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Ann Thorac Surg 2003;76:1774-1775
© 2003 The Society of Thoracic Surgeons
a Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Center, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
e-mail: shivchoudhary{at}hotmail.com
To the Editor:
We read with interest the report by Ha and colleagues [1]. The authors concluded that mild or moderate aortic valve disease can be left alone at the time of mitral valve operation with negligible risk for a later aortic valve procedure. If the initial aortic valve lesion is aortic regurgitation (AR), we agree with their conclusion, but our experience dictates otherwise if the initial lesion is aortic stenosis (AS).
In 2001, we [2] presented our experience. A total of 284 patients aged 7 to 62 years (mean age, 23.5 ± 12.2 years) who had undergone mitral valve intervention and had had mild aortic valve disease initially were followed up for 2 to 18 years (mean follow-up, 10.8 ± 3.7 years). At initial intervention, 232 patients had pure mild AR (group A) and 52 patients, mild AS with or without AR (group B).
In 11 patients (5%) in group A, marked AR (moderate in 6 and severe in 5) developed over an interval of 9 to 17 years (mean interval, 12.1 ± 2.8 years). An additional patient had moderate AS and severe AR after 10 years. In group A, freedom from development of moderate to severe aortic valve disease was 100%, 97.0% ± 17%, and 87.4% ± 4.6% at 5, 10, and 15 years, respectively.
In group B, among the patients with mild AS alone initially, 7 had substantial AS (moderate in 4 and severe in 3) after a follow-up of 1 year to 12 years (mean follow-up, 4.9 ± 4.2 years). Ten patients with both mild AS and AR initially had major aortic valve disease after a follow-up of 1 year to 13 years (mean follow-up, 4 ± 3.5 years). This included severe AS in 1 patient, moderate AS in 2 patients, and combined moderate to severe AS and moderate to severe AR in 7. Thus, 17 patients (33%) in group B experienced the development of marked AS ± AR over 1 year to 13 years (mean follow-up, 4.9 ± 3.8 years). In this group, freedom from development of moderate to severe aortic valve disease was 75.6% ± 6.2%, 61.5% ± 8.5%, and 46.1% ± 11.2% at 5, 10, and 15 years, respectively, values significantly lower (p < 0.001) than those in group A. Similarly, the average duration for progression of aortic valve disease was significantly shorter in group B compared with group A (4.9 ± 3.8 years versus 11.9 ± 2.7 years; p < 0.001).
Thus, in our experience, patients who initially have mild AS (± AR) frequently progress to marked AS (± AR). Like Ha and colleagues, Vaturi and associates [3] found progression of mild aortic valve disease to be very rare. However, if the results of both these studies are analyzed separately for patients with mild or moderate AS at initial presentation, this observation may not remain valid. Vaturi and co-workers found that 43% (3/7) of patients with mild AS initially showed progression to moderate or severe AS (± AR). Similarly, Ha and colleagues reported that 6 of 7 patients who had mild or moderate AS (± AR) had development of moderate or severe AS (± AR). The follow-up status of the seventh patient and the follow-up periods of these patients were not provided. It would be of interest to know the follow-up and the final outcome for each of these patients.
The aortic valve area in an adult is about 3.0 cm2 (range, 2.6 to 3.6 cm2), and a gradient becomes detectable only when this area becomes less than 2 cm2. Thus there is a marked decrease in aortic valve area before resting gradients develop across the aortic valve[4]. This represents advanced commissural fusion and valvular deformity. In contrast, mild AR can develop even with a slight deformity of one or more leaflets. Consequently, the presence of mild AS signifies a greater degree of aortic valve disease than does mild AR. In addition, turbulence caused by a stenotic valve can contribute to leaflet damage and rapid progression of the disease. These observations are supported by Otto and colleagues [5], who reported rapid progression of asymptomatic mild AS.
In our practice, we approach mild or moderate AS aggressively. If the patient is undergoing an open heart procedure for mitral valve disease, moderate AS is never left untreated. However, in the presence of mild AS, the management strategy depends upon the mitral valve procedure. If it is open mitral commissurotomy or mitral valve repair, mild AS can be left alone with close postoperative monitoring. However, if the pathological condition of the mitral valve pathology warrants mitral valve replacement, the aortic valve should always be inspected. If the valve is found to be grossly deformed, valve replacement is performed.
References
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