Mitral valve surgery after percutaneous mitral

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Tricuspid valve repair by a modified DeVega technique [9] and aortic valve .... valvuloplasty, usually used by the intervention cardiologists is not appropriate ...


European Journal of Cardio-Thoracic Surgery 47 (2015) e1–e6 doi:10.1093/ejcts/ezu365

Cite this article as: Coutinho GF, Branco CF, Jorge E, Correia PM, Antunes MJ. Mitral valve surgery after percutaneous mitral commissurotomy: is repair still feasible? Eur J Cardiothorac Surg 2015;47:e1–e6.

Mitral valve surgery after percutaneous mitral commissurotomy: is repair still feasible? Centre of Cardiothoracic Surgery, University Hospital and Medical School, Coimbra, Portugal * Corresponding author. Centro de Cirurgia Cardiotorácica, Hospitais da Universidade, 3000-075 Coimbra, Portugal. Tel: +351-239-400418; fax: 351-239-829674; e-mail: [email protected] (M.J. Antunes). Received 25 June 2014; received in revised form 7 August 2014; accepted 13 August 2014

Abstract OBJECTIVES: Due to progression of rheumatic disease, percutaneous mitral commissurotomy (PMC) is a palliative procedure. We aimed at evaluating the outcomes of patients requiring surgery for failure of PMC, focusing on the fate of the mitral valve (MV) (repair versus replacement). METHODS: From January 1993 through December 2012, 61 patients with previous PMC were submitted to MV surgery. Detailed operative findings were collected from all patients and an intraoperative anatomical score was introduced to predict reparability. Time to surgery, overall survival and freedom from reoperation were analysed. RESULTS: The mean time to surgery after PMC was 6.9 ± 5.9 years and indications were restenosis in 25 patients (41%) and mitral regurgitation or mixed lesion in 36 (59%). Nine patients (14.8%) had more than one previous intervention. Intraoperative inspection of the valve revealed leaflet laceration outside the commissural area in 27 patients (44.3%). Valve repair was accomplished in 38 patients (62.3%). Pulmonary hypertension, calcification and intraoperative anatomical score were independently associated with the probability of valve replacement (OR 1.12, OR 7.03 and OR 4.49, respectively, P < 0.05). There was no hospital mortality. MV area increased on average 1.6 cm2 after surgery to 2.7 cm2; 5-, 10- and 20-year survival rates were 98.1 ± 1.9, 91 ± 5.2 and 82.7 ± 9.2%, respectively. The rate of freedom from mitral reoperation (for repaired cases) at 5, 10 and 15 years was 100, 95.8 ± 4.1 and 87.8 ± 8.5%, respectively. There was no difference in survival between repaired or replaced MVs, but the former had less valve-related events during follow-up. CONCLUSION: The MV can be repaired after failed PMC, with very low complication rates and excellent long-term results. Hence, whenever possible, these patients should be sent to reference centres where repair can be successfully achieved. Keywords: Percutaneous mitral commissurotomy • Mitral restenosis • Mitral valve repair

INTRODUCTION The incidence of rheumatic fever has dropped drastically in the last decades in Western countries. However, due to immigrant flows and to progression of the disease in previously affected patients, we still come across this valvular problem in our practice, especially in patients in the fifth to seventh decade of life, who have had rheumatic fever in their childhood and youth, four or five decades ago when the disease was still endemic in our country. Mitral valve (MV) stenosis (MS) is the most common form of presentation of rheumatic disease and is characterized by leaflet thickening, commissural fusion and involvement of the subvalvular apparatus (thickening, shortening and fusion of the chordae tendineae) [1]. Occasionally, massive annular calcification may lead to MV obstruction [2]. Since MS is a consequence of a mechanical obstruction to diastolic flow, the only effective and definite treatment when the disease becomes clinically disabling [mitral valve area (MVA)

≤1.5 cm2] is the relief of the obstacle [3]. At the present time, there are three options to treat symptomatic MS: Percutaneous mitral commissurotomy (PMC), open mitral commissurotomy (OMC) and MV replacement (MVR). Although we believe that it still has a place in some circumstances, closed mitral commissurotomy was practically abandoned in developed countries some three decades ago [4]. PMC has become rapidly the procedure of choice in patients with favourable anatomical characteristics (Wilkins score ≤8) [5], for being a less invasive procedure and associated with a prompt recovery of the patient, in comparison to surgery [6]. A significant early and late failure rate after the percutaneous procedure has been documented, and the majority of studies predict that after PMC it is almost inevitable to replace the MV when surgery is required for mitral restenosis, regurgitation or mixed lesion [7]. However, our personal experience has shown very distinctive results. Hence, we have defined the following as aims to this study: the evaluation of the causes of immediate and long-term failure after PMC, the feasibility of MV repair, and survival and freedom from reoperation after MV surgery.

© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

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Gonçalo F. Coutinho, Carlos Filipe Branco, Elisabete Jorge, Pedro M. Correia and Manuel J. Antunes*


G.F. Coutinho et al. / European Journal of Cardio-Thoracic Surgery

MATERIALS AND METHODS Patient population From January 1992 through December 2013, 1874 patients with rheumatic MV disease and no previous mitral intervention (closed or open commissurotomy or PMC) were submitted to MV surgery, of which 1514 (80.8%) had their valves repaired, independently of the valve lesion (stenosis, regurgitation or mixed). During the same period, 61 patients with previous PMC required MV surgery for technical failure of the procedure or evolution of the disease, and constitute the study population. For the purpose of this work, we have defined early failure of PMC as those cases that needed surgery up to 1 year after the percutaneous procedure and this occurred in 13 cases (21.3%). Nine patients (14.8%) had more than one previous PMC. Valve repair was accomplished in 38 patients (62.3%). The mean age of this group was 51.7 ± 12.7 years and female sex prevailed (n = 56, 91.8%). The majority of patients were in NYHA functional class III–IV (n = 43, 70.5%), 8.2% had a previous history of cerebrovascular accident and 63.9% were in atrial fibrillation (AF) at the time of surgery. The mean EuroSCORE II was 1.98, which represents a low surgical risk population. There were significant differences in demographic characteristics and preoperative echocardiographic findings between patients who had a mitral prosthesis implanted and those who had their valves repaired (Table 1). Patients submitted to MVR were older, with a higher EuroSCORE II and with indicators of more advanced mitral disease (left atrial enlargement, pulmonary hypertension and marked calcium infiltration). Institutional review board authorization was obtained for this study.

Evaluation of the mitral valve All patients had at least a preoperative transthoracic echocardiogram (TTE), an intraoperative 2D transoesophageal echocardiogram

and a postoperative TTE. Severe stenosis was defined as MVA below 1 cm2 and/or mean transmitral gradient >10 mmHg. Preoperative MVA was determined anatomically (2D echocardiography, planimetry) and functionally (Doppler pressure half-time method); however, functional MVA determination was the reference method in evaluating patients after surgery [8]. The evaluation included calculation of an echocardiographic score (Wilkins) [5] and of an intraoperative morphological score derived from the accumulated experience of 2344 patients with rheumatic mitral disease submitted to MV surgery in our department. Briefly, the operative score consists of four factors (anterior leaflet mobility, degree of leaflet thickening, degree of chordae tendineae involvement and degree and/or location of mitral calcification), each with three possible degrees (1–3), adding to a total of 4–12 (Table 2). This model showed very good predictive ability, with an area under the curve (AUC) of the receiver operating characteristic (ROC) curve of 0.870 [95% confidence interval (CI) 0.744–0.996, P < 0.0001], and no evidence of lack of fit based on the Hosmer–Lemeshow statistic (χ 2 = 5.8, P = 0.559). The higher the score, the more severe is the rheumatic involvement and less likely the probability to repair the valve.

Operative data and follow-up The operative technique was standard for all patients and included cardiopulmonary bypass with mild hypothermia (30°C) and intermittent antegrade cold crystalloid cardioplegia infused in the aortic root. Most cases were done through a median sternotomy, but in 4 patients the access route was a right anterolateral thoracotomy. MV exposure was obtained by left atriotomy, posterior to Waterston’s groove. We were able to preserve the MV in 38 cases (62.3%). As expected, there were significant differences in the operative findings

Table 1: Demographic and echocardiographic characteristics of patients submitted to mitral valve repair or replacement who had previous PMC Variables Demographic Age (years) Female sex NYHA III–IV Atrial fibrillation Tricuspid disease Aortic valve disease More than one PMC EuroSCORE II Echocardiographic Pure stenosis Mitral regurgitation (degree) Ejection fraction (%) Left ventricular systolic diameter (mm) Left ventricular diastolic diameter (mm) Left atrium diameter (mm) MVA (mm) Systolic pulmonary artery pressure (mmHg) Mitral calcification Echocardiographic score

Repair, n = 38 (62.3%)

Replacement, n = 23 (37.7%)


48.5 ± 13.0 35 (92.1%) 27 (71.1%) 21 (55.3%) 9 (23.7%) 6 (15.8%) 3 (7.9%) 1.37 ± 0.7

57.2 ± 10.2 21 (91.3%) 16 (69.6%) 18 (78.3%) 13 (56.5%) 9 (39.1%) 6 (26.1%) 3.13 ± 2.60

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