Outcomes of Mitral Valve Replacement after Closed Mitral Valvotomy: A Retrospective Cohort Study
DOI:
https://doi.org/10.1532/hsf.2293Abstract
Background: The incidence of rheumatic fever and rheumatic heart disease still remains high in the developing countries. Mitral stenosis is predominantly due to rheumatic origin and affects females more than males. Historically, closed mitral valvotomy (CMV) was the first effective intervention for mitral stenosis. We studied the immediate and early surgical outcomes of MVR in patients with history of CMV to see whether their disease behaves differently, when compared with patients without prior CMV undergoing MVR.
Methods: This single center retrospective cohort study was conducted in Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India. Patients who underwent MVR from January 2008 to December 2012 at our institute were studied. The hospital records of 90 patients were analyzed both in the CMV cohort and also in the non-CMV cohort. Preoperative details, intraoperative parameters, immediate postsurgery echocardiography parameters, and follow-up echocardiography details at
1 year and 5 years were studied.
Results: Both the cohorts were similar in age, height, weight, and BSA. In the CMV cohort, 67% were females and in the non-CMV cohort 48% were females. Most of the patients in both the cohorts presented with functional classes 2 and 3. The mean duration between onset of symptoms and MVR in the CMV cohort and the non-CMV cohort was
24.6 years and 6.25 years, respectively. Fifty-nine patients in the CMV cohort had preoperative atrial fibrillation, whereas 47 patients in the non-CMV cohort presented with atrial fibrillation. The mean left atrial (LA) size of patients with sinus rhythm and atrial fibrillation was 46.34 (SE, 0.852) and 55.21(SE, 0.808), respectively. Preoperative echocardiographic assessment revealed a mean ejection fraction of 62% and 63%, mean mitral stenosis gradient of 13 mm Hg and 14.7 mm Hg, mean LA size of 53.2 mm and 50.5 mm, and mean right ventricular systolic pressure of 47.5 mm Hg and 43.6 mm Hg in the post-CMV cohort and in the non-CMV cohort, respectively. The CMV cohort had a longer cardiopulmonary bypass time (111.5 minutes) in comparison with the non-CMV cohort (97 minutes). The aortic cross-clamp time remained similar in both the cohorts. Thirty-six percent of the post-CMV cohort patients had a valve size of 25, and 48% of patients belonging to the non-CMV cohort had a valve size of 27. The percent of moderate-to-severe subvalvar pathology was 88 in both the cohorts. Patients belonging to the post-CMV cohort had a median ventilation time of
16.35 hours, and the patients of the non-CMV cohort had a median ventilation time of 13.75 hours. The duration of ICU stay was 4.41 (SE, 0.188) days and 4.13 (SE, 0.153) days, and length of hospital stay was 8.93 (SE, 0.230) days and 9.13 (SE, 0.313) days in the CMV and the non-CMV cohorts, respectively. Inotropic requirement, measured by the vasoactive inotropic score, was higher in the post-CMV group (11.9), when compared to the other cohort (9.7). Right ventricular (RV) function and pulmonary arterial hypertension assessed in the immediate postoperative period, at 1 year, and at
5 years did not show any significant difference.
Conclusion: The percentage of females in the CMV cohort is higher. Delaying the valve replacement by performing a surgical palliative procedure like CMV, is beneficial in female patients in the child-bearing age group so that they can complete the families. The disease process started earlier in the CMV cohort, and they had a longer duration of illness before undergoing MVR. Even with the longer duration of disease, the RV function, LA size, PA pressures, and mitral stenosis gradients were comparable. Therefore, CMV prevented progression of the disease in the CMV group. The mean LA size is significantly higher in patients with atrial fibrillation. The CMV cohort had a longer cardiopulmonary bypass time. The duration of ventilation, ICU stay, and hospital stay were similar in both cohorts. Inotrope requirement was higher in the post-CMV group. RV function and pulmonary arterial hypertension assessed in the immediate postoperative period, at 1 year, and at 5 years did not show any significant difference.
References
Brock R. 1975. Long-term results after closed mitral valvotomy. Isr J Med Sci 11:122-9.
Carapetis JR. 2007. Rheumatic heart disease in developing countries. N Engl J Med 357:439-41.
Chemla D, Humbert M, Sitbon O, Montani D, Hervé P. 2015. Systolic and mean pulmonary artery pressures: are they interchangeable in patients with pulmonary hypertension? Chest 147:943-50.
Ellis LB, Singh JB, Morales DD, Harken DE. 1973. Fifteen-to-twenty-year study of one thousand patients undergoing closed mitral valvuloplasty. Circulation 48:357-64.
Gaies MG, Jeffries HE, Niebler RA, et al. 2014. Vasoactive-inotropic score is associated with outcome after infant cardiac surgery: an analysis from the Pediatric Cardiac Critical Care Consortium and Virtual PICU System Registries. Pediatr Crit Care Med;15:529-37.
Hoeper MM, Bogaard HJ, Condliffe R, et al. 2013. Definitions and diagnosis of pulmonary hypertension. J Am Coll Cardiol 62(25 suppl):D42-50.
Kim HJ, Cho GY, Kim YJ, et al. 2015. Development of atrial fibrillation in patients with rheumatic mitral valve disease in sinus rhythm. Int J Cardiovasc Imaging 31:735-42.
Kossaify A. 2015. Echocardiographic assessment of the right ventricle, from the conventional approach to speckle tracking and three-dimensional imaging, and insights into the “right way” to explore the forgotten chamber. Clin Med Insights Cardiol 9:65-75.
Maeder MT, Weber L, Buser M, et al. 2018. Pulmonary hypertension in aortic and mitral valve disease. Front Cardiovasc Med 5:40.
Manjunath CN, Srinivas P, Ravindranath KS, Dhanalakshmi C. 2014. Incidence and patterns of valvular heart disease in a tertiary care high-volume cardiac center: a single center experience. Indian Heart J 66:320-6.
Mariyamballi R, Thimmappa N, Bindumathi PL, Pillai P, Balasundaram B. 2016. Correlation of left atrial size and atrial fibrillation in RHD with mitral valve disease. J Evolution Med Dent Sci 5:978-81.
McLaren MJ, Markowitz M, Gerber MA. 1994. Rheumatic heart disease in developing countries: the consequence of inadequate prevention. Ann Intern Med 120:243-5.
Pavankumar P, Venugopal P, Kaul U, et al. 1988. Closed mitral valvotomy during pregnancy: a 20-year experience. Scand J Thorac Cardiovasc Surg 22:11-5.
Rudski LG, Lai WW, Afilalo J, et al. 2010. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography: endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr 23:685-713; quiz 786-8.
Shah SN, Sharma S. Mitral stenosis. [updated 2018 Oct 27; accessed 2018 Mar 5]. In: StatPearls [internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan– . Available from: https://www.ncbi.nlm.nih.gov/books/NBK430742/.
Souttar HS. 1925. The surgical treatment of mitral stenosis. Br Med J 2:603-6.
Suzuki S, Kondo J, Imoto K, et al. 1993. [Long-term results of closed mitral commissurotomy--comparative study of closed mitral commissurotomy, open mitral commissurotomy and mitral valve replacement]. Nihon Kyobu Geka Gakkai Zasshi 41(9):1460-6. Japanese.
Tadele H, Mekonnen W, Tefera E. 2013. Rheumatic mitral stenosis in children: more accelerated course in sub-Saharan patients. BMC Cardiovasc Disord 13:95.
