Long-Term (29 Years) Results of Reconstructive Surgery in Rheumatic Mitral Valve Insufficiency

Abstract

Background-Results of conservative surgery are well established in degenerative mitral valve (MV) insufficiency.However, there are controversies in rheumatic disease. This study is the evaluation of one center for rheumatic MV insufficiency based on a functional approach. Methods and Results-From 1970 to 1994, 951 patients with rheumatic MV insufficiency were operated on with the reconstructive techniques elaborated by Alain Carpentier. Aortic valve diseases were excluded. Mean age was 25.8 years (4 to 75), and sinus rhythm was present in 63%. The functional classification used was type I, normal leaflet motion, 71 patients (7%); type II, prolapsed leaflet, 311 patients (33%); and type III, restricted leaflet motion, 345 patients (36%). The combined lesion of prolapse of the anterior leaflet and restriction of the posterior was present in 224 patients (24%). Surgical techniques used were implantation of a prosthetic ring in 95%, shortening of the chords and leaflet enlargement with autologous pericardium, and commissurotomy. Hospital mortality rate was 2%. The mean follow-up was 12 years (maximum, 29 years): 8618 patients per year. Actuarial survival was 89Ϯ19% at 10 years and 82Ϯ18% at 20 years. The rate of thromboembolic events was 0.4% patients per year (33 events), with 3 deaths. Freedom from reoperation was 82Ϯ19% at 10 years and 55Ϯ25% at 20 years. The main cause (83%) of reoperation was progressive fibrosis of the MV. The actuarial rate of reoperation was 2% patients per year and was correlated to the degree of preoperative fibrosis. Conclusions-Conservative

Rheumatic and Nonrheumatic Valvular Heart Disease

“…18 Furthermore, multivariate analysis showed active rheumatic carditis at the time of surgery to be the only predictor of valve failure and need for reoperation. The results for mitral valve repair for rheumatic mitral regurgitation from Carpentier et al 19 look somewhat better, and we can only speculate that more aggressive disease, as evidenced by a younger mean age and higher incidence of active carditis in our patients, accounts for the difference. Notwithstanding these differences, mitral valve repair offers significant advantages over valve replacement in terms of need for anticoagulation and risk of prosthetic valve thrombosis.…”

2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary

“…MV repair is recommended in preference to MVR when surgical treatment is indicated for patients with chronic severe primary MR involving the anterior leaflet or both leaflets when a successful and durable repair can be accomplished I B [195][196][197][199][200][201][202][203] Concomitant MV repair or replacement is indicated in patients with chronic severe primary MR undergoing cardiac surgery for other indications…”

Influence of Hospital Procedural Volume on Care Process and Mortality for Patients Undergoing Elective Surgery for Mitral Regurgitation

“…Mitral valve repair is associated with lower perioperative morbidity and mortality, better preservation of left ventricular function, avoidance of long-term anticoagulation and the associated risks of bleeding, a low rate of thromboembolic complications, a low risk of infective endocarditis, excellent freedom from reoperation, and improved long-term survival. [11][12][13] Although individual centers with an interest in mitral valve surgery have demonstrated high repair rates, the majority of patients having mitral valve surgery in North America continue to receive a replacement rather than a repair. 14 We observed a dramatic effect of hospital procedural volume on mitral valve repair rates, with repair rates climbing from 47.7% in the lowest-volume quartile to 77.4% in the highest-volume quartile.…”