Combined Aortic And Mitral Dystrophic Insuffiency : A Standardized Repair With Mitral And Aortic Ring Annuloplasty
Mazin A. Fatani1, Mustafa Zakkar2, Pouya Youssefi1, Alain Berrebi1, Jean Luc Monin1, Nizar Khelil1, Mathieu Debauchez1, Emmanuel Lansac1.
1Institute Mutualiste Montsouris, Paris, France, 2St George's Hospital, London, United Kingdom.
OBJECTIVE: Repair of combined dystrophic mitral and aortic insufficiency (AI) remains a challenge. We report outcomes of a standardized repair approach using mitral and aortic ring annuloplasty.
METHODS: Between 2003 and 2017, 612 aortic valve repair were performed including 28 combined aortic and mitral valve repairs. Mitral regurgitation was moderate in 6 (21.5%) and severe in 22 (78.5%) patients and was the primary indication of surgery in only 3 (10.7%) patients. Eighteen percent of patients had bicuspid aortic valves, 25% had Marfan and 3.5% had healed infective endocarditis.
RESULTS: Besides mitral repairs, aortic valve repair was isolated in 39.3% (double sub and supravalvular annuloplasty), with a tubular aorta replacement combined with annuloplasty in 10.7% or as part of a root replacement (remodeling with annuloplasty) in 50%. Twenty-five percent of patients had additional cardiac procedures. A second cross clamp was needed in 3 patients (10.7%) due to residual mitral regurgitation, a residual AI or uncontrollable bleeding. Overall, there was no in-hospital mortality. Two patients (7.1%) required a permanent pacemaker insertion within 30 days one of which also had a tricuspid valve annuloplasty. None of the patients had post-operative renal failure but 7% needed re-exploration for bleeding. Survival at 8 years was 90.9% (CI 0.8- 1) with one death secondary to pancreatic cancer and one with an undetermined cause. Two patients required re-interventions for severe AI at 2 and 4 years, both were from the early period where the intraoperative effective height assessment was not done and without an undersized calibrated annuloplasty. Freedom from re-intervention was 84.4% (CI 0.7-1) at 8 years. None of the patients required a mitral valve re-intervention and none developed infective endocarditis, ischemic stroke, bleeding or a thromboembolic event. CONCLUSIONS: Concomitant aortic and mitral repair had a low operative mortality and morbidity as well as favorable long-term outcomes.
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