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Mitral valve surgery after percutaneous mitral commissurotomy: is repair still feasible?
Gonçalo F Coutinho1, Carlos Filipe Branco1, Elisabete Jorge1
1Centre of Cardiothoracic Surgery, University Hospital and Medical School, Coimbra, Portugal.
Objectives:
Due to progression of rheumatic disease, percutaneous mitral commissurotomy (PMC) is a palliative procedure. We aimed at evaluating the outcomes of patients requiring surgery for failure of PMC, focusing on the fate of the mitral valve (MV) (repair versus replacement).
Methods:
From January 1993 through December 2012, 61 patients with previous PMC were submitted to MV surgery. Detailed operative findings were collected from all patients and an intraoperative anatomical score was introduced to predict reparability. Time to surgery, overall survival and freedom from reoperation were analysed.
Results:
The mean time to surgery after PMC was 6.9±5.9 years and indications were restenosis in 25 patients (41%) and mitral regurgitation or mixed lesion in 36 (59%). Nine patients (14.8%) had more than one previous intervention. Intraoperative inspection of the valve revealed leaflet laceration outside the commissural area in 27 patients (44.3%). Valve repair was accomplished in 38 patients (62.3%). Pulmonary hypertension, calcification and intraoperative anatomical score were independently associated with the probability of valve replacement (OR 1.12, OR 7.03 and OR 4.49, respectively, P<0.05). There was no hospital mortality. MV area increased on average 1.6 cm2 after surgery to 2.7 cm2; 5-, 10- and 20-year survival rates were 98.1±1.9, 91±5.2 and 82.7±9.2%, respectively. The rate of freedom from mitral reoperation (for repaired cases) at 5, 10 and 15 years was 100, 95.8±4.1 and 87.8±8.5%, respectively. There was no difference in survival between repaired or replaced MVs, but the former had less valve-related events during follow-up.
Conclusion:
The MV can be repaired after failed PMC, with very low complication rates and excellent long-term results. Hence, whenever possible, these patients should be sent to reference centres where repair can be successfully achieved.
Insights
Mitral valve repair after failed percutaneous mitral commissurotomy (PMC) is feasible and yields excellent long-term survival. Reference centers offer successful repair, minimizing reoperation rates for mitral valve (MV) disease.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Cardiac Valve Disease
Background:
- Percutaneous mitral commissurotomy (PMC) is a palliative treatment for rheumatic mitral disease.
- Failure of PMC necessitates further intervention, often leading to mitral valve (MV) surgery.
- Evaluating outcomes of MV surgery after PMC is crucial for patient management.
Purpose of the Study:
- To assess the outcomes of patients undergoing mitral valve surgery following failed PMC.
- To determine the success rates of mitral valve repair versus replacement in this patient cohort.
- To identify factors influencing the choice between mitral valve repair and replacement.
Main Methods:
- A retrospective analysis of 61 patients who underwent MV surgery after PMC between 1993 and 2012.
- Development and application of an intraoperative anatomical score to predict MV reparability.
- Analysis of time to surgery, overall survival, and freedom from reoperation.
Main Results:
- 62.3% of patients (38/61) successfully underwent mitral valve repair.
- Pulmonary hypertension, calcification, and the anatomical score predicted the need for valve replacement.
- Excellent long-term survival (20-year rate: 82.7%) and low reoperation rates (15-year rate: 87.8% for repaired MVs) were observed.
Conclusions:
- Mitral valve repair is a viable and safe option after failed PMC, offering excellent long-term results.
- Patients requiring surgery after PMC should be referred to specialized centers for potential valve repair.
- Successful repair leads to fewer valve-related events compared to replacement.
