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Ann Thorac Surg 2004;78:65-66
© 2004 The Society of Thoracic Surgeons
Department of Cardiothoracic Surgery, Mount Sinai Medical Center 1190 Fifth Ave New York, NY 10029, USA
e-mail: farzan.filsoufi{at}mountsinai.org
e-mail: david.adams{at}mountsinai.org
Professor Alain Carpentier always tells his audience "a mitral valve replacement is a catastrophe." In virtually every published series, patients undergoing mitral valve replacement have decreased survival compared with those treated by mitral valve repair [1]. The ideal mitral valve substitute remains elusive, and young patients (ie, <65 years old) face the difficult choice between a lifetime of anticoagulation and a 1% to 3% per year bleeding risk if they select a mechanical prosthesis, and a significant risk of reoperation due to long-term structural deterioration if they undergo bioprosthetic valve replacement. Very young patients who are at greater risk for early structural valve degeneration and those patients in developing countries where anticoagulation management is challenging face a particularly daunting choice. Hope that cryopreserved mitral homografts might be a solution have receded due to limited durability and high early reoperation rates, particularly in young patients [2]. Kabbani and coworkers are to be congratulated for their continued pursuit of an alternative mitral replacement strategy utilizing a pulmonary autograft in a top-hat configuration. In the 1960s William and colleagues [3] made early attempts to place a semilunar valve in the orthotopic mitral position in dogs. In 1967, Hubka and coworkers [4] and Bigelow and associates [5] reported their experience with replacement of the mitral valve using an aortic homograft. That same year, Ross published the replacement of mitral valve with a pulmonary autograft [6]. In 1999, Ross and Kabbani revitalized the original concept of this procedure [7], and this current manuscript gives the short-term follow-up of their courageous series [8].
It is important to emphasize that Carpentier's techniques of repair can be successfully applied in many patients with rheumatic mitral valve disease, including those with predominantly mitral regurgitation with very acceptable long-term results [9]. The absence of a complete description of valve pathology (Carpentier's functional classification and specific valvular lesions) makes it difficult to interperate the actual indication for replacement in this series. We were surprised, however, that a majority of patients had no leaflet calcification, which in our experience is associated with an increased likelihood of valve repair in rheumatic patients. The replacement of the mitral valve with a pulmonary autograft is a complex operation with a "learning curve" as reflected by their results. In this series, 5 patients presented with early graft obstructions related to technical failure and required reoperation. Furthermore, although the overall goal of the authors is commendable, an operative mortality rate of 5% following mitral valve replacement in a patient population with a mean age of 39 years also highlights the technical difficulty of their operative strategy compared with standard prosthetic valve replacement.
We are a very long way away from the "projected" algorithm described in Figure 7, of the current article, and only surgeons with extensive experience with complex valve surgery should consider the implantation of a pulmonary autograft in the mitral position. The lack of long-term results also remains a major unknown. Current clinical data does not support the use of the pulmonary autograft in the mitral position in adult patients with pathology not suitable for valve repair because other replacement options provide satisfactory long-term results [10, 11] and are associated with less operative risks. The true advantage of the pulmonary autograft in the mitral position may one day be realized in infants and children, especially if the potential of growth of the conduit can be preserved. In this series the authors described slitting the Dacron sleeve in two congenital patients to allow for annular enlargement over time. We have recently described orthotopic pulmonary autograft mitral valve replacement in a pig model, which may extend the potential of growth even further [12]. More experience with alternative surgical techniques to reconstruct the right ventricular outflow tract will also make pulmonary autograft mitral substitute more attractive in growing children, where pulmonary homograft mismatch remains a potential consideration. Although the concept of using semilunar valves in the mitral position is not new, this current series is by far the largest and most complete to date, and provides stimulation to continue to pursue the dream of a growing, resilient, and nonthrombogenic mitral valve substitute, particularly for our very young.
References
This article has been cited by other articles:
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  A. S. Kumar, S. Talwar, and A. Gupta Mitral valve replacement with the pulmonary autograft: midterm results. J. Thorac. Cardiovasc. Surg., August 1, 2009; 138(2): 359 - 364. [Abstract] [Full Text] [PDF]
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