Mitral valve repair in rheumatic disease. The flexible solution.

Abstract

BACKGROUND Mitral valve repair in rheumatic disease is technically more difficult, and there is little information on the long-term stability of this technique. METHODS AND RESULTS From January 1975 to December 1990, 327 patients underwent mitral valve repair with the Duran flexible ring annuloplasty for rheumatic valve disease. Mean age was 45.4 +/- 12.6 years (range, 23 to 73 years). The techniques used for valve repair include a Duran flexible ring annuloplasty in all cases, commissurotomy in 272 (83.2%), papillary muscle splitting in 171 (52.3%), and subvalvular apparatus repair in 59 patients (18.0%). One hundred one patients required associated tricuspid valve surgery (30.8%). Hospital mortality was 3.36%, being lower for patients with isolated mitral valve repair (2.7%) than those with mitrotricuspid surgery (4.9%). Mean follow-up was 8.6 years (range, 1 to 17 years) and was 96.5% completed. Thirty-four patients required reoperation for severe mitral insufficiency in 12, mitral restenosis in 18, and aortic valve disease in 4. The actuarial curve free from reoperation for mitral cause at 16 years is 89.9 +/- 3.2%. Late mortality occurred in 42 patients (13.2%). Actuarial survival curve at 16 years is 84.0 +/- 3.2% for isolated mitral valve repair and 64.6 +/- 6.7% for mitrotricuspid patients. CONCLUSIONS Mitral valve reconstruction with Duran flexible ring annuloplasty in rheumatic valve disease entails a low hospital mortality with satisfactory long-term clinical results.

Mitral valve repair with a malleable bovine pericardium ring

“…Long-term results showed ventricular function restored to normal levels, significantly improved survival ratios in particular following solely mitral procedures 34 , which in the present work were performed in 71.8% of the patients. Associated with this was the introduction of various valve repair techniques 13,21,40,41 as well as recognition of the problems caused by valve replacement procedures like prosthesis degeneration, infection, transvalvular gradients, paravalvular leaking, hemolysis, and thromboembolic events 8,37 .…”

“…This permitted the achievement of a better result, 65% of the patients passing to functional class I with recovery of left ventricular geometry and mechanical function of the mitral valve, as is also reported in the literature 26,28,34,35 . A follow-up period of 16 months showed a survival ratio of 93.8%; other studies, with lower 29 or equal 36 follow-up periods, reported 98% indexes.…”

“…A study by Bernal et al 34 , utilizing a complete, malleable ring, revealed that 89.9±3.2% of their rheumatic patients remained free of reoperation over a 16-year period. In this case, the risk of reoperation curve showed two critical periods with a high incidence, during the first two years, and 10 years after surgery.…”

“…A follow-up period of 16 months showed a survival ratio of 93.8%; other studies, with lower 29 or equal 36 follow-up periods, reported 98% indexes. Studies with follow-up periods of five 26,28 , eight 35 and 16 34 years, reported survival rates of respectively, 90 to 98.8±1.2%, 88±4%, and 76.1±-3.1%. It is common to find valve repair leading to a higher survival rate in comparison with valve replacement 37 .…”

“…These are probably due to histopathological alterations occurring in the mitral valve during rheumatic disease, including among others, intercellular edema, collagen fiber fragmentation, and lymphocyte and plasma cell infiltration. Nevertheless, Bernal et al 34 and Antunes et al 43 affirm that valvalve repair is an excellent alternative for the treatment of patients with rheumatic mitral valve disease.…”