Stentless Mitral Valve Implantation in Comparison to Conventional Mitral Valve Repair or Replacement at Five Years[*]

Abstract

Objective: A chordally supported stentless mitral valve (SMV) may be a suitable prosthesis for patients with severe degenerative mitral valve disease. We analyzed the five-year results and compared them with results after conventional mitral valve repair or replacement. Methods: 155 patients, operated on since August 1997, were evaluated. 53 patients (ages, 68 ± 8 years, 37 female, valve repair not feasible) received a SMV (Quattro^TM), 51 patients (69 ± 9 years, 32 female) had mitral valve repair (MVR) and 51 patients (66 ± 9 years, 32 female) had a conventional mitral valve replacement (MVP). There were no significant differences with respect to preoperative NYHA functional class, left ventricular ejection fraction, cardiac index and surgical risk, according to the EuroSCORE. Mean follow-up is 64 ± 18 (21 - 89) months. Results: Surgery was performed using a median sternotomy (32 [SMV]/20 [MVR]/34 [MVP]) or a lateral minithoracotomy 21/31/17 approach. The SMV was safely attached to the papillary muscles. In-hospital mortality was 1, 2 and 4 respectively; re-operation was required in 6, 2 and 3 patients. Five-year survival rate was 80.6 ± 4.4 % (SMV), 80.2 ± 5.6 % (CMV) and 82.6 ± 5.6 % (MVP), p = n.s. After hospital discharge, there was no significant difference in mortality in comparison to an age-matched control population. Echocardiography revealed acceptable SMV hemodynamics with preservation of left ventricular function. Conclusion: Midterm results after SMV implantation are comparable to conventional approaches. Complete preservation of the annulo-ventricular continuity is advantageous and close to physiologic hemodynamics can be achieved. Long term follow-up is required.

Mitral valve replacement - stentless bioprostheses - stentless mitral valve - mitral valve repair

References

• 1 Davis E A, Greene P S, Cameron D E. et al . Bioprosthetic versus mechanical prostheses for aortic valve replacement in the elderly.  Circulation. 1996;  94 (Suppl 2) S121-125
• 2 Jones E L, Weintraub W S, Craver J M. et al . Interaction of age and coronary disease after valve replacement: implications for valve selection.  Ann Thorac Surg. 1994;  58 378-384
• 3 Burr L H, Jamieson W R, Munro A I. et al . Porcine bioprostheses in the elderly: clinical performance by age groups and valve positions.  Ann Thorac Surg. 1995;  60 S264-269
• 4 Fann J I, Miller D C, Moore K A. et al . Twenty year clinical experience with porcine bioprostheses.  Ann Thorac Surg. 1996;  62 1301-1311
• 5 Jamieson W R, Burr L H, Munro A I. et al . Carpentier-Edwards standard porcine bioprosthesis: a 21-year experience.  Ann Thorac Surg. 1998;  66 S40-43
• 6 Jamieson W R. Modern cardiac valve devices-bioprostheses and mechanical prostheses: State of the art.  J Card Surg. 1993;  8 89-98
• 7 Walther T, Falk V, Diegeler A. et al . Effectiveness of different anticalcification treatments for stentless aortic bioprostheses.  Thorac Cardiovasc Surg. 1999;  47 23-25
• 8 Fann J I, Burdon T A. Are the indications for tissue valves different in 2001 and how do we communicate these changes to our cardiology colleagues?.  Curr Opin Cardiol. 2001;  16 126-135
• 9 Hetzer R, Bougioukas G, Franz M. et al . Mitral valve replacement with preservation of papillary muscles and chordae tendineae - revival of seemingly forgotten concept.  Thorac Cardiovasc Surg. 1983;  31 291-296
• 10 David T E, Uden D E, Strauss H D. The importance of the mitral apparatus in left ventricular function after correction of mitral regurgitation.  Circulation. 1986;  74 116-120
• 11 Reardon M J, David T E. Mitral valve replacement with preservation of the subvalvular apparatus.  Curr Opin Cardiol. 1999;  14 104-110
• 12 Middlemost S J, Sussman M, Patel A. et al . The stentless quadrileaflet bovine pericardial mitral valve: early clinical results.  J Heart Valve Dis. 1999;  8 174-179
• 13 Walther T, Walther C, Falk V. et al . Early clinical results after stentless mitral valve implantation and comparison with conventional valve repair or replacement.  Circulation. 1999;  100 (Suppl 19) II78-83
• 14 Walter T, Lehmann S, Falk V. et al . Midterm result after stentless mitral valve replacement.  Circulation. 2003;  9 (Suppl 1) II85-89
• 15 Liao K, Wu J J, Frater R W. Intraoperative epicardial echo/Doppler evaluation of a stentless, chordally supported quadricusp mitral bioprostheses.  ASAIO J. 1993;  39 M634-M638
• 16 Frater R WM, Liao K, Seifter E. Stentless Chordally Supported Mitral Bioprosthetic Valve. New Horizons and the Future of Heart Valve Bioprostheses. 1st ed. Austin, TX; Silent Partners 1994: 103-119
• 17 Walther T, Falk V, Walther C. et al . Combined stentless mitral valve implantation and radiofrequency ablation.  Ann Thorac Surg. 2000;  70 1080-1082
• 18 Edmunds L H, Clark R E, Cohn L H. et al . Guidelines for reporting morbidity and mortality after cardiac valvular operations.  Ann Thorac Surg. 1996;  62 932-935
• 19 Acar C, Tolan M, Berrebi A. et al . Homograft replacement of the mitral valve: graft selection, technique of implantation, and results in forty-three patients.  J Thorac Cardiovasc Surg. 1996;  111 367-380
• 20 Acar C. Editorial: The mitral homograft - is it worthwhile?.  J Thorac Cardiovasc Surg. 2000;  120 448-449
• 21 Kumar A S, Choudhary S K, Mathur A. et al . Homograft mitral valve replacement: Five years' results.  J Thorac Cardiovasc Surg. 2000;  120 450-458
• 22 Kalmar P, Irrgang E. Cardiac surgery in Germany during 2000.  Thorac Cardiovasc Surg. 2001;  49 XXXIII-XXXVIII

1 Presented as a moderated poster at the 4th joint meeting of the German, Austrian and Swiss Societies for Thoracic and Cardiovascular Surgery in Hamburg, 17 February 2004