actuarial survival and actuarial freedom from reoperation in the literature.
Author
No. of patients
Age (years) [range]
Pure MR
Acute rheumatic carditis 16.6%
Antunes7 1987
241
21.5 11.8
53.1%
Duran8 1991
200
28.2 [5–74]
38.5%
9
Follow-up (months) [range]
Freedom from reoperation
Actuarial survival
5 years
5 years
31.7 15.6 [12–60]
78%*
15.1 [6–30]
77%y
10 years
90%* 95%y
Bernal 1993 Skoularigis10 1994
327 254
45.2 12.6 [23–73] 18 9 [6–52]
27.2% 72%
32%
103.2 [12–204] 60 35 [1–132]
Chauvaud11 2001
951
25.8 18 [4–75]
67%
4%
144
82%
Kumar12 2006
898
22.4 10.1 [4–70]
45.9%
62.7 31.8 [6–180]
81%
Present study
97
24 1.4 [8–74]
81.4%
0
58.8 4.2 [6–137]
89.9% 74.9%
94.5%
10 years
z
78.1%z 83.9%
82.7%
89% 92% 95.5%
89.2%
*At 4.5 years. yAt 30 months. zAt 16 years. MR: mitral regurgitation.
is not in agreement with some other studies. Bernal and colleagues9 reported that 73% of patients had mixed lesions (45.6% predominant stenosis and 27.2% predominant regurgitation); the actuarial freedom from reoperation at 16 years was 89.9%, which was better than in many other studies. Skoularigis and colleagues10 also had many patients (33%) with mixed lesions; the actuarial freedom from reoperation at 10 years was 82%. They considered important factors were the severity of mitral valve pathology and the reparative techniques performed. The mitral valve leaflet and subvalvular apparatus pathology were most important for predicting the success of repair. The severity or extent of calcification, leaflet retraction, and chordal fusion made reparative techniques more difficult and could result in a higher rate of reoperation. Chauvaud and colleagues11 showed that freedom from reoperation differed according to the functional type of regurgitation. Patients with functional type III had the highest rate of reoperation. At 20 years, freedom from reoperation was 65%, 63%, and 46% for types II (anterior) and III (posterior), II, and III, respectively. Regarding the surgical technique, one factor that might give the different results among various studies could be the technique and type of annuloplasty. In the early study of Duran and colleagues,8 only 79% of patients had ring implantation for annuloplasty. This might be one reason why the actuarial freedom from reoperation at 30 months was only 77%. Bernal and colleagues9 noted that reoperation occurred at two time periods: during the early years or later years after surgery. Early reoperations were always necessary for an error of indication or technical failure, but late operations often resulted from a progression of the valve disease. Chauvaud and colleagues11 found that 20% of their patients were reoperated on. Among these patients, mitral valve fibrosis with associated stenosis and recurrent regurgitation was present in 83%, and technical failure occurred in 17%. In the study of
Kumar and colleagues,12 35 patients underwent reoperation; 48% required reoperation between 25 and 175 months. Pathology at reoperation was typically recurrent rheumatic heart disease. There are 3 key factors for successful mitral valve repair in rheumatic patients. The first is good selection of patients with no acute rheumatic activity at the time of operation and suitable mitral valve morphology for repair. The second is well-defined surgical techniques to restore mitral valve function: adequate leaflet mobilization for restricted pathology, correction of prolapse pathology, and ring annuloplasty to stabilize and strengthen the repaired valve morphology. The third is prevention of progression of the valve disease by continuing penicillin prophylaxis. The limitations of this study relate to its retrospective nature. Various reparative techniques were used during the study period and depended partly on the surgeons’ experience. This factor might have affected the midterm results. Although mitral valve repair in rheumatic patients is associated with significant rates of valve failure and reoperation, it has a satisfactory survival rate. However, reoperation has a low operative mortality rate and many patients with MR remain in NYHA functional class I. Mitral valve repair for rheumatic patients is a good alternative to valve replacement, especially for young patients, to avoid life-long risks associated with a prosthetic valve. Presented at the 24th Annual Congress of the Association of Thoracic and Cardiovascular Surgeons of Asia, Hanoi, Vietnam, November 5–8, 2014. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest statement None declared.
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References 1. Enriquez-Sarano M, Schaff HV, Orszulak TA, Tajik AJ, Bailey KR and Frye RL. Valve repair improves the outcome of surgery for mitral regurgitation. A multivariate analysis. Circulation 1995; 91: 1022–1028. 2. Grossi EA, Galloway AC, Miller JS, et al. Valve repair versus replacement for mitral insufficiency: when is a mechanical valve still indicated? J Thorac Cardiovasc Surg 1988; 115: 389–394. 3. Carapetis J. Rheumatic heart disease in Asia. Circulation 2008; 118: 2748–2753. 4. Duran CG, Revuelta JM, Gaite L, Alonso C and Fleitas MG. Stability of mitral reconstructive surgery at 10–12 years for predominantly rheumatic valvular disease. Circulation 1988; 78(Suppl I): 91–96. 5. Deloche A, Jebara VA, Relland JY, et al. Valve repair with Carpentier techniques. The second decade. J Thorac Cardiovasc Surg 1990; 99: 990–1002. 6. Carpentier A. Cardiac valve surgery—the ‘‘French Correction’’. J Thorac Cardiovasc Surg 1983; 86: 323–337. 7. Antunes MJ, Magalhaes MP, Colsen PR, Colsen PR and Kinsley RH. Valvuloplasty for rheumatic mitral valve disease. A surgical challenge. J Thorac Cardiovasc Surg 1987; 94: 44–56.
8. Duran CM, Gometza B and De Vol EB. Valve repair in rheumatic mitral disease. Circulation 1991; 84(Suppl III): 125–132. 9. Bernal JM, Rabasa JM, Vilchez FG, Cagigas JC and Revuelta JM. Mitral valve repair in rheumatic disease. The flexible solution. Circulation 1993; 88: 1746–1753. 10. Skoularigis J, Sinovich V, Joubert G, et al. Evaluation of the long-term results of mitral valve repair in 254 young patients with rheumatic mitral regurgitation. Circulation 1994; 90(Suppl II): 167–174. 11. Chauvaud S, Fuzellier JF, Berrebi A, Deloche A, Fabiani JN and Carpentier A. Long-term (29 years) results of reconstructive surgery in rheumatic mitral valve insufficiency. Circulation 2001; 104: 1–12. 12. Kumar AS, Talwar S, Saxena A, Singh R and Velayoudam D. Results of mitral valve repair in rheumatic mitral regurgitation. Interact Cardiovasc Thorac Surg 2006; 5: 356–361.
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Original Article
Mitral valve repair for rheumatic mitral regurgitation: Mid-term results
Asian Cardiovascular & Thoracic Annals 0(0) 1–7 ß The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492315576282 aan.sagepub.com
Somchai Waikittipong
Abstract Aim: This retrospective study was undertaken to evaluate the midterm results of mitral valve repair for rheumatic mitral regurgitation, in term of survival rate and late valve failure. Methods: From January 2003 to January 2014, 97 patients underwent mitral valve repair in our hospital. Age ranged from 8 to 74 years, mean 24 1.4 years; 74 (76%) patients were female. Mean preoperative functional class was 2.47 0.07. Mean preoperative ejection fraction was 59.9% 2%. The lesions were pure mitral regurgitation in 79 (81.4%) patients, predominant mitral regurgitation with stenosis in 9 (9.3%), and predominant mitral stenosis with regurgitation in 9 (9.3%). Seventy-one (73%) patients were in normal sinus rhythm. Results: One patient died in the postoperative period, and 8 were lost during follow-up. Follow-up time ranged from 6 to 137 months, mean 58.8 4.2 months. There were 6 late deaths. Actuarial survival at 5 and 10 years was 95.5% and 89.2%, respectively. Twenty-seven (27.8%) patients had mitral regurgitation during follow-up, and 7 underwent reoperation with no hospital mortality. Freedom from reoperation at 5 and 10 years was 94.5% and 82.7%, respectively. Freedom from reoperation or progression of mitral regurgitation at 5 and 10 years was 70.4% and 61.8%, respectively. Freedom from all late events at 5 and 10 years was 68 % and 56.4%, respectively. Conclusions: Mitral valve repair for rheumatic mitral regurgitation is associated with a significant rate of valve failure and reoperation. However, it has a satisfactory survival rate and is a good alternative to valve replacement, especially for young patients, to avoid the life-long risks of a prosthetic valve.
Keywords Mitral valve, mitral valve insufficiency, postoperative complications, rheumatic heart disease, treatment outcome
Introduction
Patients and methods
Mitral valve repair is the procedure of choice for degenerative mitral valve disease because it has lower rates of thromboembolism, reoperation, and endocarditis compared to mitral valve replacement.1,2 It also preserves left ventricular function better than mitral valve replacement. Rheumatic heart disease is still a common cause of mitral valve disease in developing countries, including Thailand.3 However, mitral valve repair in rheumatic heart disease is more technically demanding,4 and the risk of reoperation is higher than in degenerative valvular heart disease.5 The aim of this study was to evaluate the midterm results of mitral valve repair in rheumatic mitral regurgitation (MR), in terms of survival rate, effectiveness and durability of the procedure, and reoperation rate.
This study was approved by the committee on ethical research of Yala Hospital. From January 2003 through January 2014, 116 consecutive patients with rheumatic MR underwent mitral valve repair in our hospital. Patients with aortic valve operations were excluded from this retrospective study; there were 97 patients eligible for inclusion in the analysis. Age ranged from 8 to 74 years, mean 24 1.4 years, median 19 years. Thirty-three (34%) patients were 15-years old or
Department of Surgery, Yala Hospital, Yala, Thailand Corresponding author: Somchai Waikittipong, MD, Department of Surgery, Yala Hospital, Maung, Yala, Thailand 95000. Email: [email protected]
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Figure 1. Age and sex distribution of 97 patients with rheumatic valve disease.
younger, and 13 (13.4%) were aged 12 years or younger. There were 74 females and 23 males. The distribution of patients according to age and sex is shown in Figure 1. The preoperative New York Heart Association (NYHA) functional class was III-IV in 45 (46.4%) cases; the mean NYHA class was 2.47 0.07, median 2.0. Twenty-six (26.8%) patients were in atrial fibrillation. The mitral valve lesion consisted of pure regurgitation in 79 (81.4%) patients, predominant regurgitation with stenosis in 9 (9.3%), and predominant stenosis with regurgitation in 9 (9.3%). The mean left ventricular ejection fraction on echocardiography was 59.9% 2%. Ten patients had associated lesions: atrial septal defect in 8 and ventricular septal defect in 2. The type of leaflet motion according to the classification of Carpentier6 was assessed by preoperative echocardiography and confirmed during surgery (Table 1). Restricted leaflet motion of the posterior leaflet was the most common functional finding. The combination of restricted posterior leaflet with prolapsed anterior leaflet was found in 6 patients. The surgical procedures are listed in Table 2. Ninety-four patients (97%) were treated by ring annuloplasty. Restriction of the leaflet was treated by leaflet mobilization techniques such as resection of secondary and tertiary chordae, splitting of the papillary muscle, and commissurotomy if there was commissural fusion. Prolapse of the leaflet was treated by various techniques depending on the lesion, such as chordal replacement with PTFE suture (WL Gore & Associates, Inc., USA), chordal transfer, or chordal shortening at the valve level. Since 2010, leaflet enlargement with autologous
Table 1. Intraoperative findings according to leaflet function classification in 97 patients with rheumatic valve disease. Mitral leaflet function
No. of patients
Type I: normal leaflet motion Annular dilatation Type II: leaflet prolapse Anterior leaflet Posterior leaflet Anterior þ posterior leaflets Type III: restricted leaflet motion Posterior Posterior þ anterior
9 (9.3%) 9 26 (26.8%) 10 14 2 62 (63.9%) 44 18
glutaraldehyde-treated pericardium was used in 3 patients with a too-small retracted anterior leaflet. Tricuspid annuloplasty was performed in 33 (34%) patients: flexible band implantation in 5, rigid ring implantation in 8, De Vega annuloplasty in 7, and posterior plication in 13. Associated operations were performed in 10 patients: closure of atrial septal defect in 8, and closure of a ventricular septal defect in 2. All patients were seen at 3- or 4-monthly intervals by a surgeon in the outpatient department. Echocardiography was performed annually or whenever an abnormal murmur was found. Eight (8.2%) patients were lost during follow-up. Follow-up time ranged from 6 to 137 months, mean 58.8 4.2 months, median 49 months. All patients under 35 years of age were given
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Table 2. Surgical techniques in 97 patients with rheumatic mitral valve disease. Surgery
No. of patients
Annuloplasty Flexible ring* Rigid ringy Semi-rigid ringz Pericardium Leaflet mobilization Commissurotomy Chordal replacement Chordal transfer Chordal shortening Leaflet resection Leaflet augmentation
49 24 21 1 60 19 21 9 5 4 3
(50.5%) (21.6%) (21.6%) (1%) (61.9%) (19.6%) (21.6%) (9.3%) (5.2%) (4.1%) (3.1%)
*Cosgrove-Edwards. yCarpentier-Edwards Classic. z Carpentier-Edwards Physio.
oral penicillin. Patients in normal sinus rhythm were given warfarin for 2 months, and those in atrial fibrillation were given lifelong warfarin. Mean standard deviation and median values were calculated for continuous variables. Simple percentages were used to express categorical variables. Late survival and the occurrence of clinical outcomes during the follow-up period were calculated by Kaplan-Meier analysis.
Results One (1%) patient died in the postoperative period. The cause of death was postoperative low cardiac output. There were 6 (6.1%) late deaths due to endocarditis in 1 case and sudden unexplained death in 5. All patients with sudden unexplained death had no residual MR before discharge. The actuarial survival at 5 and 10 years was 95.5% and 89.2%, respectively (Figure 2). One patient developed a cerebral embolism. This patient had predominant mitral stenosis with regurgitation. She had preoperative atrial fibrillation and continued receiving anticoagulants. However, she developed a cerebral embolism 10 years after the operation. No patient had anticoagulant-related complications. There were 27 (27.8%) patients who had MR during follow-up: grade 1 in 12, grade 2 in 13, and grade 3 in 2. Seven patients underwent reoperation with no hospital mortality. The interval between the first operation and reoperation ranged from 4 to 99 months. Findings at reoperation revealed that the causes of MR were progression of residual MR in 5 patients and recurrence of MR from disease progression in 2. One patient is awaiting reoperation. The
remaining patients are in NYHA functional class I or II. Freedom from reoperation at 5 and 10 years was 94.5% and 82.7%, respectively (Figure 3). The causes of late MR in all patients were residual MR in 9 patients and progression of the valve lesion in 18. The freedom from reoperation or progression of MR at 5 and 10 years was 70.4% and 61.8%, respectively (Figure 4). The remaining patients were in NYHA functional class I. There were 61 patients free from all events including late death, reoperation, and progression of MR. Freedom from all late events at 5 and 10 years was 68% and 56.4%, respectively (Figure 5).
Discussion The long-term result of mitral valve repair for rheumatic valvular heart disease varies in the literature; the actuarial survival rate at 10 years ranges from 89% to 92% (Table 3), and the freedom from reoperation at 10 years ranges from 81% to 89%. The actuarial survival rate and freedom from reoperation in our study were comparable to those in other studies. Many factors are reported to be associated with late valve failure, including age, status of rheumatic carditis at the time of operation, mitral valve pathology, surgical techniques, and progression of the valvular disease itself. Antunes and colleagues7 demonstrated that patients under 12-years old have significantly worse rates of survival and complication-free survival. They reported a 27% reoperation rate for very young rheumatic patients (mean age 16 years). Duran and colleagues8 reported that the incidence of reoperation was 26.8% in patients less than 20 years of age and 4.5% in those over 20 years of age. However, Chauvaud and colleagues11 found that young age was not a predisposing factor for reoperation. The overall freedom from reoperation at 10 years in their study was 82%, while the freedom from reoperation at 10 years in patients younger than 19 years was 81%. In fact, the exact predisposing factor might be the higher incidence of acute rheumatic carditis in younger patients. Many studies have shown that the presence of acute rheumatic carditis at the time of operation is associated with a higher rate of late valve failure. In a study by Skoularigis and colleagues,10 32% of patients had acute rheumatic carditis at the time of operation, and the actuarial freedom from reoperation at 5 years was only 74.9%. They showed that only active rheumatic carditis was an independent predictor of reoperation. In the study of Antunes and colleagues,7 16.6% of patients had acute rheumatic carditis at the time of surgery, actuarial freedom from reoperation at 5-years was only 78%. Duran and colleagues8 also showed that among the reoperated patients, 4 had active rheumatic carditis at the time of their first surgery, and 4 more had
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Figure 2. Actuarial survival (number in parenthesis is number of patients at risk).
Figure 3. Freedom from reoperation (number in parenthesis is number of patients at risk).
a reactivation after surgery. In the study of Chauvaud and colleagues,11 freedom from reoperation in patients operated on in the acute phase of rheumatic fever was only 71% at 10 years, while freedom from reoperation
in all patients was 82% at 10 years. The occurrence of mixed mitral stenosis and regurgitation was also reported to be associated with a higher rate of late valve failure. Antunes and colleagues7 showed that
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Figure 4. Freedom from reoperation or progression of mitral regurgitation.
Figure 5. Freedom from all late events (number in parenthesis is number of patients at risk).
the best results were obtained in their mitral stenosis group and the worst in the mixed mitral valve disease group. Kumar and colleagues12 also demonstrated that patients with isolated MR were likely to have better
long-term results than those with mixed lesions. The majority of their patients in whom significant MR developed, had mixed lesions, and this was an independent predictor of late valve failure. However, this
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Table 3. Actuarial survival and actuarial freedom from reoperation in the literature.
Author
No. of patients
Age (years) [range]
Pure MR
Acute rheumatic carditis 16.6%
Antunes7 1987
241
21.5 11.8
53.1%
Duran8 1991
200
28.2 [5–74]
38.5%
9
Follow-up (months) [range]
Freedom from reoperation
Actuarial survival
5 years
5 years
31.7 15.6 [12–60]
78%*
15.1 [6–30]
77%y
10 years
90%* 95%y
Bernal 1993 Skoularigis10 1994
327 254
45.2 12.6 [23–73] 18 9 [6–52]
27.2% 72%
32%
103.2 [12–204] 60 35 [1–132]
Chauvaud11 2001
951
25.8 18 [4–75]
67%
4%
144
82%
Kumar12 2006
898
22.4 10.1 [4–70]
45.9%
62.7 31.8 [6–180]
81%
Present study
97
24 1.4 [8–74]
81.4%
0
58.8 4.2 [6–137]
89.9% 74.9%
94.5%
10 years
z
78.1%z 83.9%
82.7%
89% 92% 95.5%
89.2%
*At 4.5 years. yAt 30 months. zAt 16 years. MR: mitral regurgitation.
is not in agreement with some other studies. Bernal and colleagues9 reported that 73% of patients had mixed lesions (45.6% predominant stenosis and 27.2% predominant regurgitation); the actuarial freedom from reoperation at 16 years was 89.9%, which was better than in many other studies. Skoularigis and colleagues10 also had many patients (33%) with mixed lesions; the actuarial freedom from reoperation at 10 years was 82%. They considered important factors were the severity of mitral valve pathology and the reparative techniques performed. The mitral valve leaflet and subvalvular apparatus pathology were most important for predicting the success of repair. The severity or extent of calcification, leaflet retraction, and chordal fusion made reparative techniques more difficult and could result in a higher rate of reoperation. Chauvaud and colleagues11 showed that freedom from reoperation differed according to the functional type of regurgitation. Patients with functional type III had the highest rate of reoperation. At 20 years, freedom from reoperation was 65%, 63%, and 46% for types II (anterior) and III (posterior), II, and III, respectively. Regarding the surgical technique, one factor that might give the different results among various studies could be the technique and type of annuloplasty. In the early study of Duran and colleagues,8 only 79% of patients had ring implantation for annuloplasty. This might be one reason why the actuarial freedom from reoperation at 30 months was only 77%. Bernal and colleagues9 noted that reoperation occurred at two time periods: during the early years or later years after surgery. Early reoperations were always necessary for an error of indication or technical failure, but late operations often resulted from a progression of the valve disease. Chauvaud and colleagues11 found that 20% of their patients were reoperated on. Among these patients, mitral valve fibrosis with associated stenosis and recurrent regurgitation was present in 83%, and technical failure occurred in 17%. In the study of
Kumar and colleagues,12 35 patients underwent reoperation; 48% required reoperation between 25 and 175 months. Pathology at reoperation was typically recurrent rheumatic heart disease. There are 3 key factors for successful mitral valve repair in rheumatic patients. The first is good selection of patients with no acute rheumatic activity at the time of operation and suitable mitral valve morphology for repair. The second is well-defined surgical techniques to restore mitral valve function: adequate leaflet mobilization for restricted pathology, correction of prolapse pathology, and ring annuloplasty to stabilize and strengthen the repaired valve morphology. The third is prevention of progression of the valve disease by continuing penicillin prophylaxis. The limitations of this study relate to its retrospective nature. Various reparative techniques were used during the study period and depended partly on the surgeons’ experience. This factor might have affected the midterm results. Although mitral valve repair in rheumatic patients is associated with significant rates of valve failure and reoperation, it has a satisfactory survival rate. However, reoperation has a low operative mortality rate and many patients with MR remain in NYHA functional class I. Mitral valve repair for rheumatic patients is a good alternative to valve replacement, especially for young patients, to avoid life-long risks associated with a prosthetic valve. Presented at the 24th Annual Congress of the Association of Thoracic and Cardiovascular Surgeons of Asia, Hanoi, Vietnam, November 5–8, 2014. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest statement None declared.
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