Mitral valve repair combined with aortic valve replacement

Combined aortic and mitral valve replacement continues to result in significant morbidity and mortality. Although mitral repair has improved the results of mitral valve surgery, its influence on combined aortic valve replacement has not been assessed.

We reviewed 38 consecutive patients who underwent aortic valve replacement (AVR) and mitral repair (MR) between 1985 and 1995. The average age was 57 years; 20 were men and 18 women. Nineteen patients were considered high risk: six had previous cardiac surgery, three were on chronic dialysis, two required emergency surgery for low output syndrome, one had a chronic tracheotomy for chronic lung disease, and seven had left ventricular ejection fraction < 30%. MR consisted of ring application alone in 28 patients, chordal shortening in nine, posterior leaflet transfer in six and posterior leaflet resection in four. AVR was accomplished with 21 bioprostheses, 14 mechanical and three allograft valves. The mean (+/-SD) cross-clamp time was 133 +/- 41 min. Additional procedures included coronary bypass in six patients and tricuspid procedures in three.

There were no operative deaths. Six patients died between 4 and 73 months postoperatively. Patient survival was 75% five and 67% 10 years after surgery. The causes of death were heart failure (two cases), and respiratory failure, drug overdose, electrolyte imbalance and unknown (one each). Logistic risk analysis was significant for females and rheumatic valve disease, bacterial endocarditis, and degenerated valve patients. During follow up there were no valve failures or endocarditis, but three embolic episodes occurred without permanent sequel.

With increased surgical expertise, improved myocardial protection of MR combined with AVR offers excellent short- and long-term results, optimal chordal preservation, no valve failure and no endocarditis; it is the ideal choice where anti-coagulation is contraindicated. The prolonged cross-clamp time was well tolerated.