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Kim HR, Kim WK, Kim HJ, Kim JB, Jung SH, Choo SJ, Chung CH, Lee JW. The fate of aortic valve after rheumatic mitral valve surgery. J Thorac Cardiovasc Surg 2023; 165:622-629.e2. [PMID: 33867129 DOI: 10.1016/j.jtcvs.2021.03.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 02/24/2021] [Accepted: 03/08/2021] [Indexed: 01/18/2023]
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.
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Affiliation(s)
- Hong Rae Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Wan Kee Kim
- Department of Thoracic and Cardiovascular Surgery, Yongin Severance Hospital, Gyeonggi-do, Republic of Korea
| | - Ho Jin Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea.
| | - Sung-Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Suk Jung Choo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Cheol Hyun Chung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Jae Won Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
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Matsuhama M, Arimura S, Sasaki K, Semba H, Kato Y, Suzuki S, Uejima T, Yajima J, Yamashita T, Kunihara T. External suture annuloplasty for mild to moderate and moderate aortic regurgitation due to an isolated type Ic lesion. Gen Thorac Cardiovasc Surg 2019; 67:855-860. [DOI: 10.1007/s11748-019-01119-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 03/27/2019] [Indexed: 11/29/2022]
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Kim DJ, Joo HC, Lee SH, Chang BC, Lee S. Natural history of mild aortic valve disease untreated at the time of rheumatic mitral valve replacement. Interact Cardiovasc Thorac Surg 2018; 27:828-835. [PMID: 29873732 DOI: 10.1093/icvts/ivy176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 05/03/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES The aim of this study was to examine long-term clinical outcomes and to assess the eventual need for aortic valve replacement (AVR) in patients with mild aortic valve disease (AVD) at the time of mitral valve replacement. METHODS Between 1990 and 2015, 1231 patients undergoing mitral valve replacement were reviewed, stratifying subjects as those with AVD (n = 363) or without AVD (NA; n = 868). Primary end points were progressive AVD (grade ≥ II) and subsequent AVR. Overall mortality and valve-related complications served as secondary end points. Propensity score matching was used for risk adjustment (n = 320 in each group). RESULTS No differences in postoperative complications or clinical outcomes were observed between groups. The 20-year overall survival was similar (before matching: NA 86.1% vs AVD 80.8%, P = 0.128; after matching: 83.5% vs 81.1%, P = 0.425). Of the entire cohort, progressive AVD was observed in 162 patients, and significant AVD (grade ≥ III) was observed in only 60 patients. Subsequent AVR was required in 37 patients due to mitral valve (MV) dysfunction or severe aortic stenosis. The 20-year freedom from significant AVD and subsequent AVR was significantly higher in the NA group than in the AVD group before and after matching (before: NA, 96.5% vs 73.7%, P < 0.001; AVD, 98.5% vs 82.3%, P < 0.001; after: 98.1% vs 73.3%, P < 0.001; 99.3% vs 82.5%, P < 0.001, respectively). CONCLUSIONS Although progressive AVD did not significantly impact long-term survival during the follow-up period, those patients qualifying initially as mild AVD may eventually progress to significant AVD after the first 5 postoperative years. Therefore, aggressive echocardiography should be performed at 5-year lapse after mitral valve replacement to determine the appropriate timing of AVR.
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Affiliation(s)
- Do Jung Kim
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun-Chel Joo
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung-Hyun Lee
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Byung-Chul Chang
- Department of Thoracic and Cardiovascular Surgery, Cha Bundang Medical Center, Cha University, Seoul, Korea
| | - Sak Lee
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
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Ramakrishna H, Gutsche JT, Patel PA, Fernando R, Agoustides JGT. Options for Incidental Moderate Aortic Stenosis During Concomitant Valve Surgery: A Clinical Update for the Perioperative Echocardiographer. J Cardiothorac Vasc Anesth 2015; 30:252-7. [PMID: 26627184 DOI: 10.1053/j.jvca.2015.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Harish Ramakrishna
- Department of Anesthesiology, Mayo Clinic, Scottsdale, AZ; Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jacob T Gutsche
- Department of Anesthesiology, Mayo Clinic, Scottsdale, AZ; Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Prakash A Patel
- Department of Anesthesiology, Mayo Clinic, Scottsdale, AZ; Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rohesh Fernando
- Department of Anesthesiology, Mayo Clinic, Scottsdale, AZ; Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G T Agoustides
- Department of Anesthesiology, Mayo Clinic, Scottsdale, AZ; Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Hwang HY, Ahn H. Routine aortic valve replacement for mild stenosis is not necessary during rheumatic mitral surgery. J Thorac Cardiovasc Surg 2014; 148:3255. [PMID: 25433897 DOI: 10.1016/j.jtcvs.2014.09.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 09/27/2014] [Indexed: 11/26/2022]
Affiliation(s)
- Ho Young Hwang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Korea
| | - Hyuk Ahn
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Korea
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Abstract
In children with rheumatic heart disease, conservative valve surgery is the best option whenever feasible. Surgeons must develop an attitude and interest in valve repair techniques that can be easily learned. Patients who undergo valve repair at an early age are at risk of requiring additional surgery over time. Mechanical valve replacement, nonetheless, should be reserved for situations where more conservative approaches are not feasible.
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Hwang HY, Kim KH, Ahn H. Attitude after a mild aortic valve lesion during rheumatic mitral valve surgery. J Thorac Cardiovasc Surg 2013; 147:1540-6. [PMID: 23886033 DOI: 10.1016/j.jtcvs.2013.05.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Revised: 04/21/2013] [Accepted: 05/10/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVE We evaluated whether rheumatic aortic valve disease of mild degree should be treated in patients undergoing mitral valve surgery. METHODS From 1992 to 2010, 197 patients (aged 52 [19-82] years, male:female = 60:137) who had rheumatic mitral valve disease and mild aortic valve disease were enrolled. The aortic valve was untreated in 114 patients (no treatment group), repaired in 40 patients (aortic valvuloplasty group), and replaced in 43 patients (aortic valve replacement group). RESULTS Operative mortality occurred in 4 patients (2.0%). There were no differences in early mortality and postoperative complications among the 3 groups. Overall survival at 5, 10, and 15 years was 96.3%, 92.1%, and 85.7%, respectively. In the no treatment group, progression-free survival in significant aortic valve disease at 5, 10, and 15 years was 98.7%, 91.3%, and 81.1%, respectively. This was not superior in the aortic valvuloplasty group (85.9%, 77.6%, and 69.8%, respectively) than in the no treatment group. Freedom from aortic valve disease was lower in patients with aortic stenosis than in those with aortic regurgitation in univariate and multivariable analyses (P < .001). Reoperation was performed in 19 patients, including 2 aortic valve reoperations. Aortic valve-related event-free survival was similar among the 3 groups. CONCLUSIONS Mild aortic valve disease in patients undergoing rheumatic mitral valve surgery could be left untreated, because preventive aortic valve operation does not result in better clinical and echocardiographic outcomes.
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Affiliation(s)
- Ho Young Hwang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Korea
| | - Kyung-Hwan Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Korea
| | - Hyuk Ahn
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Korea.
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Saedi S, Heidarali M, Saedi T, Bakhshandeh Abkenar H, Sadr-Ameli MA. Short-term Changes in Aortic Regurgitation after Percutaneous Mitral Valvuloplasty. Int Cardiovasc Res J 2013; 7:5-7. [PMID: 24757611 PMCID: PMC3987422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 03/05/2013] [Accepted: 03/07/2013] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the short- term effects of percutaneous mitral valvuloplasty (PMV) on coexisting AR. METHODS Clinical, echocardiographic and catheterization data from hospital records of a total of 327 patients with rheumatic mitral stenosis who underwent PMV at a tertiary centre were retrospectively reviewed and aortic regurgitation changes 48 hours post PMV was recorded. RESULTS The study population consisted of 282 females and 45 males. Mean age at the time of intervention was 47.13±11 years. Before PMV, 142 (43.3%) patients had no AR, 124 (37.9%) had mild AR and 61 (18.7%) had moderate AR. There was no change in AR severity in post- PMV follow-up. AR progression after PMV and during the follow-up was not significant and there was no increase in the need for aortic valve replacement (AVR) procedures. CONCLUSIONS Our findings indicated that a considerable number of patients with rheumatic mitral stenosis had concurrent AR. At the time of PMV concomitant AR does affect procedural success and is not associated with inferior outcomes. Patients with moderate degrees of AR remain good candidates for PMV.
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Affiliation(s)
- Sedigheh Saedi
- Department of Cardiology, Rajaei Cardiovascular, Medical and Research Centre, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Mona Heidarali
- Department of Cardiology, Rajaei Cardiovascular, Medical and Research Centre, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Tehereh Saedi
- Department of Cardiology, Rajaei Cardiovascular, Medical and Research Centre, Tehran University of Medical Sciences, Tehran, IR Iran,Corresponding author: Tehereh Saedi, Department of Cardiology, Rajaei Cardiovascular, Medical and Research Centre, Tehran University of Medical sciences, Tehran, IR Iran. Tel/Fax: +9821- 23922868, E-mail:
| | - Homman Bakhshandeh Abkenar
- Department of Cardiology, Rajaei Cardiovascular, Medical and Research Centre, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Mohammad Ali Sadr-Ameli
- Department of Cardiology, Rajaei Cardiovascular, Medical and Research Centre, Tehran University of Medical Sciences, Tehran, IR Iran
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Sadr-Ameli M, Heidarali M, Saedi S, Saedi T, Firoozi A, Madani M, Bakhshandeh H. Natural History of Aortic Regurgitation following Percutaneous Mitral Valvuloplasty. Res Cardiovasc Med 2012; 2:50-4. [PMID: 25478490 PMCID: PMC4253756 DOI: 10.5812/cardiovascmed.8051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Revised: 02/10/2012] [Accepted: 02/11/2012] [Indexed: 11/16/2022] Open
Abstract
Background: Objectives: Materials and Methods: Results: Conclusions:
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Affiliation(s)
- Mohammadali Sadr-Ameli
- Cardiac Electrophysiology Research Center, Rajaie Cardiovascular Medical and Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Mona Heidarali
- Cardiac Electrophysiology Research Center, Rajaie Cardiovascular Medical and Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Sedigheh Saedi
- Cardiac Electrophysiology Research Center, Rajaie Cardiovascular Medical and Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
- Corresponding author: Sedigheh Saedi, Cardiac Electrophysiology Research Center, Rajaie cardiovascular Medical and Research Center, Vali-Asr Ave, Niayesh Blvd, Tehran, IR Iran. Tel.: +98-2123923017, Fax: +98-2123923017, E-mail:
| | - Tehereh Saedi
- Cardiac Electrophysiology Research Center, Rajaie Cardiovascular Medical and Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Ata Firoozi
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Mohsen Madani
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Hooman Bakhshandeh
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
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Darke M, Pawloski J, Khabbaz KR, Mahmood F. Rheumatic mitral and aortic stenosis: to replace or not to replace--that is the question--part 2. J Cardiothorac Vasc Anesth 2010; 24:364-5. [PMID: 20362240 DOI: 10.1053/j.jvca.2010.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Melanie Darke
- Department of Anesthesia and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
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Darke M, Pawloski J, Khabbaz KR, Mahmood F. Rheumatic mitral and aortic stenosis: to replace or not to replace--that is the question--part 1. J Cardiothorac Vasc Anesth 2010; 24:191-2. [PMID: 20123241 DOI: 10.1053/j.jvca.2009.10.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Melanie Darke
- Department of Anesthesia and Critical Care, Cardiovascular Institute/Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Abstract
BACKGROUND The aim of this study was to assess the early and mid-term results of patients who underwent cardiac operations due to cardiac pathologies other than aortic valve (AV) disease, but also had mild-to-moderate aortic valve insufficiency that was repaired during the same session. METHODS A total of 43 patients who underwent AV repair for mild-to-moderate aortic insufficiency between January 2003 and February 2009, in addition to the procedure performed for their main pathology necessitating the surgical intervention, were included in the present study. Cardiac function was evaluated, before and after the operation. RESULTS Hospital mortality rate was 4.6% (two patients). After the operations, significant improvements were observed in aortic insufficiency (0.57 +/- 0.50 vs. 2.86 +/- 0.48, p = 0.001), New York Heart Association class (1.08 +/- 0.28 vs. 3.03 +/- 0.44, p = 0.001), and left atrial diameter (47.37 +/- 9.28 vs. 42.35 +/- 7.02; p = 0.001). However, left ventricular end diastolic and end-systolic diameters remained unchanged. Two patients were re-operated for AV disease during the follow-up period; thus, at five years, the rate of freedom from re-operation due to AV pathology was 90.7 +/- 6.3%. CONCLUSIONS Cusp shaving is a feasible option that can be performed with low risk for concomitant aortic insufficiency.
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Sanchez-Ledesma M, Cruz-Gonzalez I, Sanchez PL, Martin-Moreiras J, Jneid H, Rengifo-Moreno P, Cubeddu RJ, Inglessis I, Maree AO, Palacios IF. Impact of concomitant aortic regurgitation on percutaneous mitral valvuloplasty: Immediate results, short-term, and long-term outcome. Am Heart J 2008; 156:361-6. [PMID: 18657669 DOI: 10.1016/j.ahj.2008.03.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2007] [Accepted: 03/07/2008] [Indexed: 12/01/2022]
Abstract
BACKGROUND The aim of the study is to examine the effect of concomitant aortic regurgitation (AR) on percutaneous mitral valvuloplasty (PMV) procedural success, short-term, and long-term clinical outcome. No large-scale study has explored the impact of coexistent AR on PMV procedural success and outcome. METHODS Demographic, echocardiographic, and procedure-related variables were recorded in 644 consecutive patients undergoing 676 PMV at a single center. Mortality, aortic valve surgery (replacement or repair) (AVR), mitral valve surgery (MVR), and redo PMV were recorded during follow-up. RESULTS Of the 676 procedures performed, 361 (53.4%) had no AR, 287 (42.5%) mild AR, and 28 (4.1%) moderate AR. There were no differences between groups in the preprocedure characteristics, procedural success, or in the incidence of inhospital adverse events. At a median follow-up of 4.11 years, there was no difference in the overall survival rate (P = .22), MVR rate (P = .69), or redo PMV incidence (P = .33). The rate of AVR was higher in the moderate AR group (0.9% vs 1.9% vs 13%, P = .003). Mean time to AVR was 4.5 years and did not differ significantly between patients with no AR, mild AR, or moderate AR (2.9 +/- 2.1 vs 5.7 +/- 3.6 vs 4.1 +/- 2.5 years, P = .46). CONCLUSIONS Concomitant AR at the time of PMV does not influence procedural success and is not associated with inferior outcome. A minority of patients with MS and moderate AR who undergo PMV will require subsequent AVR on long-term follow-up. Thus, patients with rheumatic MS and mild to moderate AR remain good candidates for PMV.
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Affiliation(s)
- Maria Sanchez-Ledesma
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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Choudhary SK, Talwar S, Kumar AS. Late outcome of mild or moderate aortic valve disease present at the time of mitral valve intervention. Ann Thorac Surg 2003; 76:1774-5. [PMID: 14602345 DOI: 10.1016/s0003-4975(03)00667-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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