Adult: Aortic Valve
The fate of aortic valve after rheumatic mitral valve surgery

Accepted for the 100th Annual Meeting of The American Association for Thoracic Surgery.
https://doi.org/10.1016/j.jtcvs.2021.03.049Get rights and content

Abstract

Objective

Deterioration of the native aortic valve function by a late progression of rheumatic disease is not infrequent in patients who underwent rheumatic mitral valve surgery; however, this phenomenon has not been clearly quantified.

Methods

A total of 1155 consecutive patients (age 52.0 ± 12.9 years; 807 female) who underwent rheumatic mitral valve surgery without concomitant aortic valve surgery from 1997 to 2015 were enrolled. The primary end point was the composite of progression to severe aortic valve dysfunction or a requirement of subsequent aortic valve replacements during follow-up. To determine the risk factors of the primary outcome, we performed the generalized linear mixed model.

Results

The baseline severities of aortic valve were none to trivial in 880 patients (76.2%), mild in 256 patients (22.2%), and moderate in 19 patients (1.6%). The latest 1062 echocardiographic assessments (91.9%; median, 81.2 postoperative months; interquartile range, 37.3-132.1 months) demonstrated 26 cases (0.33%/patient-year) meeting the primary end point during follow-up. Cumulative incidence of the primary end point at 10 years was 0.4% ± 0.3% and 7.4% ± 2.5% depending on the presence of mild or greater aortic valve dysfunction at baseline (P < .01). In multivariable analyses, aortic valve peak pressure gradient (odds ratio, 1.14; 95% confidence interval, 1.10-1.20), aortic regurgitation degree (mild over none: odds ratio, 3.26; 95% confidence interval, 1.15-9.23), and time (odds ratio, 1.30; 95% confidence interval 1.19-1.41) were significantly associated with the occurrence of the primary end point.

Conclusions

Progression of severe aortic valve dysfunction and the need for aortic valve replacement are uncommon in patients undergoing rheumatic mitral valve surgery. However, such events were relatively common among those with mild or greater aortic valve dysfunction at the time of mitral valve surgery.

Section snippets

Study Subject and Outcome Measures

By using the institutional database of the Asan Medical Center, Seoul, Korea, we identified 1877 consecutive adult patients who underwent rheumatic MV surgery between January 1997 and December 2015. Among these, patients who underwent concomitant cardiac tumor resection or infective endocarditis and patients who had previously undergone mitral surgery were excluded (n = 146). We also excluded those who underwent concomitant AV surgery (AVR in 545, AV plasty in 20) and those who were missing

Study Subjects

The baseline variables of patients are summarized in Table 1. The mean age of the patients was 52.0 ± 12.9 years, and 807 (69.9%) were female. Atrial fibrillation (AF) was combined in the 856 patients (74.1%). At the time of MV surgery, 880 patients (76.2%), 256 patients (22.2%), and 19 patients (1.6%) had none, mild, and moderate degrees of AVD, respectively (Table 2). Among patients with moderate AVD, 6 patients have moderate degrees of pure AR and 5 patients have moderate degrees of pure AS.

Discussion

The present study demonstrated that severe dysfunction of native AV in patients undergoing rheumatic MV surgery was uncommon (Figure 5). Also, the development of severe AVD or the requirement of subsequent AVRs after MV surgery was associated with the AV peak pressure gradient, degree of AR, and time. To the best of our knowledge, our study on the fate of AV after rheumatic MV surgery has the largest cohort.

Most of the rheumatic heart disease lesions that require surgery involve the MV, and a

Conclusions

Progression of severe AVD and the need for AVR are uncommon in patients undergoing rheumatic MV surgery. However, such events were relatively common among those with mild or greater AVD at the time of MV surgery. Further comparative studies are warranted to determine whether concomitant AV surgery during rheumatic MV surgery may offer clinical benefits in patients with mild to moderate AVD.

References (13)

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Institutional Review Board approval number: Institutional Review Board of Asan Medical Center (No. 2020-0875), May 7, 2021.

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