Open mitral commissurotomy in the current era: indications, technique, and results.
BACKGROUND
The present retrospective study is focused on indications, techniques, and results of open mitral commisurotomy in the current era.


METHODS
Of the 1,280 patients undergoing open-heart surgical procedures for rheumatic mitral stenosis between January 1990 and July 2000, 276 (21.6%) patients underwent open mitral commissurotomy. Major indications included presence of left atrial thrombus/clot (n = 82, 29.7%), severe subvalvular disease (n = 110, 39.8%), mitral valve calcification (n = 42, 15.2%), mild mitral regurgitation (n = 28, 10.0%), associated aortic valve disease (n = 55, 19.9%), organic tricuspid valve disease (n = 20, 7.2%), and failure or restenosis after closed or balloon mitral valvuloplasty (n = 55, 19.9%). Age of patients ranged from 7 to 67 years (mean, 30.2 +/- 12 years). The majority (76%) were in New York Heart Association class III or IV, and 6.9% were in congestive heart failure. Atrial fibrillation was present in 134 (48.6%) patients. Mitral valve area ranged from 0.3 to 0.7 cm2 (mean, 0.52 +/- 0.12 cm2). Mid-diastolic gradients across the mitral valve ranged from 8 to 34 mm Hg (mean, 14.5 +/- 6.2 mm Hg), and end-diastolic gradients ranged from 8 to 42 mm Hg (mean, 15.2 +/- 5.7 mm Hg). Open mitral commissurotomy was performed using standard cardiopulmonary bypass. Associated aortic valve procedure was performed in 55 patients, and either tricuspid valvotomy or repair was performed in 28 patients.


RESULTS
There were four early deaths. All these patients had associated aortic valve procedure (Ross procedure in 2 and homograft aortic valve replacement in 2). Three patients developed severe mitral regurgitation in early postoperative period (< or = 30 days) and required reoperation. Predischarge echocardiography showed mitral valve area from 1.4 to 3.5 cm2 (mean, 2.6 +/- 0.6cm2) and moderate mitral regurgitation in 4 patients. Follow-up ranged from 1 to 130 months (mean, 64.5 +/- 28.6 months). There was no late death. There were three reoperations for mitral valve failure, and an additional 2 patients developed severe mitral stenosis (mitral valve area < 1.0 cm2). In operative survivors, freedom from mitral valve failure at 10 years was 87.0% +/- 3.5%. In patients with isolated open mitral commissurotomy, the incidence of thromboembolism was 0.5%/patient-year.


CONCLUSIONS
Open mitral commissurotomy provides excellent early and long-term results in a selected group of patients.
Choudhary
Shiv Kumar
SK
Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.
Dhareshwar
Jayesh
J
Govil
Akhil
A
Airan
Balram
B
Kumar
Arkalgud Sampath
AS
D000293:Adolescent; D000328:Adult; D000368:Aged; D001281:Atrial Fibrillation / Q000150:complications; D002114:Calcinosis / Q000601:surgery; D002315:Cardiopulmonary Bypass; D002404:Catheterization; D002648:Child; D004452:Echocardiography; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000150:complications; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000601:surgery*; D008944:Mitral Valve Insufficiency / Q000209:etiology / Q000601:surgery; D008946:Mitral Valve Stenosis / Q000601:surgery; D011183:Postoperative Complications; D012008:Recurrence; D012086:Reoperation; D012189:Retrospective Studies; D012214:Rheumatic Heart Disease / Q000601:surgery; D013923:Thromboembolism / Q000209:etiology; D014261:Tricuspid Valve / Q000601:surgery