Surgery for rheumatic mitral regurgitation in patients below twenty years of age. An analysis of failures.
OBJECTIVE
Mitral valve repair is less stable in rheumatic than in degenerative disease. This failure rate is inversely related to the age of the patient. Based on our clinical experience, we selected the group of patients with the worst results for this study: (i) rheumatic, (ii) age 20 or under, (iii) pure mitral regurgitation (MR), and, (iv) no aortic disease.


METHODS
Between 1988 and 1995, 83 consecutive patients complied with these characteristics. No patient was excluded. Replacement (MVR) was performed in 26 and repair (MRp) in 57 (69%).


RESULTS
There was one hospital death (1%) with an actuarial survival at 48 months of 74.8% +/- 19% for MVR and of 97.9% +/- 2.1% at 78 months for MRp. There were no thromboembolic events. Reoperation was required in one MVR (4%) and in 21 MRp (37%), within same admission in six, within three months in eight, under one year in three, and beyond in four cases. Severe MR appeared in five further cases. No statistical difference was found between the preoperative clinical data, operative findings and surgical maneuvers of those patients with successful and unsuccessful repair. The rate of failure was similar after Kay (14/29) and Duran (12/28) annuloplasty. All patients showed a rapid decrease in left ventricular dimensions. Early failures showed elongation of previously shortened chordae at reoperation, together with more reduction in systolic dimension than the other groups. Late failures were more related to progression of the rheumatic process. No clear relationship between rheumatic activity and failure rate was found.


CONCLUSIONS
Rheumatic mitral regurgitation in the young remains a serious problem. The treatment of this frequent pathology in the developing countries needs a new approach based on the knowledge that it starts at the annulus. Earlier surgery at this level might prevent its further progression, avoiding the problems of secondary chordal elongation.
Gometza
B
B
Department of Cardiovascular Diseases, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.
al-Halees
Z
Z
Shahid
M
M
Hatle
L K
LK
Duran
C M
CM
D000293:Adolescent; D000328:Adult; D001705:Bioprosthesis; D002648:Child; D002675:Child, Preschool; D018450:Disease Progression; D005260:Female; D005500:Follow-Up Studies; D006350:Heart Valve Prosthesis / Q000379:methods*; D006801:Humans; D008297:Male; D008944:Mitral Valve Insufficiency / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D011183:Postoperative Complications / Q000401:mortality; D012086:Reoperation; D012189:Retrospective Studies; D012214:Rheumatic Heart Disease / Q000150:complications* / Q000401:mortality / Q000601:surgery; D015996:Survival Rate