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Repair for rheumatic mitral valve disease. The controversy goes on!
  1. Manuel J Antunes
  1. Correspondence to Dr Manuel J Antunes, Center of Cardiothoracic Surgery, Faculty of Medicine, University Hospital, Coimbra, Portugal; antunes.cct.chuc{at}sapo.pt

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Valvuloplasty is now widely accepted as the best method of treatment of mitral valve regurgitation, but repair for rheumatic mitral valve disease is commonly believed to yield poorer results by comparison with other aetiologies, especially the degenerative form. This is a natural consequence of the evolutionary nature of the rheumatic inflammatory process that continues beyond surgery.

However, rheumatic valve disease assumes different formats in different populations. In the developing countries of the southern hemisphere, including South America, Sub-Saharan Africa and parts of Asia, patient populations are characterised by their low mean age (20–30 years), which renders them susceptible to repeated bouts of the disease. Hence, antibiotic prophylaxis must be continued after surgery until a much older age, and WHO now recommends lifelong prophylaxis in patients with severe valve disease or who have had valve surgery. In the vast majority of cases, mitral regurgitation is caused by elongated anterior leaflet chordae causing prolapse of the leaflet, which is usually small and retracted, as is the posterior leaflet. Dilated annulus, in most cases, and commissural fusion, relatively frequent, complete the complex set of lesions that makes repair technically so much more difficult.

However, the major problem here is the increased need for reoperation for progressive fibrosis and distortion of the valve caused by the progression or recurrence of the rheumatic process (figure 1). But it is essential to emphasise that valve replacement in these populations also has poorer outcomes, in some reports clearly worse than those of repair, mainly due to deficient socioeconomic conditions leading to non-compliance to therapy. In this set-up, prosthetic valve replacement is plagued by several types of complications that carry high mortality and morbidity. Thrombosis and thromboembolism are the most feared; thrombosis of mechanical prosthesis is a very lethal complication with a mortality of up to 60% and …

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