Mitral valve replacement: Long-term results, with particular reference to changes in pulmonary vascular resistance

Abstract

, were reviewed from one to three years after operation. These patients had presented with serious mitral valve disease and there was a high incidence of severe dyspnoea and persistent congestive failure before operation. There were four operative deaths, and two survivors had poor results due to regurgitation alongside the prosthesis. The remaining 10 patients showed considerable improvement. Although no diuretics were given after operation there was little dyspnoea and congestive failure resolved. Anticoagulant therapy is given after operation, and there have been few embolic incidents. The pulmonary vascular resistance was raised to between 6 and 11 units before operation in six patients. There was no undue mortality in this group, and post-operative cardiac catheterization showed a considerable fall in resistance and an increase in cardiac output, suggesting resolution of the pulmonary vascular obstruction. Tricuspid incompetence in these patients disappeared post-operatively. We conclude that mitral valve replacement can restore a patient severely disabled by mitral valve disease to a nearly normal life. We do not regard pulmonary hypertension as a contraindication to operation. Starr and Edwards (1961) showed that it was possible to correct the mechanical abnormalities in mitral valve disease by replacing the valve with a mechanical prosthesis, and they demonstrated that the procedure gave effective relief of symptoms in patients with serious disability. Replacement of the mitral valve with the Starr-Edwards prosthesis has been performed in 50 patients at St. Bartholomew's Hospital since the end of 1963, and there are 39 survivors, a mortality rate of 22 %. Our first successful mitral valve replacement was performed as a desperate measure in a severely ill patient with considerable pulmonary vascular obstruction (Fig. 1). Following this experience we have continued to operate on such patients, and we do not regard the presence of pulmonary vascular disease as a contraindication to mitral valve replacement. As a result of this policy many of our patients have had serious congestive heart failure with tricuspid incompetence at the time of operation. There has been a gratifying improvement in the pulmonary vascular obstruction and in the congestive failure after operation in these patients.The present report is based on the post-operative evaluation of the 16 patients operated on before October 1965. Four of these patients died at operation. The 12 survivors have been followed for from one to three years, with particular reference to the fall in pulmonary vascular resistance which has followed the operation. METHODSClinical features before and after operation have been classified as slight, moderate, severe or gross abnormalities and coded from 0 (for normal) to 4 on this basis. Congestive failure was regarded as slight if the venous pressure was controlled by diuretic therapy, and as gross if hepatic puls-ation or severe oedema persisted in spite of this treatment. Right and left ventricular hypertrophy were...

Pulmonary hypertension in mitral valve disease: 56 surgical patients reviewed.

“…Publications in the earlier days of bypass surgery had shown that the overall surgical mortality for mitral valve surgery had been higher in this group of patients (Nichols et al, 1964;Hamer et al, 1968). The present survey of mitral valve operations in a fouryear period has revealed that, despite the findings of severe pulmonary hypertension and a high pulmonary vascular resistance in 56 patients, the hospital mortality of 5-4% was the same as in a group of 336 consecutive patients whose pulmonary artery systolic pressure was less than 70 mmHg.…”

Mitral valve replacement in the presence of severe pulmonary hypertension.

“…Although pulmonary vascular resistance is regarded as a useful index of severity of pulmonary hypertension, its validity has been questioned (Rudolph and Nadas, 1962) and its interpretation may be difficult (Fritts and Cournand, 1959;Braunwald, Braunwald, and Morrow, 1962). Hamer et al (1968) suggested that higher values of PVR do not necessarily indicate more severe disease of the pulmonary vasculature. The concept of PVR may be valid for steady flow situations where the resistance varies with the pressure difference across the circuit, but higher values of PVR may be related to low cardiac output as well as to an increase in PAm-LAm (Hollinrake, Baidya, and Yacoub, 1973).…”

Early Results of Mitral Valve Replacement in Severe Pulmonary Artery Hypertension—An Institutional Prospective Study

“…With progression of disease, PVR also increases due to reactive pulmonary vasoconstriction and organic changes in the pulmonary microvasculature. The presence of severe PAH not only has an influence on the prognosis of mitral valve disease, it also affects the postoperative outcome as borne by several studies [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19]. Some authors have shown that severe PAH regresses after MVR/mitral valve repair [4][5][6][7][8][9][10][11][12][13][14][15].…”

“…The presence of severe PAH not only has an influence on the prognosis of mitral valve disease, it also affects the postoperative outcome as borne by several studies [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19]. Some authors have shown that severe PAH regresses after MVR/mitral valve repair [4][5][6][7][8][9][10][11][12][13][14][15]. However, others have shown that severe PAH is associated with higher postoperative mortality especially in patients with supra-systemic PA pressures [15][16][17][18][19][20][21][22][23][24][25].…”