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J Thorac Cardiovasc Surg 1996;112:238-247
© 1996 Mosby, Inc.
SURGERY FOR ACQUIRED HEART DISEASE |
From the Royal North Shore Hospital, Sydney, New South Wales, Australia.
Received for publication June 13, 1995 Revisions requested July 25, 1995; revisions received Sept. 28, 1995 Accepted for publication Oct. 20, 1995. Address for reprints: J. M. Alvarez, FRACS, Department of Cardiac Surgery, Sir Charles Gairdner Hospital, Nedlands, 6009 Perth, Australia.
Abstract
From January 1969 to December 1992, mitral valve reconstructive operations were performed on 155 patients with degenerative mitral valve disease. There were 102 male and 53 female patients, with a mean age of 60.5 ± 9.2 years, a mean duration of symptoms of 3.8 ± 2.7 years, and 34% were in atrial fibrillation. All patients were in New York Heart Association functional classes III and IV before operation. The degree of mitral regurgitation was severe in 94% and moderate in 6%, and 50.9% of patients had moderate to severe impairment of left ventricular function. Emergency operation was undertaken in 7.1% of cases; 19% of patients underwent additional procedures. All patients had posterior mitral leaflet pathology and 19 patients had anterior mitral leaflet pathology. Ring annuloplasty was used in only 3% of cases. The operative mortality rate was 3.9%, 9% of patients had morbid events, and 4.5% of patients had repair failure within 6 months. All patients have been followed up with serial echocardiography for a mean time of 5.2 ± 0.3 years (range 0.5 to 24 years). Immediately after operation, 92.9% had no mitral regurgitation to mild mitral regurgitation. At last follow-up, 96.9% had no mitral regurgitation to mild mitral regurgitation by echocardiography and 98% of patients were in New York Heart Association functional classes I and II. The actuarial survival at 15 years was 46% ± 11%, freedom from reoperation was 84.9% ± 11%, freedom from infective endocarditis was 96.0% ± 11%, freedom from thromboembolism was 90.4% ± 11%, and freedom from all valve-related events was 36.7% ± 11%. It is well documented that repair of degenerative mitral valves offers excellent short-term and medium long–term benefits. This series represents the longest follow-up reported outside Europe. Our results beyond 10 years support our conclusion that an annuloplasty ring is not an absolute prerequisite for achieving successful repair of proven durability in most patients with degenerative mitral valve disease. (J THORAC CARDIOVASC SURG 1996;112:238-47)
In Australia, degenerative mitral valve (MV) disease is the leading cause of mitral regurgitation (MR) necessitating operation. Repairing these valves has become accepted as the goal of treatment because these repairs have stood the test of time with excellent functional status. It has also become accepted that the incorporation of an annuloplasty ring is integral to a successful repair of proven durability.
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This report is a retrospective analysis of 155 patients with degenerative MV disease who underwent MV reconstructive operations at our institution from 1969 to 1992. In the vast majority (97%) of these cases, an annuloplasty ring was not required. We present the 10- to 15-year results of this technique.
Materials and methods
From January 1969 to December 1992, 167 patients underwent MV reconstruction for degenerative MV disease; 155 patients (93%) were followed up; their cases could be analyzed and form the basis of this report. In 12 cases, although we could attest that the patients survived, these survivors were unavailable for follow-up. Inadequate documentation precluded satisfactory analysis regarding outcome of the mitral repair, and these cases were therefore excluded from analysis. Preoperative data are given in Table I. All patients were in New York Heart Association (NYHA) functional classes III and IV before operation and had moderate to severe MR according to two-dimensional echocardiography (2DE). Coronary angiography and ventriculography were performed in patients older than 40 years. Left ventricular function was estimated by 2DE, contrast ventriculography, or both.
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The MV was exposed by an incision paralleling Waterston's groove. Patients with coronary artery disease had all distal anastomoses performed before the MV repair and in addition had cardioplegia perfused through the grafts. Aortic and tricuspid procedures were undertaken after the MV repair. The competency of the MV was assessed during operation by injecting saline solution into the left ventricle through the valve with a bulb syringe. Transesophageal echocardiography became available in 1991 and has since been used routinely. In addition, all patients underwent immediate postoperative 2DE and have been followed up with serial 2DE.
Operative details are given in Table II. All patients had posterior mitral leaflet (PML) pathology, with the central segment of the PML most frequently involved and chordal elongation or rupture universally present. The anterior mitral leaflet (AML) was involved in 19 cases. All patients had variable degrees of annular dilatation. Active endocarditis was present in two patients. Additional procedures were performed in 30 cases, with most of these procedures being coronary artery bypass grafting.
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(Table II), as shown in Fig. 1. These results have been published previously. 2 Prolapse of the PML was managed with a wide quadrangular excision of approximately 60% to 70% of the PML. The margins of the PML remnants were then sutured together by means of interlocking horizontal mattress sutures and reinforced by an over-and-over whip stitch. The suture material used was 2-0 polyester. Through this method, a tension-relieving local basal annuloplasty was achieved (Fig. 2).
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Results
There were six operative deaths (3.9%; Table III); one patient early in this series died of the cerebral effects of massive air embolism during cardiopulmonary bypass (CPB), another patient died of fulminant peritonitis after perforation of a duodenal ulcer, and one patient died of intestinal infarction caused by severe gallstone pancreatitis. All of these patients had competent valves on 2DE and at autopsy. Three patients died of the effects of low–cardiac output syndrome in association with severe MR. In addition to these three patients, an additional four patients had early failure of the MV repair for a total of seven cases of perioperative MV repair failure (4.5%), with five proceeding to MV replacement. The first two had normal left ventricular function (ejection fractions 55% and 57%); the rest had moderate left ventricular impairment (ejection fraction 45%).
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In the remaining three cases of perioperative MV repair failure, one patient was weaned from CPB with moderate MR, which progressed to severe MR during the next 2 weeks. This female patient had extensive calcification of the posterior anulus and extremely friable tissues, presumably from long-standing steroid treatment for systemic lupus erythematosus. It was also judged to be too risky (preoperative ejection fraction 40%) to proceed to immediate MV replacement, and this patient's condition quickly deteriorated. She died on day 28 after operation, and autopsy revealed a basal periannular tear of the PML. Because of the extensive calcification present, she had undergone a limited resection of the PML with an extremely limited basal annuloplasty; annular dilatation and left ventricular enlargement were not prominent in this case. The second patient with perioperative MV repair failure had an extremely disorganized MV with AML and PML pathology; mild MR was present immediately after operation and progressed to severe MR during the next 4 weeks. At MV replacement, the cause of the MR was found to be rupture of chordae of the AML, in addition to the chordae previously shortened on the PML. The final patient with perioperative MV repair failure also had an extremely disorganized valve with advanced myxomatous changes. Although the patient was free of MR after operation, a murmur appeared on day 7 and progressed to severe MR during the next 4 weeks. At MV replacement, a tear in the medial PML segment was found adjacent to an intact suture line.
Patient survival
Fourteen patients had one or more morbid events (9%; Table IV). Patients were followed up for a mean of 5.2 ± 0.3 years (range 0.5 to 24 years). There were 11 late deaths, 10 of which were cardiac related. Of these patients, 10 had recent 2DE documenting no MR to trivial MR before death. Fig. 3 shows actuarial survivals at 10 and 15 years of 80.4% ± 5% and 46% ± 11%, respectively.
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Table IV). Of the 110 patients in NYHA functional class I, 41 have no MR on 2DE, 48 have trivial MR, and 21 have mild MR. Of the 16 patients in NYHA functional class II, four have no MR on 2DE, 10 have mild MR, and have moderate MR. Of the remaining three patients in NYHA functional class II, two have moderate MR and one has mild MR. Currently no patients have significant MR warranting MV replacement.
Postoperative 2DE
Table IV summarizes the results of 2DE immediately after operation and at last follow-up; 92.9% of patients had no MR to mild MR immediately after repair and 96.9% had no MR to mild MR at last follow-up. No patient had evidence of systolic anterior motion of the AML producing left ventricular outflow tract obstruction.
Reoperation for recurrent MR
Five additional patients required reoperation for severe MR more than 6 months after initial operation. At reoperation, four underwent MV replacement and one patient, a 46-year-old man, underwent a rerepair after 8 years and required further reoperation 2 years later. In both instances, the original repairs were intact and the cause of the MR was additional chordal rupture of the AML; at the second reoperation, the MR was replaced. This patient exhibited no significant annular dilatation or left ventricular chamber enlargement on both dates of operation and had no MR after the first operation and trivial MR after the first reoperation.
Among the remaining cases, a 57-year-old man who had moderate MR after repair and was in NYHA functional class II had rapid deterioration of MR 10 years after initial repair; at reoperation the initial repair was intact and the cause of the MR found to be additional chordal ruptures of the AML and PML. The last three patients had moderate MR after repair; in all three cases, the surgeon had noted severe annular dilatation in association with extremely disorganized valves with advanced myxomatous changes at the initial operation. Progression of MR occurred in variable time frames, necessitating reoperation at 10 months, 13 months, and 3 years. At reoperation, the cause of the MR was found to be tears along the medial segment of the remaining PML.
Freedoms from reoperation for structural valve degeneration, which accounted for all cases of required MV replacement, were 90.1% ± 4% and 84.9% ± 11% at 10 and 15 years, respectively (Fig. 4).
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Event-free survival
Freedoms from all valve-related events at 1, 10, and 15 years were 91.6% ± 2%, 68.5% ± 6% and 36.7% ± 11%, respectively (Fig. 7).
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The efforts of Carpentier 3 and Duran and associates 4 have led to a resurgence of enthusiasm for MV reconstructive operations. It has become nearly axiomatic that a surgeon confronted with a patient with severe MR from degenerative MV disease should endeavor to repair the valve. The acceptance of this dictum, although gradual at first, has gathered significant momentum; Australia, like North America, is no exception. The concept of repairing these valves dates to the late 1950s, however, with the pioneering work of McGoon 5, Gerbode and coworkers, 6 and Merendino and colleagues. 7 On the foundation of these principles and techniques, MV repairs have been performed at this institution since the mid 1960s. A key feature of these techniques is the absence of universal incorporation of annuloplasty rings.
Although many consider annuloplasty rings integral to achieving a consistently reproducible and successful repair with proven durability, a not insignificant minority do not hold this view. 8-11 As experience increased at this institution, so too did the efforts to repair all degenerative MVs. Throughout the last decade, some 80% to 85% of these valves were repaired; from 1990 on more than 95% of these valves were repaired.
MV repair carries a low operative mortality, and our series' mortality of 3.9% compares favorably with published series. 12,13 Our long-term survivals, including operative mortality, of 80.4% ± 5% at 10 years and 46.0% ± 11% at 15 years are also in keeping with published reports. The impressive feature common to these survivors is their excellent functional status, with 98% in NYHA functional classes I and II and no MR to mild MR on 2DE in 96.9%. Currently there are no patients awaiting MV replacement because of significant MR.
The perennial concern with MV repair is its durability; of the many factors contributing to successful repair, we believe the key to be stabilization of the posterior anulus by a localized annuloplasty to relieve any tension on the reconstructed leaflets. In our experience, the placement of three to four interrupted, interlocking mattress sutures achieves this goal. As a consequence of this procedure,the PML in essence becomes a platform against which the AML opens and closes. On 2DE, the valve appears functionally like a monocuspid valve. Our freedoms from reoperation at 10 and 15 years were 90.1% ± 4% and 84.9% ± 11%, respectively; these results are equivalent to other large published series in which annuloplasty rings were universally employed.
We carefully assessed the cases of all patients who had died for cause of death and found that 10 of the 11 deaths were cardiac related. In four cases, death was the result of acute myocardial infarction (two patients had undergone coronary grafting in association with their repair); in six cases, death was the result of sudden cardiac death (three patients had a history of frequent ventricular arrhythmias). There was no MR in six cases, trivial MR in four cases, and moderate MR in one case; except for one patient, who died of malignancy, all patients who died had been in NYHA functional classes I and II immediately before death. The mean age of this group was 70.2 years.
In all, there were 12 cases (7.7%) with inadequate repairs; in nine of these cases the MV was severely disorganized, exhibiting advanced myxomatous changes. Annular dilatation was considered a major feature in six of the nine cases. Most of our MV repair failures occurred during the first postoperative year in patients with advanced myxomatous changes; this feature was also seen in the series of David and coworkers. 15 In three cases the cause of the recurrence of MR was chordal rupture in previously intact chordae, and annular dilatation was not a prominent feature either at the original repair or at the time of reoperation.
Although many advocate universal use of annuloplasty rings in all MV reconstructive operations, annuloplasty rings are not without problems. Systolic anterior motion with left ventricular outflow tract obstruction has been reported in 4% to 10% of cases, although recent modifications seem to have reduced this prevalence. 16 We have not had any such occurrences. Although this has been described with MV repair without the use of annuloplasty rings, 17 it is a rare event under these circumstances. Ring dehiscence has also been reported to occur in 4% to 8% of cases. Although the ring is a foreign body, the reported frequencies of endocarditis and thromboembolism with annuloplasty rings appear to be the same as those in our series. The use of these rings is certainly more time-consuming and definitely more expensive, a consideration in today's cost-conscious society.
With respect to AML repair, 2 all of the patients who underwent such repair also underwent PML repair. These patients had a shorter follow-up period of 32 months (range 2 to 102 months); 15 patients are in NYHA functional class I and four are in functional class II; five patients have an audible murmur classed as mild MR on 2DE and an additional five patients have trivial MR detected on 2DE alone. No patient in this group has yet required reoperation as a result of failure of the MV repair.
We opted to use annuloplasty rings of the Duran type solely in complex repairs involving the AML as a further margin of safety. 18 In retrospect, six of the repair failures might have been prevented by the use of an annuloplasty ring. In all of these cases, however, the MV was severely disorganized and advanced degenerative changes were present. Given the reported higher failure rate in the subgroup of cases with this disease variant and the recent published results showing excellent survival among patients with MV replacement in which chordal preservation techniques are used, 19 an argument can be made for performing repairs only in less unfavorable groups. Some endeavor to repair all valves, even when advanced calcification is present. 20 We found that half of our repair failures occurred in the last 3 years of a 25-year experience as we began to repair a higher proportion of valves, however, and this fact may serve to temper enthusiasm for attempting to repair all valves.
In conclusion, MV repair for degenerative disease is possible in an overwhelming majority of patients, with low operative mortality, high long-term survival, and excellent functional status. We believe that an annuloplasty ring is not an absolute prerequisite for long-term successful repair in most cases. The subgroup of patients with advanced degenerative disease, significant annular dilatation, or extensive annular calcification is at greatest risk of failure of the repair.
References
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