title: Mitral valve surgery after percutaneous mitral commissurotomy: is repair still feasible?
abstract: OBJECTIVE
  Due to progression of rheumatic disease, percutaneous mitral commissurotomy (PMC) is a palliative procedure. We aimed at evaluating the outcomes of patients requiring surgery for failure of PMC, focusing on the fate of the mitral valve (MV) (repair versus replacement).
  
  
  METHODS
  From January 1993 through December 2012, 61 patients with previous PMC were submitted to MV surgery. Detailed operative findings were collected from all patients and an intraoperative anatomical score was introduced to predict reparability. Time to surgery, overall survival and freedom from reoperation were analysed.
  
  
  RESULTS
  The mean time to surgery after PMC was 6.9±5.9 years and indications were restenosis in 25 patients (41%) and mitral regurgitation or mixed lesion in 36 (59%). Nine patients (14.8%) had more than one previous intervention. Intraoperative inspection of the valve revealed leaflet laceration outside the commissural area in 27 patients (44.3%). Valve repair was accomplished in 38 patients (62.3%). Pulmonary hypertension, calcification and intraoperative anatomical score were independently associated with the probability of valve replacement (OR 1.12, OR 7.03 and OR 4.49, respectively, P<0.05). There was no hospital mortality. MV area increased on average 1.6 cm2 after surgery to 2.7 cm2; 5-, 10- and 20-year survival rates were 98.1±1.9, 91±5.2 and 82.7±9.2%, respectively. The rate of freedom from mitral reoperation (for repaired cases) at 5, 10 and 15 years was 100, 95.8±4.1 and 87.8±8.5%, respectively. There was no difference in survival between repaired or replaced MVs, but the former had less valve-related events during follow-up.
  
  
  CONCLUSIONS
  The MV can be repaired after failed PMC, with very low complication rates and excellent long-term results. Hence, whenever possible, these patients should be sent to reference centres where repair can be successfully achieved.
authors.affiliation: Centre of Cardiothoracic Surgery, University Hospital and Medical School, Coimbra, Portugal.
authors.forename: Gonçalo F
authors.initials: GF
authors.lastname: Coutinho
authors.affiliation: Centre of Cardiothoracic Surgery, University Hospital and Medical School, Coimbra, Portugal.
authors.forename: Carlos Filipe
authors.initials: CF
authors.lastname: Branco
authors.affiliation: Centre of Cardiothoracic Surgery, University Hospital and Medical School, Coimbra, Portugal.
authors.forename: Elisabete
authors.initials: E
authors.lastname: Jorge
authors.affiliation: Centre of Cardiothoracic Surgery, University Hospital and Medical School, Coimbra, Portugal.
authors.forename: Pedro M
authors.initials: PM
authors.lastname: Correia
authors.affiliation: Centre of Cardiothoracic Surgery, University Hospital and Medical School, Coimbra, Portugal antunes.cct.huc@sapo.pt.
authors.forename: Manuel J
authors.initials: MJ
authors.lastname: Antunes
mesh_terms: D004452:Echocardiography; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000601:surgery*; D008944:Mitral Valve Insufficiency / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D008946:Mitral Valve Stenosis / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D012086:Reoperation / Q000706:statistics & numerical data; D012214:Rheumatic Heart Disease / Q000401:mortality / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome
keywords: Mitral restenosis; Mitral valve repair; Percutaneous mitral commissurotomy