clinical cardiology: original article
Mitral valve repair versus replacement in simultaneous aortic and mitral valve surgery Marian Urban MD, Jan Pirk MD, Ondrej Szarszoi PhD, Ivo Skalsky MD, Jiri Maly PhD, Ivan Netuka PhD M Urban, J Pirk, o szarszoi, I skalsky, J Maly, I Netuka. Mitral valve repair versus replacement in simultaneous aortic and mitral valve surgery. exp Clin Cardiol 2013;18(1):22-26. BaCkgroUNd: Double valve replacement for concomitant aortic and mitral valve disease is associated with substantial morbidity and mortality. Excellent results with valve repair in isolated mitral valve lesions have been reported; therefore, whether its potential benefits would translate into better outcomes in patients with combined mitral-aortic disease was investigated. Methods: A retrospective observational study was performed involving 341 patients who underwent aortic valve replacement with either mitral valve repair (n=42) or double valve replacement (n=299). Data were analyzed for early mortality, late valve-related complications and survival. resUlts: The early mortality rate was 11.9% for valve repair and 11.0% for replacement (P=0.797). Survival (± SD) was 67±11% in mitral valve repair with aortic valve replacement and 81±3% in double valve
T
en per cent to 12% of patients admitted to surgical service with valvular heart disease have involvement of both the mitral and aortic valves (1,2). While aortic valve replacement (AVR) during double valve surgery is not contentious, the choice of mitral valve procedure (repair versus replacement) remains controversial. Some authors claim improved late survival rates for mitral valve repair (MVP) with AVR compared with double valve replacement (DVR) in patients with concomitant mitral and aortic lesions (3). The well-known advantages of MVP over mitral valve replacement (MVR) include a lower rate of late valve-related complications, such as infective endocarditis, thromboembolism and bleeding events, which are attributable to the postsurgical requirement for anticoagulation. These potential benefits may be diminished in patients who undergo MVP+AVR with mechanical prosthesis. Several studies (4-6) advocate caution in patients with rheumatic disease and report higher reoperation rates in patients who undergo mitral valve reconstruction. The optimal choice of mitral valve procedure in patients with double valve disease is, thus, more complex, and the well-documented benefits of MVP over MVR in isolated valve disease do not necessarily extrapolate to patients with double valve disease (7). Remarkably, few data exist to objectively guide the surgical management of patients with concomitant mitral-aortic disease and no specific recommendations regarding patients with multiple valve disease have been developed in the American College of Cardiology/American Heart Association practice guidelines (8).
Methods
Patients The present study included patients with concomitant mitral and aortic valve lesions who underwent double valve surgery at the Institute for Clinical and Experimental Medicine, Prague (Czech Republic), between 1995 and 2009. All patients who underwent a previous sternotomy for cardiac valve-related procedures (with the exception of open mitral commissurotomy) and infective endocarditis were excluded from the study. Patients were divided into two separate groups according to the type of surgery performed – either MVP+AVR or DVR. Mitral valve disease was classified as rheumatic, degenerative or ischemic. Body surface area
replacement at five years of follow-up (P=0.187). The percentage of patients who did not experience major adverse valve-related events at five years of follow-up was 83±9% in those who underwent mitral valve repair with aortic valve replacement and 89±2% in patients who underwent double valve replacement (P=0.412). Age >70 years (HR 2.4 [95% CI 1.1 to 4.9]; P=0.023) and renal dysfunction (HR 1.9 [95% CI 1.2 to 3.7]; P=0.01) were independent predictors of decreased survival. CoNClUsIoNs: In patients with double valve disease, both mitral valve repair and replacement provided comparable early outcomes. There were no significant differences in valve-related reoperations, anticoagulationrelated complications or prosthetic valve endocarditis. Patient-related factors appear to be the major determinant of late survival, irrespective of the type of operation. key Words: Aortic valve replacement; Double valve surgery; Mitral valve repair; Mitral valve replacement
was calculated according to the Mosteller formula (9). Left ventricle (LV) ejection fraction was derived from the biplane Simpson method (10) and standard LV dimensions were measured according to current guidelines (10,11). A logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) was calculated for all patients (12). Pulmonary hypertension was defined as a mean pulmonary artery pressure >25 mmHg at rest (13). Renal insufficiency was defined as a serum creatinine level >120 µmol/L. Early mortality was defined as all-cause mortality at 60 days regardless of the patient’s location. Complications were defined in accordance with published guidelines for reporting morbidity and mortality after cardiac valvular operations. They included structural deterioration, nonstructural dysfunction, valve thrombosis, embolism, bleeding events, prosthetic valve endocarditis, valve-related reoperation and valve-related mortality, sudden unexplained death, cardiac death, all-cause mortality and major adverse valve-related events. Valve-related mortality was defined as any death caused by structural deterioration, nonstructural dysfunction, valve thrombosis, embolism, a bleeding event or operated valve endocarditis, death related to reintervention on the operated valve or sudden unexplained death. Major adverse valve-related events included valve-related mortality, all valve-related morbidity, and the need for a new pacemaker or defibrillator within 14 days after the valve intervention (14). operative procedures All procedures were performed through a median sternotomy using cardiopulmonary bypass with aortobicaval cannulation with moderate systemic hypothermia (32°C to 34°C). Myocardial protection was achieved using an antegrade cold blood cardioplegia delivered directly into the coronary ostia and topical ice slush. Depending on the morphology of the mitral valve, a decision was made to repair or replace the valve. The basic principles of the Carpentier technique were applied in the repairs. On completing the repair, the mitral valve was tested by injecting cold saline into the LV cavity to verify correct coaptation of the leaflets. If the repair was deemed inadequate, the valve was replaced with either a mechanical or tissue prosthesis depending on the patient’s age and comorbidities. All patients in the
Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic Correspondence: Dr Marian Urban, Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Videnska 1958/9, Prague 140 21, Czech Republic. Telephone 420-733-677-694, fax 420-236-052-776, e-mail [email protected]
22
©2013 Pulsus Group Inc. All rights reserved
Exp Clin Cardiol Vol 18 No 1 2013
Double valve surgery
replacement group underwent a chordal-sparing procedure. After completing the mitral valve procedure, the aortic valve was replaced using standard surgical techniques. An additional surgical procedure was subsequently performed depending on the individual patient’s concomitant cardiac lesions. Proper valve function was assessed using transesophageal echocardiography before termination of cardiopulmonary bypass. Postoperative anticoagulation Anticoagulation with warfarin sodium was initiated on the first postoperative day. Patients who underwent DVR using mechanical prostheses received lifelong anticoagulation with a target international normalized ratio (INR) range of 2.5 to 3.5. Patients who underwent AVR using a mechanical prosthesis and MVP received lifelong anticoagulation with a target INR range of 2.0 to 3.0. Patients who underwent AVR with a tissue prosthesis concomitant with either MVR using a tissue prosthesis or MVP received anticoagulation with a target INR range of 2.0 to 3.0 for three months. After that time, these patients were treated with lifelong antiplatelet therapy. All patients remaining in atrial fibrillation received anticoagulation regardless of the type of surgery performed. The INR was checked at regular intervals at the physician-led outpatient clinic. All patients were managed according to previously published guidelines on antiplatelet and anticoagulation therapy for patients with prosthetic heart valves (15). data collection and follow-up Demographic, clinical and echocardiographical data were extracted from the hospital’s electronic database and individual patient notes and were tabulated in spreadsheets (Excel, Microsoft Corporation, USA). The present retrospective study was approved by the institutional Medical Ethics Committee with individual patient consent waived. Follow-up data were retrieved from the most recent record of outpatient visits from the hospital database. In cases of missing data, clinical and echocardiographical parameters were obtained from the referring cardiologist using a structured mailed questionnaire. Follow-up was 93% complete and totaled 162 patient years in the repair group and 1236 patient years in the replacement group. statistical analysis Normally distributed continuous variables were presented as mean ± SD. Categorical variables were presented as the percentage of the sample. The χ2 test, Fisher’s exact test, unpaired Student’s t test and the Mann-Whitney U test were used, as appropriate, to evaluate the difference between baseline and demographic characteristics between the two study groups. Univariate logistic regression analysis was performed to identify preoperative and intraoperative risk factors for early mortality. Multivariate analysis could not be performed because the ratio of events per variable was too small (16). Late survival and time-dependent events were assessed using Kaplan-Meier survival analysis. The log-rank test was used for comparison of unadjusted survival and freedom from events between the two groups. The events were also expressed in linearized form (per cent per 100 patient years). The Cox proportional hazard model with forward conditional entry was used for multivariate analysis of statistically significant univariate factors to evaluate potential predictors of late mortality. In addition to the type of mitral valve operation, 28 other demographic, clinical and echocardiographical parameters were tested in univariate analysis. Continuous variables were dichotomized either by convention (age, LV ejection fraction) or by a median split (body surface area, ejection fraction, LV end diastolic dimension, cross-clamp time, cardiopulmonary bypass time and blood loss). Only variables with P
Mitral valve repair versus replacement in simultaneous aortic and mitral valve surgery Marian Urban MD, Jan Pirk MD, Ondrej Szarszoi PhD, Ivo Skalsky MD, Jiri Maly PhD, Ivan Netuka PhD M Urban, J Pirk, o szarszoi, I skalsky, J Maly, I Netuka. Mitral valve repair versus replacement in simultaneous aortic and mitral valve surgery. exp Clin Cardiol 2013;18(1):22-26. BaCkgroUNd: Double valve replacement for concomitant aortic and mitral valve disease is associated with substantial morbidity and mortality. Excellent results with valve repair in isolated mitral valve lesions have been reported; therefore, whether its potential benefits would translate into better outcomes in patients with combined mitral-aortic disease was investigated. Methods: A retrospective observational study was performed involving 341 patients who underwent aortic valve replacement with either mitral valve repair (n=42) or double valve replacement (n=299). Data were analyzed for early mortality, late valve-related complications and survival. resUlts: The early mortality rate was 11.9% for valve repair and 11.0% for replacement (P=0.797). Survival (± SD) was 67±11% in mitral valve repair with aortic valve replacement and 81±3% in double valve
T
en per cent to 12% of patients admitted to surgical service with valvular heart disease have involvement of both the mitral and aortic valves (1,2). While aortic valve replacement (AVR) during double valve surgery is not contentious, the choice of mitral valve procedure (repair versus replacement) remains controversial. Some authors claim improved late survival rates for mitral valve repair (MVP) with AVR compared with double valve replacement (DVR) in patients with concomitant mitral and aortic lesions (3). The well-known advantages of MVP over mitral valve replacement (MVR) include a lower rate of late valve-related complications, such as infective endocarditis, thromboembolism and bleeding events, which are attributable to the postsurgical requirement for anticoagulation. These potential benefits may be diminished in patients who undergo MVP+AVR with mechanical prosthesis. Several studies (4-6) advocate caution in patients with rheumatic disease and report higher reoperation rates in patients who undergo mitral valve reconstruction. The optimal choice of mitral valve procedure in patients with double valve disease is, thus, more complex, and the well-documented benefits of MVP over MVR in isolated valve disease do not necessarily extrapolate to patients with double valve disease (7). Remarkably, few data exist to objectively guide the surgical management of patients with concomitant mitral-aortic disease and no specific recommendations regarding patients with multiple valve disease have been developed in the American College of Cardiology/American Heart Association practice guidelines (8).
Methods
Patients The present study included patients with concomitant mitral and aortic valve lesions who underwent double valve surgery at the Institute for Clinical and Experimental Medicine, Prague (Czech Republic), between 1995 and 2009. All patients who underwent a previous sternotomy for cardiac valve-related procedures (with the exception of open mitral commissurotomy) and infective endocarditis were excluded from the study. Patients were divided into two separate groups according to the type of surgery performed – either MVP+AVR or DVR. Mitral valve disease was classified as rheumatic, degenerative or ischemic. Body surface area
replacement at five years of follow-up (P=0.187). The percentage of patients who did not experience major adverse valve-related events at five years of follow-up was 83±9% in those who underwent mitral valve repair with aortic valve replacement and 89±2% in patients who underwent double valve replacement (P=0.412). Age >70 years (HR 2.4 [95% CI 1.1 to 4.9]; P=0.023) and renal dysfunction (HR 1.9 [95% CI 1.2 to 3.7]; P=0.01) were independent predictors of decreased survival. CoNClUsIoNs: In patients with double valve disease, both mitral valve repair and replacement provided comparable early outcomes. There were no significant differences in valve-related reoperations, anticoagulationrelated complications or prosthetic valve endocarditis. Patient-related factors appear to be the major determinant of late survival, irrespective of the type of operation. key Words: Aortic valve replacement; Double valve surgery; Mitral valve repair; Mitral valve replacement
was calculated according to the Mosteller formula (9). Left ventricle (LV) ejection fraction was derived from the biplane Simpson method (10) and standard LV dimensions were measured according to current guidelines (10,11). A logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) was calculated for all patients (12). Pulmonary hypertension was defined as a mean pulmonary artery pressure >25 mmHg at rest (13). Renal insufficiency was defined as a serum creatinine level >120 µmol/L. Early mortality was defined as all-cause mortality at 60 days regardless of the patient’s location. Complications were defined in accordance with published guidelines for reporting morbidity and mortality after cardiac valvular operations. They included structural deterioration, nonstructural dysfunction, valve thrombosis, embolism, bleeding events, prosthetic valve endocarditis, valve-related reoperation and valve-related mortality, sudden unexplained death, cardiac death, all-cause mortality and major adverse valve-related events. Valve-related mortality was defined as any death caused by structural deterioration, nonstructural dysfunction, valve thrombosis, embolism, a bleeding event or operated valve endocarditis, death related to reintervention on the operated valve or sudden unexplained death. Major adverse valve-related events included valve-related mortality, all valve-related morbidity, and the need for a new pacemaker or defibrillator within 14 days after the valve intervention (14). operative procedures All procedures were performed through a median sternotomy using cardiopulmonary bypass with aortobicaval cannulation with moderate systemic hypothermia (32°C to 34°C). Myocardial protection was achieved using an antegrade cold blood cardioplegia delivered directly into the coronary ostia and topical ice slush. Depending on the morphology of the mitral valve, a decision was made to repair or replace the valve. The basic principles of the Carpentier technique were applied in the repairs. On completing the repair, the mitral valve was tested by injecting cold saline into the LV cavity to verify correct coaptation of the leaflets. If the repair was deemed inadequate, the valve was replaced with either a mechanical or tissue prosthesis depending on the patient’s age and comorbidities. All patients in the
Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic Correspondence: Dr Marian Urban, Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Videnska 1958/9, Prague 140 21, Czech Republic. Telephone 420-733-677-694, fax 420-236-052-776, e-mail [email protected]
22
©2013 Pulsus Group Inc. All rights reserved
Exp Clin Cardiol Vol 18 No 1 2013
Double valve surgery
replacement group underwent a chordal-sparing procedure. After completing the mitral valve procedure, the aortic valve was replaced using standard surgical techniques. An additional surgical procedure was subsequently performed depending on the individual patient’s concomitant cardiac lesions. Proper valve function was assessed using transesophageal echocardiography before termination of cardiopulmonary bypass. Postoperative anticoagulation Anticoagulation with warfarin sodium was initiated on the first postoperative day. Patients who underwent DVR using mechanical prostheses received lifelong anticoagulation with a target international normalized ratio (INR) range of 2.5 to 3.5. Patients who underwent AVR using a mechanical prosthesis and MVP received lifelong anticoagulation with a target INR range of 2.0 to 3.0. Patients who underwent AVR with a tissue prosthesis concomitant with either MVR using a tissue prosthesis or MVP received anticoagulation with a target INR range of 2.0 to 3.0 for three months. After that time, these patients were treated with lifelong antiplatelet therapy. All patients remaining in atrial fibrillation received anticoagulation regardless of the type of surgery performed. The INR was checked at regular intervals at the physician-led outpatient clinic. All patients were managed according to previously published guidelines on antiplatelet and anticoagulation therapy for patients with prosthetic heart valves (15). data collection and follow-up Demographic, clinical and echocardiographical data were extracted from the hospital’s electronic database and individual patient notes and were tabulated in spreadsheets (Excel, Microsoft Corporation, USA). The present retrospective study was approved by the institutional Medical Ethics Committee with individual patient consent waived. Follow-up data were retrieved from the most recent record of outpatient visits from the hospital database. In cases of missing data, clinical and echocardiographical parameters were obtained from the referring cardiologist using a structured mailed questionnaire. Follow-up was 93% complete and totaled 162 patient years in the repair group and 1236 patient years in the replacement group. statistical analysis Normally distributed continuous variables were presented as mean ± SD. Categorical variables were presented as the percentage of the sample. The χ2 test, Fisher’s exact test, unpaired Student’s t test and the Mann-Whitney U test were used, as appropriate, to evaluate the difference between baseline and demographic characteristics between the two study groups. Univariate logistic regression analysis was performed to identify preoperative and intraoperative risk factors for early mortality. Multivariate analysis could not be performed because the ratio of events per variable was too small (16). Late survival and time-dependent events were assessed using Kaplan-Meier survival analysis. The log-rank test was used for comparison of unadjusted survival and freedom from events between the two groups. The events were also expressed in linearized form (per cent per 100 patient years). The Cox proportional hazard model with forward conditional entry was used for multivariate analysis of statistically significant univariate factors to evaluate potential predictors of late mortality. In addition to the type of mitral valve operation, 28 other demographic, clinical and echocardiographical parameters were tested in univariate analysis. Continuous variables were dichotomized either by convention (age, LV ejection fraction) or by a median split (body surface area, ejection fraction, LV end diastolic dimension, cross-clamp time, cardiopulmonary bypass time and blood loss). Only variables with P
![[Mitral valve repair versus mitral valve replacement].](/assets/img/hold.png)
