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Ann Thorac Surg 2005;79:1921-1925
© 2005 The Society of Thoracic Surgeons

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Original article: Cardiovascular

Aortic Valve Repair for Rheumatic Aortic Valve Disease

Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India

Accepted for publication November 22, 2004.

^_* Address reprint requests to Dr Kumar, Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi—110 029, India (E-mail: asampath_kumar{at}hotmail.com).

	Abstract

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
BACKGROUND: The aim of this study is to assess the long-term results of aortic valve repair in patients with rheumatic aortic valve disease.

METHODS: From April 1991 through December 2003, 61 patients with rheumatic aortic valve disease underwent aortic valve repair. Mean age was 23.7 ± 9.3 years (range, 6 to 53 years). Thirty-nine (63.9%) patients were in New York Heart Association functional class III. Reparative procedures included cuspal thinning (n = 59), commissurotomy (n = 45), subcommissural annuloplasty (n = 24), commissural plication (n = 12), perforation closure using pericardium (n = 2), and decalcification of cusps (n = 2). Associated procedures included mitral valve repair (n = 36) and tricuspid valve repair with mitral valve repair (n = 5).

RESULTS: Early mortality was 4.9% (3 patients). Mean follow-up was 93.8 ± 46.4 months (range, 6 to 160 months, median, 103 months). Forty-six survivors (65%) had no or trivial or mild aortic regurgitation. Four patients required reoperation for valve dysfunction. There were no late deaths. Actuarial and reoperation-free survival, at 160 months, was 95.2% ± 2.8% and 85.4% ± 6.7%, respectively. Freedom from significant aortic stenosis or regurgitation was 52.4% ± 16.9%.

CONCLUSIONS: Aortic valve repair in patients with rheumatic aortic valve disease is feasible and yields gratifying long-term results.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Aortic valve replacement (AVR) with a prosthesis has been the preferred surgical therapy for patients requiring surgery for significant aortic valve disease [1]. Aortic valve repair has generally been preferred for patients with aortic regurgitation (AR) associated with ventricular septal defect, aortic dissection, or annuloaortic ectasia [2–5]. Experience with aortic valve repair in patients with rheumatic heart disease is limited, and long-term follow up of valve repair in this subset of patients is limited [6–12]. In 1994, we first described our early experience with aortic valve repair in 22 patients with rheumatic AR [13]. With the passage of time our experience has grown and the follow-up has increased; we now present detailed results with long-term follow-up.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
From April 1991 through December 2003, 858 patients with rheumatic aortic valve disease underwent surgery; 61 (7.2%) of these underwent aortic valve repair, and the rest underwent isolated aortic valve replacement (n = 456) or combined aortic replacement and mitral valve repair or replacement (n = 341). Repair was attempted in another 5 patients in our initial experience: three of these operations were unsuccessful and were abandoned in favor of immediate AVR; two had failure within a week requiring AVR. Of the 61 patients undergoing successful repair, 41 patients (67%) were males and 20 (33%) were females. The mean age was 23.7 ± 9.3 years (range, 6 to 53 years). All these patients had evidence of rheumatic heart disease, and the aortic valve disease was graded as moderate (n = 3) or severe (n = 58) in these patients. Pure AR was present in 48 (78.7%) patients, pure aortic stenosis (AS) was present in 6 (9.7%) patients, and mixed AS and AR was present in 7 (11.3%) patients. The predominant presenting symptom was dyspnea on exertion. Thirty-nine (63.9%) patients were in New York Heart Association class III. Congestive heart failure was present in 2 patients. Twenty (32.8%) patients had atrial fibrillation.

Preoperative transthoracic echocardiography was performed in all patients. Cardiac catheterization and cineangiography was performed if there was suspicion of associated mitral valve disease. Aortic regurgitation was graded by Doppler echocardiography or angiography or both according to previously published criteria [14, 15]. On a qualitative scale of +1 to +4, AR with grade +1 was considered of mild severity. After January 1996, intraoperative transesophageal echocardiography (TEE) was performed using a Hewlett-Packard Sonos 1500, 2500, or 5500 ultrasound system (Hewlett-Packard Co, Andover, MA). Echocardiographic assessment included a systematic study of the aortic annulus, thickness and mobility of the aortic valve cusps, presence of calcification, regurgitant jet, and gradients across the aortic valve. The mitral and tricuspid valves were also assessed in a similar fashion. Criteria of possible aortic valve repair on TEE included minimal or no calcification of aortic valve leaflets, some degree of mobility of cusps, and at least 2 to 3 mm of central leaflet coaptation.

Surgical Technique
The surgical approach was through a median sternotomy in all patients. Aortic and two-stage atrial cannulation was used in patients with isolated aortic valve disease. In patients with mitral valve disease, aortobicaval cannulation was performed. Before 1996 moderately hypothermic (32°C) cardiopulmonary bypass was used; since 1996 normothermic perfusion was used in all patients. Direct ostial cold-blood cardioplegia and topical ice slush were used for myocardial protection. Mitral valve repair was performed first if the patient had associated mitral valve disease by using the techniques described by us elsewhere [16]. Aortic valve repair was attempted only if the mitral valve repair was satisfactory and the patient had moderate or severe aortic valve disease. The aortic valve was inspected for stenosis, calcification, perforation, annular dilatation, leaflet prolapse, and deficient or retracted leaflet tissue. Operative findings included commissural fusion (n = 45, 73.8%), cusp thickening (n = 59, 95.2%), calcification in cusps (n = 5, 8.2%), cusp perforation (n = 2, 3.3%), cusp prolapse (n = 16, 26.2%), rolling of the cusps (n = 37, 60.7%), associated mitral valve disease (n = 36, 59%), and combined aortic, mitral, and tricuspid valve disease (n = 5, 8.2%).

A variety of reparative procedures were performed. These have been described by us earlier [13] and by others [17] and are briefly outlined below.

Commissurotomy was performed when commissural fusion was present (n = 45, 73.8%). A No. 11 blade was used to open the commissure up to the aortic wall.

Cuspal thinning (n = 59, 95.2%) was performed by peeling off the thickened endocardium using a vascular forceps (Fig 1). The peeling off was started from the left ventricular outflow tract, and this fibrous peel was removed in a upward direction toward the free edge of the aortic valve cusps to remove all the excessive tissue and to make the valve leaflets thin and pliable.

View larger version (37K): [in this window] [in a new window]   Fig 1. Technique of cuspal thinning. The thickened endocardium is peeled from the left ventricular outflow tract using a vascular forceps. (a) Longitudinal section. (b) Cross section.

Commissural plication as described by Trusler and associates [2] was used to reduce the commissural angle in 12 (19.4%) patients. Other techniques included closure of the perforation using autologous glutaraldehyde-treated pericardium (n = 2, 3.3%) and decalcification of cusps (n = 2, 3.3%).

Associated procedures included mitral valve repair in 36 (59.7%) patients and tricuspid valve repair with mitral valve repair in 5 (8.2%) patients. No patient had mitral valve replacement.

Assessment of Repair
The mitral valve repair was assessed by injecting cold saline solution into the left ventricular cavity using a bulb syringe and observing the coaptation of leaflets. Aortic valve repair was assessed as follows: (1) the cusps were visually inspected, gentle traction was applied on the commissures, the center of the cusps was pressed, and leaflets were aligned with each other to observe for redundant tissue; and (2) since 1996, intraoperative TEE was routinely used for assessment of repair after weaning from cardiopulmonary bypass. No more than trivial or mild AR was accepted after TEE with normal hemodynamics.

Follow-Up
Before discharge from the hospital, transthoracic echocardiography was carried out in all patients. No anticoagulants or antiplatelet drugs were prescribed for patients undergoing isolated aortic valve repair. For patients undergoing mitral valve repair using an annuloplasty ring in addition, acenocoumarin was prescribed for 6 weeks along with aspirin 150 mg per day for life. Long-acting benzathine penicillin was prescribed every 3 weeks to all patients younger than 45 years of age. All survivors were seen in the outpatient clinic after 1, 3, and 6 months and then at yearly intervals and underwent clinical examination and echocardiography. The period between January 2004 and September 2004 was the closing interval when 55 of the 58 survivors were last seen and underwent echocardiography. Their last follow-up during this period was taken for reporting the results.

Statistical Analysis
All data were statistically analyzed using the SPSS for Windows 10.0 software package (SPSS Inc, Chicago, IL). Descriptive statistics, ie, mean and standard deviation, have been calculated for continuous variables, and simple percentages are presented when applicable. Univariate analysis was done using ² and Fisher’s exact tests. Actuarial estimates were calculated and compared using the Kaplan-Meier analysis with Mantel-Cox log rank test. Aortic regurgitation was considered to be significant if it was moderate or severe. Peak transvalvular gradient of 50 mm Hg or greater across the aortic valve was considered significant AS. Factors analyzed as predictors of early and late mortality and the development of significant AS or AR included age, sex, type of lesion (AS, AR, or both), preoperative New York Heart Association class, preoperative congestive heart failure, valve pathologic disease (commissural fusion, cusp thickening, calcification, cusp perforation, cusp prolapse, rolling of cusps), left ventricular dysfunction (ejection fraction <0.50, n = 24), associated mitral valve disease, cardiopulmonary bypass and aortic cross-clamp times, and the use of various techniques of repair. All these variables were subjected to a stepwise multiple logistic regression analysis to determine the prognostic factors for development of significant AS or AR.

	Results

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
All the patients survived the operation. The mean aortic cross-clamp time for isolated aortic valve repair was 40.2 ± 15.9 minutes (range, 26 to 59 minutes) and the mean cardiopulmonary bypass time was 65.2 ± 12.4 minutes (range, 45 to 73 minutes). For patients who required additional mitral valve repair, the mean aortic cross-clamp and cardiopulmonary bypass times were 68.3 ± 15.6 minutes (range, 56 to 82 minutes) and 84 ± 13.9 minutes (range, 75 to 103 minutes), respectively. Six (9.8%) patients required inotropic support. The mean duration of mechanical ventilation was 16 hours (range, 11 to 72 hours). Mean hospital stay was 6.2 ± 1.6 days (range, 5 to 16 days). Twelve patients continued to be in atrial fibrillation.

Mortality
There were 3 (4.9%) early deaths. The first patient was a 30-year-old woman with associated mitral valve disease and severe left ventricular dysfunction. She was noted to have severe AR in the immediate postoperative period, and she underwent emergency AVR after which she died of persistent low cardiac output. She had undergone cuspal thinning and subcommissural annuloplasty for aortic valve repair and had only trivial AR on TEE after the repair. At reoperation, the suture used for annuloplasty had given away, leading to severe AR. Because of unstable hemodynamics and the family’s request, repeat repair was not attempted and AVR was performed. The other 2 patients were a 15-year-old woman and a 38-year-old man. These patients had undergone combined aortic and mitral valve repair and died of persistent congestive heart failure as a result of severe left ventricular dysfunction within 30 days of operation. In both these patients the aortic and mitral valve repairs were satisfactory.

Late Outcome
Follow-up ranged from 6 to 160 months (mean, 93.8 ± 46.4 months; median, 103 months). The total follow-up was 454.4 patient-years. Among survivors, 6 (10%) patients were followed up for 12 or more years, 19 (33%) patients were followed up for 10 or more years, 23 (40%) patients were followed up for more than 5 years, and 3 (5%) patients were followed up for more than 3 years. When reporting freedom from valve-related events, the standard published guidelines were followed [18].

There were no thromboembolic complications and hemolysis in the operative survivors. One patient experienced infective endocarditis (0.2 events per 100 patient-years). He was successfully treated with antibiotics.

Valve Function
None of the 58 survivors had significant AR at the time of discharge from the hospital. Forty-six (79.4%) patients have trivial to mild or no AR at the closing interval. The remaining 12 (20.6%) patients have significant AR that was moderate in 7 and severe in 5 patients; 4 of these also had significant AS (peak transvalvular gradient of 50 mm Hg or more across the aortic valve). All 4 patients with severe AS and AR underwent uneventful AVR with a prosthesis 96.5 ± 28 months (range, 72 to 132 months) after the initial operation. Two of them also had a simultaneous mitral valve replacement for significant mitral stenosis with regurgitation. At reoperation, all these patients had evidence of progression of the rheumatic disease with shrunken cusps, new cuspal thickening, and commissural fusion. Two patients who had mitral valve replacement also had severe subvalvular fusion and calcific mitral stenosis at reoperation. One patient with severe aortic and mitral regurgitation is awaiting reoperation. Freedom from development of moderate or severe aortic valve disease was 82.5% ± 6.3% (95% confidence interval [CI], 69.8 to 95.2) at a median of 103 months and 52.5% ± 16.9% (95% CI, 25.5 to 79.5) at 160 months of follow-up (Fig 2). Significant aortic valve disease occurred in these patients after a mean period of 110.5 ± 33.8 months (range, 60 to 160 months) after initial operation. The probability of development of AS or AR was high in patients with mixed regurgitant and stenotic lesions (hazard ratio, 2.03; 95% CI, 1.8 to 2.9; p = 0.003).

View larger version (16K): [in this window] [in a new window]   Fig 2. Freedom from significant aortic valve disease (Kaplan-Meier) after aortic valve repair. (AR = aortic regurgitation; AS = aortic stenosis.)

View larger version (17K): [in this window] [in a new window]   Fig 3. Freedom from reoperation (Kaplan-Meier) after aortic valve repair.

Functional Class
All 46 patients who have none or trivial to mild AR are in New York Heart Association class I. Of the 7 patients with moderate AR, 4 are free of symptoms; 3 patients are in New York Heart Association class II or III owing to development of associated moderate mitral valve disease. All 5 patients with severe AR and AS were in New York Heart Association class III, and 4 of them have undergone reoperation.

Late Deaths and Survival
There were no late deaths. Actuarial survival was 95% ± 2.8% at the median follow-up and at 160 months (Fig 4). Event-free survival in operative survivors was 78.3% ± 3.4% (95% CI, 71.6 to 85) at 103 months and 48.5% ± 15.9% (95% CI, 20 to 77) at 160 months.

View larger version (16K): [in this window] [in a new window]   Fig 4. Actuarial survival (Kaplan-Meier) after aortic valve repair.

	Comment

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

The advantages of valve repair compared with replacement include (1) better hemodynamics, (2) normal growth of the aortic annulus, (3) freedom from anticoagulation, (4) avoidance of prosthetic valve-related complications such as hemorrhage, thromboembolic phenomenon, hemolysis, and prosthetic valve endocarditis, (5) rapid degeneration of bioprosthesis in younger patients, and (6) unsuitability of the pulmonary autograft in young patients with rheumatic AR [21]. However, aortic valve repair is technically more demanding than mitral valve repair [6, 7, 19] and carries a high failure rate because of the complexity of the valve pathologic disease, which includes deformed cusps, combined stenosis and regurgitation, and restricted mobility of cusps. Assessment of the reparability and postrepair assessment of aortic valve function are also difficult. Duran [17] has used a flexible laryngoscope to assess postrepair aortic valve function. Recurrent rheumatic activity further tends to make the repair less stable.

Proper patient selection on the basis of the pathologic disease of the valve is essential to avoid an immediate unsuccessful repair. In our initial experience of 22 patients [13], there were five early failures, which necessitated immediate AVR in 3 patients, and 2 patients required AVR within a week of surgery. These 5 patients are not included in this study for assessment of long-term results as the repair was not satisfactory in the first instance and our assessment of the repair was without TEE. We have overcome this problem to a great extent with the routine use of TEE. The aortic valve is systematically assessed before attempting repair, and valves are considered suitable for repair only if there is minimal calcification of aortic valve leaflets, some degree of mobility of cusps, and at least 2 to 3 mm of leaflet coaptation. Also, we do not accept suboptimal results after repair (moderate or severe AR); only trivial or mild AR is considered acceptable. However, there is a definite risk of reoperation related to progressive damage to the valve leaflets, annular dilatation, and recurrent attacks of rheumatic activity. A combination of factors may be responsible for these in any given patient. However, considering the advantages of valve repair versus replacement and the safety of reoperations in present surgical practice, this is no longer a concern.

In patients with bicuspid aortic valve and AR, the 5-year freedom from reoperation is 87% [21], whereas in patients with AR as a result of rheumatic heart disease, the freedom from reoperation is 77% to 94% at only 30 months after operation [11]. However, we have achieved a greater freedom from reoperation during a longer follow-up period because of proper patient selection and tailoring the surgery to suit a particular patient.

More than half of our patients had combined aortic and mitral valve repair, and only 4 patients have required reoperation at a mean period of 110.5 ± 33.8 months. This has been particularly important in young patients and in women of child-bearing age in whom anticoagulation is best avoided. Although this report focuses on the results of aortic valve repair, our experience is contrary to previous reports in which the limited durability of combined aortic and mitral valve repair has led others to restrict aortic valve repair along with mitral valve repair for only young nonrheumatic patients with bicuspid aortic valve and degenerative mitral valve disease [7, 19, 20]. However, as observed by others and also by us, AS limits the durability of the repair. Poor left ventricular function is not a contraindication for repair [6].

Limitations of the Study
A limitation of this study is that the patients were highly selected and repair was not attempted in unsuitable patients. Also only patients with a successful aortic valve repair as assessed intraoperatively are included for long-term follow-up. There is a learning curve, and, as in our initial experience [13], AVR may be required in some patients. Also analysis of a large number of factors to predict variables associated with failure may be inaccurate because of the small number of patients and the lower number of valve-related events.

Conclusions
Aortic valve repair for patients with rheumatic aortic valve disease is feasible and yields gratifying long-term results in selected patients. Appropriate methods of repair need to be individualized to the valve pathology for a good long-term result.

	Acknowledgments

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
We thank Rajvir Singh, PhD (Biostatistics), for statistical analysis.

	References

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Sachin Talwar Arkalgud Sampath Kumar Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Talwar, S. Articles by Sampath Kumar, A. Search for Related Content PubMed PubMed Citation Articles by Talwar, S. Articles by Sampath Kumar, A. Related Collections Valve disease