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J Thorac Cardiovasc Surg 1996;112:727-730
© 1996 Mosby, Inc.
SURGERY FOR ACQUIRED HEART DISEASE |
From the Department of Cardiovascular & Thoracic Surgery, Postgraduate Institute of Medical Education and Research,Chandigarh, India.
Received for publication July 28, 1995 Revisions requested Sept. 19, 1995; revisions received Feb. 7, 1996 Accepted for publication Feb. 13, 1996. Address for reprints: R. K. Suri, FAMS, FIACS, Professor and Head, Department of Cardiovascular and Thoracic Surgery, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh—160 012, India.
Abstract
The costs of heart operations and the problems related to anticoagulation after prosthetic valve replacement are among the limitations faced by patients in nonindustrialized countries with mitral stenosis caused by chronic rheumatic heart disease. The young age at which these patients are seen also compels the surgeon to preserve the native valve. The least costly and optimal way to achieve this objective is by closed mitral valvotomy. After closed mitral valvotomy, mitral restenosis is commonly encountered. We report here our 10-year experience with operation on 113 consecutive patients with mitral restenosis. Closed transventricular revalvotomy was performed with Tubbs dilator in 105 of 113 patients. Mean age was 34.3 years, with a male to female ratio of 1:1.5. Most patients were in New York Heart Association functional classes III and IV (74.3% and 19.4%, respectively). Mean interval between first and second valvotomy was 9.4 years. Hospital mortality rate was 2.8%, trivial postoperative mitral regurgitation occurred in 16.1%, and moderately severe regurgitation occurred in 1.9%. Early postoperative systemic embolism occurred in 3.8% of the cases. Moderate to excellent symptomatic improvement was noted in 89.4% of the cases and poor results were seen in 10.2%. Late follow-up of 76 patients ranged from 2 to 10 years (mean 3.8 years), with 39.4% patients in New York Heart Association class I and 50% in class II. Close mitral revalvotomy is thus an economical, simple, and safe palliative procedure that carries good long-term results. (J THORAC CARDIOVASC SURG 1996;112:727-30)
With the introduction of cardiopulmonary bypass, the technique of closed transventricular mitral valvotomy (CMV) for mitral stenosis was virtually abandoned in industrialized countries. This technique continues to be used in most centers in nonindustrialized countries, however, because of its cost-effectiveness and to avoid the problem of anticoagulation therapy after prosthetic mitral valve replacement (MVR). Restenosis is a known complication after CMV, and its prevalence has been reported to range widely, varying between 2% and 60%.
1-3 Approximately 10% of patients returning to the hospital with persistent or recurrent symptoms 6 years after operation have true restenosis. 4 Virtually no differences have been reported with respect to the short-term results achieved with the three available palliative procedures: CMV, open mitral valvotomy or commissurotomy (OMV), and balloon mitral valvotomy (BMV). 5 It will take more time, however, for evaluation of long-term results of OMV and BMV.
Considering the relatively younger age at which our patients are seen and their socioeconomic status, our effort has been to adopt a palliative procedure with a low cost and without problems of anticoagulation, while at the same time preserving the native valve. In this retrospective study, we analyzed the results of CMV in 105 of total 113 consecutive patients with mitral restenosis at the Post Graduate Institute of Medical Education and Research, Chandigarh, India.
Patients and methods
This study comprises 113 consecutive patients with mitral restenosis who underwent reoperation during a 10-year period (January 1982 to December 1992). These patients were evaluated clinically and echocardiographically. Most were found to be suitable candidates for closed mitral revalvotomy (CMR). Six patients with heavily calcified valves underwent MVR, and two patients in whom a left atrial clot was detected on echocardiography underwent OMV. In the remaining 105 patients, CMR was carried out. One hundred two of these patients underwent CMR for the first time and three patients had successful second CMRs. Patients who had symptoms within 3 years of the first CMV were excluded from this study because they were considered to have an inadequate initial valvotomy.
Of 113 patients with mitral restenosis, 45 were male and 68 were female (1:1.5). Their ages ranged from 14 to 56 years, with a mean of 34.3 years (Table I). Most of the patients were in New York Heart Association functional classes III (74.3%) and IV (19.4%). Hemoptysis was present in 15.9% of the patients, and atrial fibrillation was present in 55% of the patients. Preoperative systemic embolic episodes occurred in 11 patients (10%), with detectable left atrial clot in only two. The mean interval between first CMV and CMR was 9.4 years; that between first CMV and MVR was 6.2 years. Preoperative echocardiographic findings are listed in Table II. Mean mitral valve area according to echocardiography was 0.74 cm2.
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A total of 76 patients who had undergone CMR were evaluated clinically and with echocardiography. Evaluation was performed 2 to 10 years (mean 3.8 years) after operation.
Results
A complete and satisfactory commissurotomy was achieved in 95 of the 105 patients who underwent CMR. In one case, the procedure had to be abandoned because the Tubbs dilator could not be negotiated across the mitral valve orifice as a result of severe subvalvular pathology. Postcommissurotomy mitral regurgitation occurred in 19 patients. Regurgitation was trivial in 17 patients (16.1%) and moderately severe in two patients (1.9%). Of the two patients with moderately severe mitral regurgitation, one underwent emergency MVR and the other died before operation of acute intractable pulmonary edema and low cardiac output. Postoperative systemic embolism occurred in four patients (3.8%). Intraoperative ventricular fibrillation that could be successfully converted with direct current shock occurred in three patients. Operative complications are listed in Table III. Early in-hospital death (defined as death occurring within 30 days after operation) after CMR was 2.8%. There were no operative complications in the three patients who underwent a second CMR. Causes of death after CMR for mitral restenosis are shown in Table IV.
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Table V. The occurrences of restenosis were 8.4 at 5 years and 20.2 at 10 years per 1000 patients per year after CMR. None of our patients had any evidence of recurrence of acute rheumatic activity. There was no subsequent increase in mitral regurgitation among patients in whom trivial mitral regurgitation perioperative had developed.
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CMV is an established surgical procedure for treatment of mitral restenosis, however, only a few studies assessing its results have been reported. 1,6,7 The current consensus in industrialized countries favors open operative techniques. 2,8 Despite many reports on the effectiveness of OMV, it is not certain whether the results are sufficiently superior to those of CMV to justify the higher cost involved in an open procedure, an important factor particularly in nonindustrialized countries. 9 Farhat and associates 10 reported a mean mitral valve area of 2.1 cm2 after OMV for noncalcific mitral stenosis. In earlier reports, survival after CMV was rather disappointing. 11,12 Recent studies, however, have shown low early and late mortality rates after CMV both for primary mitral stenosis and restenosis. 1,6,13 MVR carries the risk of thromboembolism, mechanical failure, prosthetic valve endocarditis, and problems related to anticoagulation. The incidences of mitral regurgitation after CMV and OMV are similar. The reported incidence of MVR after OMV in a follow-up of 4.4 years to 8.6 years is 7% to 18%. 2,14 Younger surgeons have shown a preference for MVR. 15,16
Although BMV has recently gained popularity, 10,17-20 its cost and short-term palliative results compared with those achieved by CMV are limiting factors. 21 In the available literature, there are no reports defining the role of percutaneous BMV for mitral restenosis. 22 The results of surgical commissurotomy (OMV, CMV) and BMV are similar, 14,23,24 and only the patient's preference and the cost factor guide the choice of the procedure to be performed. In an editorial, Frater 5 cautioned that the results achieved by BMV are as good as those of CMV, provided that complications (including residual atrial septal defect, cardiac perforation, and iatrogenic mitral regurgitation) are not in excess of those associated with operation. It has been predicted that in appropriately selected patients the long-term clinical outcome after BMV may be expected to be similar to the available data for surgical commissurotomy (OMV, CMV). 25
Restenosis is the result not only of inadequate valvotomy but also of a continuing fibrotic process. 1 Progressive restenosis correlates not only with time but also with the pathologic state of valve at surgical intervention. 5 The relatively younger age of our patients, a mean of 34.3 years, forced us to evolve a strategy to conserve the native valve through CMV or CMR. Any other procedure would have led to increased costs and lesser acceptability of a valvular prosthesis in our social milieu. Logically, the basic social circumstances and inadequate health care facilities available for our population group at risk, compels us to adopt the most cost-effective procedures in our country. The results have been so gratifying in our patients that we believe every effort should be made to preserve the native valve until a more acceptable valve substitute is available.
MVR caries the hazards of anticoagulation, with the necessity of life-long expenditure and strict treatment compliance. Because most of our population at risk has a rural background and poor socioeconomic status, compliance with an anticoagulation schedule is always doubtful in our country, and noncompliance often leads to serious post-MVR complications.
In our experience, the early operative mortality rate is less than that reported for earlier series, 6,13 is easily comparable with that of OMV, 8,26,27 and is certainly less than that for MVR. 28 Mitral regurgitation carries an important prognostic significance for functional outcome necessitating MVR 19,20 but was trivial in most of our cases (16.1%). There is no reported difference in the prevalences of mitral regurgitation associated with the three palliative procedures available for the treatment of mitral stenosis. 25 The limitation common to CMV, BMV, and OMV is calcified valve; that common to both CMV and BMV is left atrial clot.
Conclusion
New York Heart Association functional class improved in most of our patients after CMR. In our opinion, CMV for mitral restenosis still offers excellent palliation with low risk, low cost, and good long-term results in most patients, without the hazards of anticoagulation.
References
This article has been cited by other articles:
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  D. H. De, A T. Pezzella, D. H. De, and A T. Pezzella Closed Mitral Commissurotomy Utilizing Right Thoracotomy Approach Asian Cardiovasc Thorac Ann, June 1, 2000; 8(2): 192 - 194. [Abstract] [Full Text] [PDF]
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 B. Iung, E. Garbarz, P. Michaud, A. Mahdhaoui, S. Helou, B. Farah, P. Berdah, P.-L. Michel, Y. Makita, B. Cormier, et al. Percutaneous mitral commissurotomy for restenosis after surgical commissurotomy: Late efficacy and implications for patient selection J. Am. Coll. Cardiol., April 1, 2000; 35(5): 1295 - 1302. [Abstract] [Full Text] [PDF]
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