Stepwise Approach for Effectiveness and Outcome Impact of Repaired Moderate Rheumatic Mitral Regurgitation during Aortic Valve Replacement for Severe Aortic Stenosis

Stepwise Approach for Effectiveness and Outcome Impact of Repaired Moderate Rheumatic Mitral Regurgitation during Aortic Valve Replacement for Severe Aortic Stenosis. Abstract Objectives: The optimal management of rheumatic moderate mitral regurgitation in cases with severe aortic stenosis remains not well defined and it is frequently not corrected as it is claimed to improve after AVR and prompt myocardial remodeling. We evaluated the effectiveness and outcome impact of repaired mitral valve on clinical and echocardiographic parameters of the patient over follow-up of six-month duration. Methods: This prospective comparable study was conducted be- tween January 2016 and June 2018 in Egypt (Department of Cardiothoracic Surgery, Cairo University, and other open heart surgery cen- ters). One hundred and thirty patients diagnosed with severe aortic stenosis and moderate rheumatic mitral regurgitation was involved in the study. Half of them (Group A) were offered aortic valve replacement and mitral valve repair with a remodeling ring annuloplasy, and the other half were offered aortic valve replacement only. Preoperative, intraoperative, postoperative, and at six-month post-surgery follow-up echocardiography was done as well as clinical correlation assessment. We excluded patients with echocardiographic evidence of mitral valve apparatus pathology (rheumatic or non-rheumatic) necessitating its replacement. Also patients with associated moder- ate-to-severe tricuspid valve regurgitation requiring concomitant re pair or replacement were excluded. We also did not involve patients with concomitant coronary artery disease as well as those having aortic aneurysms or dissections necessitating intervention. Results: Patients of both groups had properly-matching preopera- tive demographic data. Mean age was 40.34 ± 6.81 years in group A and 43.60 ± 6.53 in group B. Male patients represented 61.53% in group A and 53.84% for group B. Group A involved 48 (73.84%) patients in NYHA class III classification; versus 51 (78.46%) patients in group B. Mean preoperative LVEF% was 60.2 ± 5.1% for group A patients; versus 61.6 ± 7.5% for group B patients. Echocardio - graphic data obtained in the early postoperative and at 6-months follow-up were compared with the preoperative profile. We had the sum of 5 patients (3.84%) mortality in both groups. All patients expressed improvement of clinical symptoms of mitral regurgitation at time of hospital discharge. And at 6-months evaluation, clear statistical significance emerged where patients of group A had significant improvement of mitral regurgitation degree (improved in 75.38% compared to 50.77% of group B patients), significant improvement of MR jet area (3.91 ± 0.8 cm 2 compared to 4.78 ±0.9 cm 2 in group B patients), and significant improvement of NYHA class (21.53% of group A in NYHA class I compared to none in group B, 78.46 % of group A compared to 46.15 % of group B in NYHA class II and 53.84% of group B remained in NYHA class III compared to none in group A). Conclusion: The presence of moderate rheumatic mitral regurgi- tation in patients who undergo aortic valve replacement for severe aortic stenosis does not affect the immediate postoperative or early (6-months) follow-up outcome. However, statistically significant dif ferences were found between both groups concerning the regres- sion of the Moderate Rheumatic MR and improvement of the MR jet area; which reflects the effect of concomitant mitral valve repair on improving both the outcome of Moderate Rheumatic MR and the clinical status of the patients. However, operative parameters were statistically significant i.e. total operative time, total bypass time and total cross clamp time between both groups. Thus, patients with LV dysfunction should be considered carefully for this option selection. We recommend considering a procedure addressing the rheumatic mitral valve with moderate regurgitation in the setting of AVR for severe AS with great concern to those with a worse preoperative left ventricular profile.