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J Thorac Cardiovasc Surg 1997;114:179-185
© 1997 Mosby, Inc.
SURGERY FOR ACQUIRED HEART DISEASE |
Received for publication Dec. 16, 1996 Revisions requested Feb. 14, 1997; revisions received March 11, 1997 Accepted for publication March 13, 1997. Address for reprints: Jean F. Obadia, MD, PhD, Service de Chirurgie Cardio-Thoracique, Hôpital Cardiologique, Boulevard Pinel, 69003 Lyon, France.
Abstract
Objective: The aim of the study was to evaluate the prognostic factors for return to sinus rhythm after mitral valve repair.Method: One hundred ninety-one patients underwent surgery for mitral valve repair, including 142 procedures for valve repair only (74%). The patients with preoperative atrial fibrillation (50.5%) were older, clinically more symptomatic, and had a greater degree of left atrial dilation than the patients who had sinus rhythm.Results: Preoperative cardiac rhythm, the duration of preoperative atrial fibrillation, and a lesser degree of left atrial hypertrophy are significant prognostic factors independent of the maintenance of sinus rhythm. The probability of return to stable sinus rhythm was 93.7% when sinus rhythm was already present before the operation and 80% when atrial fibrillation was intermittent or of less than 1 year's duration; probability declined abruptly for durations over 1 year. No significant difference in patient survival was noted between those who had sinus rhythm (99% ± 0.9% at 1 year and 86% ± 6.6% at 5 years) and those who had atrial fibrillation in the preoperative period (95% ± 3.1% at 1 year and 86% ± 8.4% at 5 years). In contrast, the postoperative return to sinus rhythm was associated with 99% ± 0.9% and 94% ± 4.8% survivals at 1 and 4 years versus 97% ± 1.5% and 77% ± 13% in the event of postoperative atrial fibrillation.Conclusion: The aim of restoring postoperative sinus rhythm after mitral valve repair should lead to surgery being conducted on patients who have sinus rhythm or recent-onset atrial fibrillation. Surgery for atrial fibrillation may be of value in patients with a long history of atrial fibrillation, providing that it does not induce prohibitive excess mortality. J Thorac Cardiovasc Surg 1997;114:179-85
The surgical repair of mitral incompetence affords numerous advantages such as the hemodynamic effects related to conservation of the subvalvular apparatus,
1,2 but the most attractive feature is indubitably the prospect of maintaining or restoring sinus rhythm (SR). In addition to increasing cardiac output, restoration of SR avoids long-term oral anticoagulant treatment. During the study, we endeavored to determine the prognostic factors for SR restoration in patients undergoing operations for mitral valve repair. These factors should also contribute to defining the potential role of surgery in atrial fibrillation (AF) in association with mitral repair. 3
Patients and methods
Patients
From November 11, 1991, to March 3, 1996, a series of 191 consecutive patients (124 men and 67 women) aged 64 ± 12 years (range 30 to 86 years) underwent operations for mitral valve repair. Dyspnea of New York Heart Association (NYHA) class III or IV was present in 55% of the patients and angina pectoris in 19%. Mitral regurgitation was mostly severe (grades III and IV), with only six patients in grade II having combined operations (three coronary bypasses and three aortic valvular replacements). In 142 patients (74%) the surgical procedure consisted in mitral valve repair only. In other patients, combined operations were involved: 33 coronary bypasses (17.3%), 6 aortic valve replacements (3.1%), 2 aortic valve repairs (1%), 2 left ventricular aneurysm corrections (1%), and 7 tricuspid valve repairs (3.6%). Three patients (1.6%) had previously undergone coronary bypass grafting. The mitral lesions consisted in 156 cases of dystrophy (81.2%), 17 cases of ischemic lesions (8.9%), 11 cases of endocarditis (5.7%), of which 6 necessitated surgery in the acute phase, 6 cases of rheumatic lesions (3.1%), and 2 cases of congenital lesions (1%).
Before the operation, SR was present in 95 patients (49.5%) and AF in 96 (50.5%). AF was permanent in 68 patients (35.4%), permanent being defined as no return at any time to SR. The durations of AF are summarized in Table I. Twenty-nine patients (15.1%) had intermittent episodes of AF. AF was considered to be intermittent when episodes of AF and SR were observed in a patient even if SR was present at the time of the operation. The latter group was considered separately because we postulated that the patients having had several, even brief, episodes of AF reduced by pharmacologic or electrical cardioversion over the months or years preceding the operation might react differently from the two other patient groups. The history of intermittent AF was variable and ranged from 2 months to 12 years (mean = 11.6 months). Two patients with SR and two patients with AF had had pacemaker implantations.
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Table II. The patients with permanent or intermittent preoperative AF were older, more symptomatic, in a more pejorative mean NYHA class, and had a greater degree of left atrial dilation according to ultrasonography. The proportion of women seemed higher, but this difference did not reach statistical significance. No significant differences were observed in hemodynamic parameters such as end-diastolic volume and ejection fraction determined by ultrasonography. We observed more episodes of thromboembolic complications among the patients who had preoperative intermittent AF or permanent AF (five versus none in the SR group, p = 0.04). Among the 33 patients with associated coronary bypass operations, 45.5% had SR and 50.5% had AF. This difference was not statistically significant.
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Anticoagulant management
Continuous intravenous anticoagulant treatment with heparin was initiated immediately after the operation. On day 5, medication was switched to oral anticoagulants. The required INR (international normalized ratio) was between 3 and 4.5. No patients received platelet aggregation inhibitors. The oral anticoagulants were maintained for at least 3 months if the patient had SR in the postoperative period or for at least 2 months after effective cardioversion, if restoration of SR was obtained secondarily.
Data collection and follow-up
Prospective computerized data entry was performed in the authors' department for all patients. All surviving patients either were seen again at consultations or were mailed a questionnaire. The data entered in the database were completed or confirmed by a survey of attending physicians. The cumulative follow-up was 458.4 years (mean follow-up 2.4 ± 1.1 years). No patient was lost to follow-up in the series. Follow-up was therefore of relatively short duration, but exhaustive.
Statistical analysis
The definitions used are those recommended by the Society of Thoracic Surgeons and The American Association for Thoracic Surgery. 4 Frequencies were compared by means of the 
2 test with Yates' correction. Actuarial survival was calculated by means of the Kaplan-Meier method. 5 The log rank test was used to test for statistically significant observed differences. All data are reported as mean ± standard deviations.
The role of left atrial diameter and preoperative AF duration in predicting the return of SR was studied by means of logistic regression. Because the duration of AF obeyed a non-Gaussian distribution, the log of duration (expressed in months) was used. Testing for correlation between AF duration and atrial diameter was also conducted. The statistical analysis was conducted with the use of the STATISTICA Software for Windows package (StatSoft, Inc., Tulsa, Okla.).
Results
Postoperative mortality and morbidity
The overall 30-day mortality rate was 4.7% (nine patients). The one death in the 86 patients with NYHA class I or II disease (1.2%) was due to a postoperative toxic/allergic reaction with generalized peripheral myolysis and anuria. Mortality in the 96 patients with nonurgent class III and IV disease was 3.1% (three patients including two with concomitant coronary revascularizations). Mortality was higher in the subgroup requiring emergency procedures, in which four of 10 patients died. The early mortality (in 182 patients with nonurgent treatment) was similar for patients with preoperative SR and for those with permanent or intermittent preoperative AF.
As evidenced by the prevalence of inotropic support during weaning from bypass (22% of patients with preoperative SR and 43% of patients with permanent or intermittent AF, p = 0.032) and intraaortic balloon use (1.9% of patients with preoperative SR and 3.9% of patients with permanent or intermittent AF, p = 0.30), the occurrence of low postoperative cardiac outputs seemed less marked in the patients with preoperative SR.
No significant difference was noted between groups in major postoperative complications including all degrees of neurologic complications.
Repeat operations
Two early valve replacements (1%) were required during the first postoperative month, because of defective initial repair. One patient underwent a second operation on day 12 to resecure a Carpentier mitral ring that had dehisced as a result of a technical error. All three patients had uncomplicated courses thereafter. Four patients underwent second operations unrelated to the quality of the initial repair: Two patients had acute endocarditis with early recurrence of vegetations necessitating reoperation and prosthetic valve replacement 4 and 5 weeks after repair; one patient had heart transplantation and another had secondary infectious endocarditis occurring 2 and 3.5 years after repair. No secondary valve replacement was necessary.
Survival
The overall proportion of patients surviving in the series was 94% ± 2.9% at 1 year and 84% ± 9.2% at 5 years. No significant difference (Fig. 1) was noted between the survival of patients who had preoperative SR (99% ± 0.9% at 1 year and 86% ± 6.6% at 5 years) and those who had permanent or intermittent preoperative AF (95% ± 3.1% at 1 year and 86% ± 8.4% at 5 years). Nevertheless, the return to stable postoperative SR in patients having survived surgery yielded actuarial survivals of 99% ± 0.9% at 1 year and 92% ± 5.6% at 5 years versus 97% ± 1.5% at 1 year and 77% ± 13% at 4 years for the patients who had postoperative AF (Fig. 2). This difference did not, however, reach the significance level in the log rank test because of the small size of the postoperative AF subgroup (n = 41). This also explains why survival is given only to 4 years in this subgroup.
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Clinical results and restoration of SR
The clinical and hemodynamic results are summarized in Table III. Only 31% of the patients had SR when they were weaned from extracorporeal circulation and remained in SR subsequently. In the other patients, AF was present at the time of weaning from extracorporeal circulation (38%) or AF developed during the postoperative period (31%). Among the patients who had secondary recovery of stable SR, resumption of SR was spontaneous in 20%, was obtained with amiodarone in 66%, or resulted from electrical cardioversion in 14%. Among the patients with stable postoperative SR, those who had SR in the preoperative period were less likely to have intermittent AF in the postoperative period (58% vs 78%, p = 0.38), and SR resumed earlier, during the first few months (75% vs 52%, p = 0.29), than in the other patients.
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Table I) was 93.7% when SR was present before the operation and 80% when AF was intermittent or of a duration less than 1 year. In contrast, in patients with AF lasting beyond 1 year, the probability of return to SR fell abruptly. Among the 143 patients with stable postoperative SR, 68% required no antiarrhythmic drugs to maintain SR.
Return to stable SR, as evidenced in the late follow-up period, also depended on the preoperative dimensions of the left atrium. The mean preoperative diameter was 50.25 mm in the patients in whom stable postoperative SR returned versus 56.1 mm in those who continued to have AF (p = 0.006).
Logistic regression analysis of patients with preoperative A
(Fig. 3). Left atrial diameter and the logarithm of AF duration were significantly correlated (r = 0.58, p < 10-6). Both were significant and independent predictive factors of the return to SR (p = 0.032 and p = 0.0006, respectively). The model yielded a correct prediction of AF persistence in 85% of patients and a correct prediction of return to SR in 88% of patients.
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Regression of atrial and ventricular diameter
Presence of SR favorably influenced a decrease in left atrial size (from 50.12 mm before the operation to 42.16 mm after the operation) compared with persistent AF (from 54.81 mm to 50.62 mm; p = 0.03). Conversely, return to SR did not influence the regression of the ventricular size.
Comments
The negative effects of AF are widely known, particularly when AF is accompanied by mitral valve disease. 6,7 The aim of the present study was therefore to determine the prognostic factors with respect to SR maintenance after mitral valve repair.
The most positive prognostic factor was the presence of preoperative SR. SR was maintained after the operation in more than 90% of patients. In the present series, about half the patients with preoperative AF had stable SR in the postoperative period. In patients with a history of intermittent AF, even of long duration, or with recent-onset AF, the probability of a return to SR remains good. However, the risk of AF persisting after valve repair becomes major in the presence of chronic preoperative AF lasting more than 1 year. In addition, SR recovery occurs early, with fewer episodes of AF during the postoperative period, in patients having preoperative SR. This may therefore promote earlier functional recovery. However, this recovery is not immediate if the patient has a history of AF. Several weeks are sometimes required for the left atrium to become smaller 8 and atrial contractile function to reemerge. 9
The second prognostic factor, independent of the preceding one in multivariate analysis, is the preoperative diameter of the left atrium. The probability of a return to SR is low when the left atrial diameter is greater than 60 mm. 10 However, the predictive value of preoperative left atrial diameter remains lower than that of preoperative cardiac rhythm or duration of AF. The postoperative evolution of the atrial size was clearly different in the patients in whom SR resumed, but we cannot say whether it is the decreased size of the atrium that allows the return to SR or whether it is the SR that permits a better reduction of the atrial size.
No other prognostic factors for return to SR were identified. In addition, the two significant criteria, preoperative rhythm and left atrial diameter, may prove to be inadequate predictors, particularly in borderline cases: stable SR resumed in 36% of the patients who had had AF for 1 to 3 years and 22% of the patients who had a left atrial diameter greater than 60 mm. As a consequence, precise prediction remains problematic even though, overall, the predictive value is satisfactory.
The low incidence of thromboembolic complications may be due in part to the limited follow-up of the series and to an insufficiently precise neurologic follow-up. Abnormal findings on computed tomographic scanning of the brain are prevalent in patients with chronic AF, indicating prior silent cerebral infarction, even in the absence of clinically evident stroke. 11
With regard to secondary conversion, the presence of preoperative AF has no predictive value. Although the return to stable postoperative SR may yield a different prognosis, a significant difference was not evident in the present series (see Figs. 1 and 2). In addition to this influence on survival, the functional improvement related to SR also needs to be taken into account. 12
The indications for mitral valve repair should take these factors into account and optimize the probability of postoperative restoration of SR. The simplest solution would be to operate earlier to increase the proportion of patients who have SR at the time of the operation. This proportion is, in fact, very dependent on patient recruitment. Depending on the series, 30% to 60% of patients already have AF when they undergo surgery. 13,14 This proportion is probably lower for teams with extensive and long-standing experience in this surgical field. Cardiologists in those circumstances have greater awareness of, and confidence in, the results of valve repair. 15-17 AF development must be considered a decisive turning point in the course of mitral regurgitation, even though it may be problematic to propose surgical therapy to patients who have few or no symptoms. However, this approach is encouraged by the well-established long-term quality of the results 18 of mitral valve repair in patients operated on with NYHA class I or II disease.
Once AF has become established, surgical methods of treating it may be considered, such as the Cox maze procedure, the efficacy of which has been firmly established. 19 However, the Cox maze procedure complicates mitral repair and significantly increases crossclamp time. 20 Consequently, the indications must be carefully evaluated and the procedure restricted to patients with a low probability of returning to SR. On the basis of our results, the Cox maze procedure could be used in cases of AF lasting longer than 1 year or when the left atrial diameter is greater than 60 mm. These considerations nonetheless have to be counterbalanced by the fact that the patient population concerned is in a highly precarious clinical and hemodynamic state, arguing against complex surgery. If the current series is analyzed including only patients who had AF for more than 1 year, a left atrial diameter greater than 60 mm, an ultrasonic ejection fraction greater than 55%, and only requiring simple valve repair (isolated posterior leaflet prolapse), nine patients could have benefited from a Cox maze procedure, that is, a quarter of the patients who had AF for more than 1 year and 4.7% of the whole series. The proportion could be increased provided that the Cox maze procedure does not result in prohibitive excess morbidity.
Conclusion
Postoperative recovery of SR after mitral valve repair is a positive prognostic factor. This objective strongly suggests prompt surgical treatment of patients with SR or with recent-onset chronic AF (less than 1 year) so as to optimize the probability of success. Surgical treatment of AF may be appropriate if restricted to patients with a long-standing history of AF or with a left atrial diameter greater than 60 mm and whose left ventricular function has been relatively well preserved.
References
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