Early and Late Results of Combined Mitral-Aortic Valve Surgery

doi:10.1016/j.hlc.2007.03.015

Heart, Lung and Circulation

Volume 16, Issue 6, December 2007, Pages 410-415

https://doi.org/10.1016/j.hlc.2007.03.015 Get rights and content

Objective

This retrospective study was designed to assess the early morbidity and mortality as well as long-term mortality of combined aortic-mitral valve procedures at a single centre.

Methods

Patients were identified by analysing the intensive care and perfusion databases, from 1989 to 2003, with 113 receiving aortic-mitral valve procedures. Eighty-four percent of patients received a mechanical bileaflet valve. Survival was assessed using a Kaplan-Meier method, and determinants of survival with the Cox proportional hazards model.

Results

There were 57 men and 56 women, median age 59 (18–84) years. The 30-day mortality was 9% (n = 10). This cohort contained a number of high risk patients, 38% were classified as New York Heart Association class IV, 33.5% had at least moderate ventricular impairment, 20% were redo procedures and 17% urgent procedures. Survival estimates at 5 and 10 years were 85% (0.76–0.90) and 65% (0.49–0.77), respectively. Multivariate pre-operative predictors of death included renal dysfunction (creatinine >200 μmol/L) and hypertension. Rheumatic aetiology was associated with improved survival.

Conclusion

This study shows acceptable short and long-term survival in patients undergoing combined aortic-mitral valve surgical procedures at a single centre. Renal impairment and hypertension were associated with a poorer long-term prognosis and rheumatic aetiology was associated with improved survival. Age, LVEF and NYHA class were not associated with a worse outcome. This may affect future decision making in light of an aging population.

Introduction

Advances in cardiac surgical techniques over the past two decades have seen a wider range of treatment options for valvular heart disease, which include valvular repair, valvuloplasty and/or valve replacement. Whilst double valve replacement (DVR) comprises approximately 2% of open-heart surgery cases, it has been regarded as a higher risk operation than other procedures such as single valve replacement.¹ Factors associated with adverse outcome in the past have included older age,2, 3 New York Heart Association (NYHA) class III or IV,2, 3, 4 low left ventricular ejection fraction,⁵ and concomitant coronary artery bypass surgery (CABG).⁶ In the past studies, double valve replacement has been associated with peri-operative morbidity and mortality of 3–15%.6, 7, 8, 9 The purpose of this study was to determine the 30-day mortality rates, and all cause mortality during the follow up period (1989 to May 2004) at a medium sized single centre. Furthermore, we analysed the data set in an attempt to determine factors which may be associated with a poor outcome.

Section snippets

Patient Population

Between January 1993 and January 2003, 113 patients, 57 men and 56 women, median age 59 years (range 18–84 years) were identified by the hospital's Intensive Care and Cardiac surgical and perfusion unit databases as undergoing double valve replacement. Patients having concomitant bypass grafting were included. The campus includes both public and private open heart surgical units (OHSU). The same group of eight surgeons, anaesthetists and cardiac perfusionists worked in both public and private

Results

The median ICU stay was two days (range 1–28 days), and median hospital stay was nine days (range 6–85).

Discussion

The 30-day mortality for double valve replacement in this single centre study was 9%. Pump failure/low cardiac output syndrome was the predominant cause in his group. Early morbidity was significant, with around one-third of patients suffering a significant complication.

The cohort studied contained 46 patients, who, based upon prior studies5, 9, 12, 13 were at higher risk of significant morbidity and mortality as evidenced by the LV grade, NYHA class, age, percentage of redo procedures as well

Limitations

This study suffers some limitations. The retrospective nature of the study can introduce selection bias. Furthermore, follow-up was not complete with 94% of patient data available for long-term survival modelling. Finally, the relatively small number of events (26 deaths of 113 patients) results in wide confidence intervals which could reduce the validity of the findings. Despite these caveats, this study's strength is that it represents a medium sized cardiac surgical unit's results which are

Conclusion

Within the limits of a retrospective study, the data presented is a modern day cohort of patients undergoing DVR in a medium sized single centre. The results are in keeping with published literature, and analysis of late mortality demonstrates a high risk group consisting of pre-existing hypertension and renal impairment/failure. Age, NYHA status and LVEF were not predictive of early or long-term mortality, which needs to be factored into the decision to repair/replace valves in an increasing

Acknowledgements

Dr Kim Connelly is supported by a Postgraduate research award from the National Heart Foundation of Australia PC 02M 0875, a Pfizer Cardiovascular Research grant, an NHMRC Neil Hamilton Fairley scholarship (ID 447712) and a TACTICS grant (Canada).

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In this narrative review, we aim to summarize the literature surrounding the assessment and management of the common, yet understudied combination of aortic stenosis (AS) and mitral regurgitation (MR), the components of which are complexly inter-related and interdependent from diagnostic, prognostic, and therapeutic perspectives. The hemodynamic interdependency of AS and MR confounds the assessment of the severity of each valve disease, thus underscoring the importance of a multimodal approach integrating valvular and extravalvular indicators of severity. A large body of literature suggests that baseline MR is associated with reduced survival post aortic valve (AV) intervention and that regression of MR post-AV intervention confers a mortality benefit. Functional MR is more likely to regress after AV intervention than primary MR. The respective natural courses of the 2 valve diseases are not synchronized; therefore, significant AS and MR at or above the respective threshold for intervention might not coincide. Surgery is primarily a 1-stop-shop procedure because of a considerable perioperative risk of repeat interventions, whereas transcatheter treatment modalities allow for a more tailored timing of intervention with reassessment of concomitant MR after AV replacement and a potential staged intervention in the absence of MR regression. In summary, AS and MR, when combined, are interlaced into a complex hemodynamic, diagnostic, and prognostic synergy, with important therapeutic implications. Contemporary approaches should consider stepwise intervention by exploiting the advantage of transcatheter options. However, evidence is needed to demonstrate the efficacy of different timing and therapeutic options.
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The data on the safety and feasibility of performing concomitant or staged transcatheter edge-to-edge repair (TEER) of the mitral valve with transcatheter aortic valve implantation (TAVI) remains limited. The Nationwide Readmission Database was used to identify TEER and TAVI procedures from October 1, 2015 to December 31, 2019, using the International Classification of Diseases, Tenth Revision, Clinical Modification administrative data. A total of 627 weighted cases of TEER and TAVI procedures were included in the analysis. Of those cases, 453 underwent staged TEER after TAVI, whereas 174 had concomitant TAVI and TEER during the same admission. Patients who underwent staged procedures were mostly men (64.8%, p = 0.02) and had a higher median age of 85 years (interquartile range 79 to 88) versus 82 years (interquartile range 72 to 86) in the concomitant procedure group. The adjusted propensity-matched mortality rate was similar for staged versus same-admission procedures (6.1% vs 7.0%, p = 0.79). In-hospital complication rates, including acute kidney injury, vascular complications, need for percutaneous coronary intervention, mechanical support, and pacemaker implantation, were higher for the same-admission TEER and TAVI group than TEER performed as a staged procedure. Nonhome facility discharges and length of hospital stay (15 vs 4 days) were also significantly higher for the concomitant same-admission TEER and TAVI groups. In conclusion, there was no difference in in-hospital mortality rate between patients who underwent concomitant or staged TEER and TAVI procedures, whereas complication rates were significantly higher in the concomitant group.
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Citation Excerpt :
In patients with two or more severely stenotic or regurgitant lesions, and who are symptomatic or have ventricular dysfunction or dilatation, all lesions should be surgically corrected during a single procedure. As such, in patients with combined severe aortic and mitral valve disease, despite the higher morbidity and mortality of double-valve surgery compared with isolated aortic valve surgery [36], concurrent mitral valve intervention should be considered at the time of AVR [6,7]. Similarly, despite higher operative risk, concomitant tricuspid valve repair or replacement is recommended (class I) in patients with severe TR undergoing surgery for aortic or mitral valve disease [6,7].
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Recent evidence has shown that moderate mitral regurgitation is common and clinically relevant in patients presenting for surgical and transcatheter aortic valve replacement for aortic stenosis. Prospective multicenter clinical trials are now indicated to resolve the clinical equipoise about whether or not mitral valve intervention also is indicated at the time of aortic valve intervention. Advances in three-dimensional transesophageal echocardiography, transcatheter mitral interventions, and surgical aortic valve replacement, including the advent of sutureless valves, likely will expand the therapeutic possibilities for moderate mitral regurgitation in the setting of aortic valve interventions for severe aortic stenosis.
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Original ArticleEarly and Late Results of Combined Mitral-Aortic Valve Surgery

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Patient Population

Results

Discussion

Limitations

Conclusion

Acknowledgements

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Am J Cardiol

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Multiple valve replacement increases the risk of reoperation for structural degeneration of bioprostheses

Ann Thorac Surg

Double-valve replacement with Medtronic-Hall or St. Jude valve

Ann Thorac Surg

Evaluation of valve-related complications in patients with Sorin Bicarbon prosthesis: a seven-year experience

J Heart Valve Dis

Original Article
Early and Late Results of Combined Mitral-Aortic Valve Surgery