Very Long-Term Results (More Than 20 Years) of Valve Repair With Carpentier's Techniques in Nonrheumatic Mitral Valve Insufficiency

Abstract

Background-Mitral valve repair is considered the gold standard in surgery of degenerative mitral valve insufficiency (MVI), but the long-term results (Ͼ20 years) are unknown. Methods and Results-We reviewed the first 162 consecutive patients who underwent mitral valve repair between 1970 and 1984 for MVI due to nonrheumatic disease. The cause of MVI was degenerative in 146 patients (90%) and bacterial endocarditis in 16 patients (10%). MVI was isolated or, in 18 cases, associated with tricuspid insufficiency. The mean age of the 162 patients (104 men and 58 women) was 56Ϯ10 years (age range 22 to 77 years). New York Heart Association functional class was I, II, III, and IV in 2%, 39%, 52%, and 7% of patients, respectively. The mean cardiothoracic ratio was 0.58Ϯ0.07 (0.4 to 0.8), and 72 (45%) patients had atrial fibrillation. Valve analysis showed that the main mechanism of MVI was type II Carpentier's functional classification in 152 patients. The leaflet prolapse involved the posterior leaflet in 93 patients, the anterior leaflet in 28 patients, and both leaflets in 31 patients. Surgical technique included a Carpentier's ring annuloplasty in all cases, a valve resection in 126 patients, and shortening or transposition of chordae in 49 patients. During the first postoperative month, there were 3 deaths (1.9%) and 3 reoperations (2 valve replacements and 1 repeat repair [1.9%]). Six patients were lost to follow-up. The remaining 151 patients with mitral valve repair were followed during a median of 17 years (range 1 to 29 years; 2273 patient-years).The 20-year Kaplan-Meier survival rate was 48% (95% CI 40% to 57%), which is similar to the survival rate for a normal population with the same age structure. The 20-year rates were 19.3% (95% CI 11% to 27%) for cardiac death and 26% (95% CI 17% to 35%) for cardiac morbidity/mortality (including death from a cardiac cause, stroke, and reoperation). During the 20 years of follow-up, 7 patients were underwent surgery at 3, 7, 7, 8, 8, 10, or 12 years after the initial operation. Valve replacement was carried out in 5 patients, and repeat repair was carried out in 2 patients. At the end of the study, 65 patients remained alive (median follow-up 19 years). Their median age was 76 years (age range 41 to 95 years). All except 1 were in New York Heart Association functional class I/II. Conclusions-Mitral valve repair using Carpentier's technique in patients with nonrheumatic MVI provides excellent long-term results with a mortality rate similar to that of the general population and a very low incidence of reoperation. (Circulation. 2001;104[suppl I]:I-8-I-11.)

Current concepts in mitral valve repair for degenerative disease

“…There is therefore no way of knowing the longterm survival outcomes of mitral valve surgery as currently practiced. Based on existing data, it appears that if surgery is undertaken before onset of symptoms and where left ventricular function is preserved, the life expectancy should be similar to that of the general population [15,35,36]. When significant symptoms of heart failure have developed (NYHA III-IV) before mitral valve surgery is undertaken, the long term survival is significantly reduced (Fig.…”

“…The longest term follow-up available is for conventional 'Carpentier' techniques. Braunberger and colleagues [36] reported in 2001 on the long term outcomes of 162 non-rheumatic patients (of whom 90% were degenerative) who underwent a Carpentier repair between 1970 and 1984. They observed that 97% of patients with posterior leaflet, 86% with anterior leaflet and 83% of patients with bileaflet prolapse were free of re-operation at 20 years (Fig.…”

Moderne Mitralklappenchirurgie

“…Abb. 3 dargestellt, aufgeschlüsselt nach den Pathologien: Wird ein Prolaps des vorderen Segels oder beider Klappensegel behandelt, kommt es bei der Resect-Strategie zu deutlich mehr Reoperationen [11], als wenn eine reine Pathologie des hinteren Segels vorliegt. Bei der Respect-Strategie unter Verwendung von Gore-Tex ® -Loops ist die Häu-figkeit einer Reoperation dagegen unabhängig von der Segelpathologie [9].…”

“…3 8 Freiheit von Reoperationen bei Patienten mit primärer Mitralklappeninsuffizienz nach Verwendung der Resect- [11] oder Respect-Technik [9], aufgeschlüsselt nach der Pathologie. BS Beide Segel vom Prolaps betroffen, HS hinteres Segel betroffen, VS vorderes Segel betroffen Abb.…”

Development of a minimally invasive mitral valve surgery program – The Innsbruck experience

“…Since few selected centers worldwide have introduced minimally invasive mitral valve surgery using femoral cannulation together with direct transthoracic or endovascular aortic cross clamping, this technique has become an alternative treatment option for non-infected, non-ischemic mitral disease [3][4][5][6]. Conventional mitral valve repair shows excellent long-term durability [7,8]. Carpentier started mitral repair in 1968, developing the widely used repair techniques including ring annuloplasty, and thus conventional mitral repair has been popular in cardiac surgery since the beginning of the 1990ies.…”