Long-term outcomes of concomitant aortic and mitral valve repair.

OBJECTIVE: To evaluate the short- and long-term outcomes of concomitant aortic (AVr) and mitral (MVr) valve repair. METHODS: This retrospective analysis of prospectively collected data identified patients who had undergone AVr and MVr surgery from March 1996 to October 2009. Patients were included if they had undergone combined repair on the aortic and mitral valves. Excluded were those <18 years in whom valve replacement was performed. Data were collected on the short-term morbidity and mortality (<30 postoperative days), long-term survival, and freedom from valve-related events and echocardiographic outcomes. RESULTS: A total of 65 patients underwent AVr and MVr (mean age, 56.4 ± 15.8 years, 46 men). Preoperatively, 30 patients (46.1%) had aortic insufficiency (AI) >2+, 20 patients had AI ≥2+ with aortic dilatation (30.7%), and 4 patients (6.1%) had aortic dilatation only. Of the 65 patients, 57 had tricuspid (87.6%) and 8 had bicuspid aortic valves (12.3%). All patients had mitral insufficiency preoperatively. One in-hospital death occurred (1.5%). At discharge, no patient had AI >2+ versus 30 patients preoperatively (P < .001), and 7 patients had AI >1+ versus 61 patients preoperatively (P < .001). At discharge, the mean left ventricular end-diastolic diameter was 48 ± 7 mm versus 59 ± 9 mm preoperatively (P < .007), and the mean left ventricular end-systolic diameter was 33 ± 5 mm versus 38 ± 14 mm preoperatively (P = .36). The mean clinical follow-up duration was 62 ± 45 months (median, 50; range, 1-177). At the latest follow-up visit, 17 patients were New York Heart Association class ≥2 versus 52 patents preoperatively (P < .001). Four cardiac deaths occurred, and at 1, 5, and 10 years, the freedom from cardiac death was 100%, 93.4% ± 3.7%, and 88.5% ± 5.9%, respectively. Eight valve reinterventions were required, and the freedom from valve reintervention at 1, 5, and 10 years was 95.3% ± 2.6%, 91.6% ± 3.6%, and 78.4% ± 8.0%, respectively. At 1, 5, and 10 years, the freedom from AI 2+ was 98.2% ± 1.7%, 93.4% ± 3.7%, and 88.3% ± 5.8% and the freedom from mitral insufficiency 2+ was 96.4% ± 2.4%, 93.3% ± 3.8%, and 93.3% ± 3.8%, respectively. CONCLUSIONS: Concomitant AVr/MVr is associated with acceptable survival and freedom from valve reintervention.

Effect of preoperative symptoms on outcomes after valve repair for degenerative aortic insufficiency.

OBJECTIVES: This study evaluated the effect of preoperative symptoms on long-term survival and valve reintervention in patients undergoing aortic valve repair (AVr) for severe degenerative aortic insufficiency (AI). METHODS: Between March 1996 and June 2010, 274 patients underwent AVr for severe AI. Seventy-seven were performed in asymptomatic patients (Group I) and 197 were performed in symptomatic (Group II). Patients in Group I were younger (43.9 ± 15.0 vs 54.1 ± 15.5 years; P < 0.001) with a higher proportion of bicuspid valves (n = 40, 51.9% vs n = 68, 30.4%; P = 0.008). Group II had more patients with impaired left ventricular (LV; n = 36, 18.3% vs n = 5, 6.4%; P = 0.013). The mean follow-ups for Group I and Group II were 43.0 ± 34.0 and 61.3 ± 39.5 months, respectively. RESULTS: There was no in-hospital mortality. Overall, leaflet repair and reimplantation were higher in Group I (P = < 0.001 and P = 0.002, respectively), whereas subcommissural annuloplasty for tricuspid AV was higher in Group II (P = 0.002). Leaflet shaving and plication were performed in more patients in Group I (P = 0.002 for both). There was no difference in early complications, but during follow-up atrial fibrillation was more frequent in Group II (P = 0.03). There were 10 late cardiac deaths, all in Group II (P = 0.04). Overall, 10-year cardiac survival was better in Group I (100 vs 77.3 ± 8.6%) but not significant (P = 0.1). At 10 years, freedom from ≥ AI2+ was 63.2 ± 8.1 vs 56.4 ± 4.5% (P = 0.4), and freedom from AV reintervention was 81.8 ± 7.1 vs 89.0 ± 2.8% (P = 0.36), in Groups I and II, respectively. In the whole cohort, 10-year freedom from AV reintervention was greater in patients with an end-diastolic diameter of <60 mm (90.0 ± 7.6 vs 76.3 ± 5.5%; P = 0.003). Multivariate analysis identified increasing age as the only independent predictor of overall survival (P = 0.03). The incidence of valve-related complications was similar. CONCLUSION: In asymptomatic patients with severe degenerative AI, AVr is associated with excellent long-term outcomes, while symptoms are associated with reduced long-term survival. In dilated LV, freedom from reoperation is lower. If feasible, early AVr is recommended in experienced centres.

Repair of aortic valve cusp prolapse.

Aortic valve preservation and repair is emerging as a feasible and attractive alternative to aortic valve replacement in young patients with aortic valve insufficiency. Cusp pathology requiring repair is present in up to 50% of patients undergoing aortic valve repair or valve preserving surgery and may occur in isolation or in conjunction with ascending aortic disease. Diagnosis of cusp prolapse can usually be made on preoperative echocardiography and is confirmed on surgical inspection. Techniques available for the correction of cusp prolapse in a trileaflet aortic valve include free margin plication, and free-margin resuspension. These techniques can be used alone or in combination and both provide stable mid-term results. Choice of technique may, therefore, be tailored to the cusp pathology encountered.