Jeswant Dillon

Is rheumatic aetiology a predictor of poor outcome in the current era of mitral valve repair? Contemporary long-term results of mitral valve repair in rheumatic heart disease †

OBJECTIVES Contemporary experience with mitral valve (MV) repair in the rheumatic population is limited. We aimed to examine the long-term outcomes of rheumatic MV repair, to identify the predictors of durability and to compare the repair for rheumatic and degenerative MVs. METHODS MV repairs for both rheumatic and degenerative lesions were analysed prospectively from our valve-repair registry. The primary outcomes investigated were mortality, survival, freedom from reoperation and freedom from valve failure. Logistic and Cox regression analyses were performed to define the predictors of reoperation and valve failure. RESULTS Between 1997 and 2010, 627 consecutive rheumatic MV repairs were performed (46.7% of all mitral repair procedures). The mean age of our study group was 32 ± 19 (range 3-75 years). In-hospital mortality was 2.4% and late mortality was 0.3%. Freedoms from reoperation for rheumatics at 5 and 10 years were 91.8 ± 4.8 and 87.3 ± 3.9%, respectively, comparable with that for degenerative valves at 92.0 ± 1.7 and 91.8 ± 4.8%, respectively (P = 0.79). Freedoms from valve failure for rheumatics at 5 and 10 years were 85.6 ± 2.3 and 72.8 ± 4.6%, respectively, whereas those for degenerative repairs were 88.7 ± 5.1 and 82.4 ± 7.7%, respectively (P = 0.45). Independent predictors for reoperation and valve failure in rheumatic patients were residual mitral regurgitation >2+ and performance of commissurotomy. CONCLUSIONS The durability of MV repair for rheumatic disease in the current era has improved and is comparable with the outstanding durability of repairs for degenerative disease. Modifications of standard repair techniques, adherence to the importance of good leaflet coaptation and strict quality control with stringent use of intraoperative transoesophageal echocardiography have all contributed to the improved long-term results.

Leaflet extension in rheumatic mitral valve reconstruction

OBJECTIVES Type IIIa mitral regurgitation (MR) due to rheumatic leaflet restriction often renders valve repair challenging and may predict a less successful repair. However, the utilization of leaflet mobilization and extension with the pericardium to increase the surface of coaptation may achieve satisfactory results. We reviewed our experience with leaflet extension in rheumatic mitral repair with emphasis on the technique and mid-term results. METHODS Between 2003 and 2010, 62 of 446 rheumatic patients had leaflet extension with glutaraldehyde-treated autologous pericardium as part of their mitral repair procedure. Their clinical and echocardiographic data were prospectively analysed. RESULTS The mean age of the rheumatic patients was 20.2 ± 11.7 years; range 3-60 years. Fourty-eight (77.4%) patients had predominant MR, while 22.6% had mixed mitral stenosis and mitral regurgitation (MS/MR). Leaflet extension was performed in the posterior, anterior and both leaflets in 77, 13 and 10% of patients, respectively. Additional repair procedures included neo-chordal replacement, chordal transfer/shortening/fenestration/resection, commissurotomy and papillary muscle splitting. All repairs were stabilized with annuloplasty rings. The follow-up was complete in all patients with a mean follow-up of 36.5 ± 25.6 months. There was no mortality in this series. At the latest follow-up, the MR grade was none/trivial in 64.5 of patients, mild in 22.6, moderate in 6.5, moderately severe in 4.8 and severe in 1.6%. Two patients had redo mitral surgery. At 5 years postoperatively, the estimated rates of freedom from reoperation and valve failure were 96.8 and 91.6%, respectively. CONCLUSIONS Repair with leaflet extension in rheumatic disease resulted in good early and mid-term outcomes. A wider utilization of this technique may increase the feasibility and durability of repair in complex rheumatic mitral valve disease.

Comparative long-term results of mitral valve repair in adults with chronic rheumatic disease and degenerative disease: Is repair for “burnt-out” rheumatic disease still inferior to repair for degenerative disease in the current era?

OBJECTIVE Mitral valve repair is perceived to be of limited durability for advanced rheumatic disease in adults. We aim to examine the long-term outcomes of repair for rheumatic disease, identify predictors of durability, and compare with repair for degenerative disease. METHODS Rheumatic and degenerative mitral valve repairs in patients aged 40 years or more were prospectively analyzed. The primary outcomes investigated were mortality, freedom from reoperation, and valve failure. Logistic regression analysis was performed to define predictors of poor outcome. RESULTS Between 1997 and 2011, 253 rheumatic and 148 degenerative mitral valves were repaired. The age of patients in both groups was similar, with a mean of 54.1 ± 8.4 years versus 55.6 ± 7.3 years (P = .49). Freedom from reoperation for rheumatic valves at 5 and 10 years was 98.4%, comparable to 95.3% (P = .12) for degenerative valves. Freedom from valve failure at 5 and 10 years was 91.4% and 81.5% for rheumatic repairs and 82.5% and 75.4% for degenerative repairs, respectively (P = .15). The presence of residual mitral regurgitation greater than 2+ before discharge was the only significant independent predictor of reoperation, whereas residual mitral regurgitation greater than 2+ and leaflet procedures were significant risk factors for valve failure. CONCLUSIONS The durability of rheumatic mitral valve repair in the current era has improved and is comparable to the outstanding durability of repairs for degenerative disease, even in the adult rheumatic population. Modifications of standard repair techniques, adherence to the importance of good leaflet coaptation, and strict quality control with stringent use of intraoperative transesophageal echocardiography have all contributed to the improved long-term results.

An Accessory Mitral Valve Leaflet Causing Left Ventricular Outflow Tract Obstruction and Associated with Severe Aortic Incompetence

This case report describes a 20‐year‐old woman with Turners syndrome who presented with reduced effort tolerance limited by dyspnea. She had previously been on pediatric cardiology follow‐up for congenital subvalvular aortic stenosis first diagnosed at age 7. Unfortunately she defaulted after two visits before any intervention could be done. Transthoracic echocardiography demonstrated severe aortic incompetence (AI) with a membrane‐like structure in the left ventricular outflow tract (LVOT). The mean pressure gradient across the LVOT on continuous wave Doppler was 41 mmHg. The membranous interventricular septum appeared aneurysmal and it was observed that the “subaortic membrane” had a connection to the anterolateral papillary muscle via a strand of chordal tissue. Further images were captured using two‐dimensional and three‐dimensional transthoracic and transesophageal echocardiography (iE33, Philips Medical Systems, Andover, MA, USA). After a review of the literature it was concluded that this appeared to be an accessory mitral valve (AMV) leaflet causing LVOT obstruction associated with AI. AMV tissue is a rare congenital malformation causing LVOT obstruction. Because it is so unusual, it may not be immediately recognizable even in a high volume echocardiography laboratory. The clue which helped with the diagnosis was the strand of chordal tissue which connected the mass to the papillary muscle. This anomaly is often associated with LVOT obstruction. (Echocardiography 2012;29:E34‐E38)

Contemporary long-term outcomes of an aggressive approach to mitral valve repair in children: is it effective and durable for both congenital and acquired mitral valve lesions?

OBJECTIVES We analysed the long-term outcomes of mitral valve (MV) repair in children and compared the repairs for both congenital and acquired lesions. METHODS A review of 634 children (≤18 years) who underwent MV repair from 1992 to 2011 was conducted [excluding patients with complete atrioventricular septal defect (AVSD), single ventricle and atrioventricular (AV) discordance]. Associated cardiac anomalies were present in 473 patients (75%). Congenital mitral lesions were found in 270 (43%) patients compared with an acquired aetiology in 364 (57%) [mainly rheumatic: 329 patients (90%)]. Mitral regurgitation (MR) was predominant in 606 (96%) patients, and 544 (86%) of these showed ≥3+ MR. Modified techniques of MV reconstructions were used. RESULTS The early mortality rate was 2% (14 patients). The mean follow-up was 55 months (1-240 months; 85% complete). The late mortality rate was 4% (23 patients) and survival rates at 10 and 15 years were 91 and 86%, respectively. There was no significant difference in 10-year survival between repairing the congenital (98%) and acquired lesions (87%) (P = 0.17). The rate of freedom from reoperation after MV repair for the entire population was 79% at 10 years, with no significant difference between congenital (80%) and acquired lesions (79%) (P = 0.20). Fifty-six patients (9%) required reoperation. Mixed MV lesions, commissural fusions and residual MR (≥2+) were the predictors of valve failure and reoperation. All survivors remain in New York Heart Association class I and none had thromboembolism or pacemaker insertion. CONCLUSIONS MV repair can be successfully applied to both congenital and acquired MV disease in children. Aggressive repair techniques and avoidance of residual MR have improved durability and survival.

Leaflet extension for repairing rheumatic mitral valve regurgitation.

It has been established that mitral valve (MV) repair is preferred over replacement in patients with mitral regurgitation (MR) caused by degenerative disease. In contrast, valve reconstruction for rheumatic MR remains controversial. Type IIIa MR due to rheumatic leaflet restriction often renders valve repair challenging and may predict a less successful repair. However, the utilization of leaflet mobilization and extension with autologous pericardium in order to increase leaflet area and surface of coaptation may achieve satisfactory results (1-3). This article represents our single-center experience of leaflet extension in rheumatic MR, with emphasis on description of the technique including tips on safeguards and pitfalls.

Primary Arterial Switch Operation for Late Referral of Transposition of the Great Arteries with Intact Ventricular Septum in the Current Era: Do We Still Need a Rapid Two-Stage Operation?

Objective: We introduced primary arterial switch operation for the patient with transposition of great arteries and intact ventricular septum (TGA-IVS) who had more than 3.5 mm of posterior left ventricle (LV) wall thickness. Methods: Between January 2013 and June 2015, a total of 116 patients underwent arterial switch operation. Of the 116 patients, 26 with TGA-IVS underwent primary arterial switch operation at more than 30 days of age. Results: The age and body weight (mean ± SD) at the operation were 120.4 ± 93.8 days and 4.1 ±1.0 kg, respectively. There was no hospital mortality. The thickness of posterior LV wall (preoperation vs postoperation; mm) was 4.04 ± 0.71 versus 5.90 ± 1.3; P < .0001; interval: 11.8 ± 6.5 days. The left atrial pressure (mm Hg; postoperative day 0 vs 3) was 20.0 ± 3.2 versus 10.0 ± 2.0; P < .0001; and the maximum blood lactate level (mmol/dL) was 4.7 ± 1.4 versus 1.4 ± 0.3; P < .0001, which showed significant improvement in the postoperative course. All cases had delayed sternal closure. The patients who belonged to the thin LV posterior wall group (<4 mm [preoperative echo]: n = 13) had significantly longer ventilation time (days; 10.6 ± 4.8 vs 4.8 ± 1.7, P = .0039), and the intensive care unit stay (days) was 14 ± 9.2 versus 7.5 ± 3.5; P = .025, compared with thick LV wall group (≥4.0 mm: n = 13). Conclusions: The children older than 30 days with TGA-IVS can benefit from primary arterial switch operation with acceptable results under our indication. However, we need further investigation for LV function.

Is it worth repairing rheumatic mitral valve disease in children? Long-term outcomes of an aggressive approach to rheumatic mitral valve repair compared to replacement in young patients†

OBJECTIVES Contemporary experience in mitral valve (MV) repair for children with rheumatic heart disease (RHD) is limited, despite the potential advantages of repair over replacement. We reviewed our long-term outcomes of rheumatic MV repair and compared them with the outcomes of MV replacement in children with RHD. METHODS This study is a review of 419 children (≤18 years) with RHD who underwent primary isolated MV surgery between 1992 and 2015, which comprised MV repair (336 patients; 80.2%) and MV replacement (83 patients; 19.8%). The replacement group included mechanical MV replacements (MMVRs) (n = 69 patients; 16.5%) and bioprosthetic MV replacements (n = 14 patients; 3.3%). The mean age with standard deviation at the time of operation was 12.5 ± 3.5 (2-18) years. Mitral regurgitation (MR) was predominant in 390 (93.1%) patients, and 341 (81.4%) patients showed ≥3+ MR. The modified Carpentier reconstructive techniques were used for MV repair. RESULTS Overall early mortality was 1.7% (7 patients). The mean follow-up was 5.6 years (range 0-22.3 years; 94.7% complete). Survival of patients who underwent repair was 93.9% both at 10 and 20 years, which was superior than that of replacement (P < 0.001). Freedom from reoperation at 10 and 20 years after MV repair was 81.7% and 72.6%, respectively, compared to 83.2% for MV replacement (P = 0.580). Forty patients underwent reoperation after the initial surgery with no operative deaths. Mixed mitral lesion and postoperative residual MR (≥2+) were the predictors for reoperation in the repair group, whereas lower body surface area and usage of bioprosthesis were significant factors for the replacement group. Freedom from thrombotic, embolic and haemorrhagic events at 10 and 20 years for patients with repair was 98.2% compared to 90.1% in patients with replacement and 67.6% for patients with MMVR (P = 0.004). CONCLUSIONS Twenty-three years of follow-up shows that MV repair is superior to MMVR in children with RHD. Hence, the rheumatic MV should be repaired when technically feasible to maximize the survival and reduce the valve-related morbidity with comparable durability to MMVR.

Validation of EuroSCORE II in patients undergoing coronary artery bypass grafting (CABG) surgery at the National Heart Institute, Kuala Lumpur: a retrospective review.

Background: The European System for Cardiac Operative Risk (EuroSCORE) II was developed in 2011 to replace the aging EUROScore for predicting in-house mortality after cardiac surgery. Our aim was to validate EuroSCORE II in Malaysian patients undergoing coronary artery bypass graft (CABG) surgery at our Institute. Methods: A retrospective single-center study was performed. A database was created to include EuroSCORE II values and actual mortality of 1718 patients undergoing CABG surgery in Malaysia from 1st January to 31st December 2016. The goodness-of-fit of EuroSCORE II was determined by the Hosmer-Lemeshow goodness-of-fit test and discriminatory power with the areas under the receiver operating characteristics (ROC) curve (AUC). Results: Observed mortality rate was 4.66% (80 out of 1718 patients). The median EuroSCORE II value was 2.06% (Inter Quartile Range: 1.94%) (1st quartile: 1.45%, 3rd quartile: 3.39%). The AUC for EuroSCORE II was 0.7 (95% CI 0.640 - 0.759) indicating good discriminatory power. The Hosmer-Lemeshow goodness-of-fit test did not show significant difference between expected and observed mortality in accordance to the EuroSCORE II model (Chi-square = 13.758, p = 0.089) suggesting good calibration of the model in this population. Cross-tabulation analysis showed that there is slight overestimation of EuroSCORE II in low-risk groups (0-10%) and slight underestimation in high-risk groups (>20%). Multivariate logistic regression analysis showed that gender, age, total hospital stay, serum creatinine and critical pre-operative state are significant predictors of mortality post-CABG surgery. Conclusion: This study indicated that the EuroSCORE II is a good predictor of post-operative mortality in the context of Malaysian patients undergoing CABG surgery. Our study also showed that certain independent variables might possess higher weightage in predicting mortality among this patient group. Therefore, it is suggested that EuroSCORE II can be safely used for risk assessment while ideally, clinical consideration should be applied on an individual basis.

A retrospective review on minimally invasive technique via endoscopic thoracic sympathectomy (ETS) in the treatment of severe primary hyperhidrosis: Experiences from the National Heart Institute, Malaysia

Background: Hyperhidrosis is due to the hyperactive autonomic stimulation of the sweat glands in response to stress. Primary hyperhidrosis is a common yet psychologically disabling condition. This study will describe our experience in managing hyperhidrosis via endoscopic thoracic sympathectomy (ETS). Methods: The information was obtained from the patient records from 1 st January 2011 until 31 st December 2016. Pertinent information was extracted and keyed into a study proforma. Results: 150 patients were operated on but only 118 patients were included in this study. The mean age was 22.9±7.3 years. The majority (54.2%) had palmar-plantar hyperhidrosis and 39.8% had associated axillary hyperhidrosis. Excision of the sympathetic nerve chain and ganglia were the main surgical technique with the majority (55.9%) at T2-T3 level. Mean ETS procedure time was 46.6±14.29 minutes with no conversion. Surgical complications were minimal and no Horner’s Syndrome reported. Mean hospital stay was 3.5±1.05 days. The majority of patients (67.8%) had only one follow-up and only half of the study sample (58.5%) complained mild to moderate degree of compensatory sweating, even though the long-term resolution is yet to be determined by another study. Following ETS, 98.3% of patients had instant relief and resolved their palmar hyperhidrosis. Predictors of CS were sympathectomy level and follow-up. The odds of reporting CS was 2.87 times in patients undergoing ETS at the T2-T3 level compared to those undergoing ETS at the T2-T4 level. The odds of reporting CS was 13.56 times in patients having more than one follow-up compared to those having only one follow-up. Conclusion: We conclude that ETS is a safe, effective and aesthetically remarkable procedure for the treatment of primary hyperhidrosis with only half of the patients developing mild to moderate degree of CS. Significant predictors of CS were sympathectomy level during ETS and frequency of follow-up after ETS.