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Ann Thorac Surg 2000;69:125
© 2000 The Society of Thoracic Surgeons

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Invited Commentaries

^a Department of Thoracic and Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA

e-mail: orsulak.thomas{at}mayo.edu

Invited commentary

The article by Kitamura and colleagues describes an interesting technique for the repair or salvage of rheumatically damaged valves beyond the reaches of percutaneous or surgical commissurotomy. The technique has some characteristics of deja vu in relation to the aortic decalcification rage more than a decade ago that ended in universal aortic regurgitation due to scarring and retraction of the leaflets. In considering this form of cosmesis for valve repair, it must be accompanied with at least a word of caution.

The mechanism of valve destruction in rheumatic heart disease is not a superficial shroud over a structurally intact valve. Rheumatic valvular heart disease is a progressive inflammatory process involving all layers of the leaflets with inflammatory cells, scarring, and calcification. Valve replacement removes the valvular inflammatory process from the equation. To cosmetically carve or "rasp" a structure resembling a valve leaflet does not correct or eliminate the process. Rheumatic valve disease is frequently an indolent and progressive disease and will continue to cause tissue reaction, retraction, and inflammation. Although the early results may be acceptable, understanding the inflammatory process will cause these patients to return with progressive valve disease in the future. However, there may be continental differences in this disease process. In rheumatic patients in the United States, the valve seen at the time of operation is in elderly patients and is knarled and retracted such that any repair is not possible.

Rheumatic involvement causes a disarray of the basic structural components of the valve, and gross remodeling or rasping will not recreate the intricate and organized layered structure of the native valve leaflets. It will be crucial that these patients are followed diligently before any widespread application of the rasping procedure is performed [1–9].

References

1. Freeman W.K., Schaff H.V., Orszulak T.A., Tajik A.J. Ultrasonic aortic valve decalcification. J Am Coll Cardiol 1990;16:623-630.[Abstract]
2. Hanson T.P., Edwards B.S., Edwards J.E. Pathology of surgically excised mitral valves. Arch Pathol Lab Med 1985;109:823-828.[Medline]
3. Waller B., Howard J., Fess S. Pathology of aortic valve stenosis and pure aortic regurgitation. A clinical morphologic assessment—Part I. Clin Cardiol 1994;17:85-92.[Medline]
4. Waller B.F., Howard J., Fess S. Pathology of mitral valve stenosis and pure mitral regurgitation—Part I. Clin Cardiol 1994;17:330-336.[Medline]
5. Waller B.F., Howard J., Fess S. Pathology of mitral valve stenosis and pure mitral regurgitation—Part II. Clin Cardiol 1994;17:395-402.[Medline]
6. Subramanian R., Olson L.J., Edwards W.D. Surgical pathology of combined aortic stenosis and insufficiency. A study of 213 cases. Mayo Clin Proc 1985;60:247-254.[Medline]
7. Subramanian R., Olson L.J., Edwards W.D. Surgical pathology of pure aortic stenosis. A study of 374 cases. Mayo Clin Proc 1984;59:683-690.[Medline]
8. Agozzino L., Falco A., de Vivo F., de Vincentiis C., de Luca L., Esposito S., Cotrufo M. Surgical pathology of the mitral valve. Int J Cardiol 1992;37:79-89.[Medline]
9. Turri M., Thiene G., Bortolotti U., Milano A., Mazzucco A., Gallucci V. Surgical pathology of aortic valve disease. Eur J Cardiothorac Surg 1990;4:556-560.[Abstract]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Thomas A. Orszulak Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Orszulak, T. A. Search for Related Content PubMed Articles by Orszulak, T. A.