Figure 1
Flow chart of patients’ recruitment based on the aetiology of mitral valve disease and the surgical approach.
Table 1
Basic characteristics of MV surgery patients based on aetiology and surgical approach.
| VARIABLES | RHEUMATIC HEART DISEASE | NON-RHEUMATIC HEART DISEASE | ||||
|---|---|---|---|---|---|---|
| TOTAL n = 814 | MITRAL REPAIR n = 167 | MITRAL REPLACE n = 647 | TOTAL n = 568 | MITRAL REPAIR n = 353 | MITRAL REPLACE n = 215 | |
| Demography | ||||||
| Age | 43 (18–70) | 41 (18–69) | 43 (18–70) | 54 (18–78)* | 54 (18–78) | 53 (18–73) |
| Female | 515 (63.3%) | 112 (67.1%) | 403 (62.3%) | 182 (32%)* | 121 (34.3%) | 61 (28.4%) |
| Body Mass Index | 21.9 (13.6–43.4) | 22.1 (13.6–39.7) | 21.8 (14.0–43.4) | 23.1 (12.9–39.1)* | 23.5 (12.9–39.1) | 22.2(14.5–39.1)‡ |
| Preoperative Comorbidities | ||||||
| Atrial Fibrillation | 587 (72.1%) | 106 (63.5%) | 481 (74.3%)† | 180 (31.7%)* | 106 (30%) | 74 (34.4 %) |
| DM with Insulin, n (%) | 6 (0.7%) | 1 (0.6%) | 5 (0.8%) | 6 (1.1%) | 4 (1.1%) | 2 (0.9%) |
| COPD, n (%) | 5 (0.6%) | 0 (0%) | 5 (0.8%) | 2 (0.4%) | 0 (0%) | 2 (0.9%) |
| Hypertension | 81 (10%) | 14 (8.4%) | 67 (10.4%) | 179 (31.5%)* | 117 (33.1%) | 62 (28.8%) |
| CKD (CCL< 50 ml/m2) | 119 (14.6%) | 26 (15.6%) | 93 (14.4%) | 146 (25.7%)* | 80 (22.7%) | 66 (30.7%)‡ |
| NYHA fc III-IV | 402 (49.4%) | 76 (45.5%) | 326 (50.4%) | 254 (44.7%) | 151 (42.8%) | 103 (47.9%) |
| Infective Endocarditis | 22 (2.7%) | 5 (3%) | 17 (2.6%) | 44 (7.7%)* | 10 (2.8%) | 34 (15.8%)‡ |
| Concomitant Cardiac Surgery/Intervention | ||||||
| CABG | 27 (3.3%) | 6 (3.6%) | 21 (3.2%) | 93 (16.4%)* | 48 (13.6%) | 45 (20.9%) |
| Aortic Valve Surgery | 238 (29.2%) | 46 (27.5%) | 192 (29.7%) | 40 (7%)* | 18 (5.1%) | 22 (10.2%)‡ |
| Tricuspid Valve Surgery | 472 (58%) | 82 (49.1%) | 390 (60.3%)† | 141 (24.8%)* | 60 (17%) | 81 (37.7%)‡ |
| ≥3 surgical procedures | 134 (16.5%) | 25 (15%) | 109 (16.8%) | 16 (2.8%)* | 4 (1.1%) | 12 (5.6%)‡ |
| History of PTMC | 13 (1.6%) | 3 (1.8%) | 10 (1.5%) | 0 (0%)* | 0 (0%) | 0 (0%) |
| CPB time | 106 (41–390) | 109 (44–251) | 105.5 (41–390) | 100 (10–515)* | 95 (10–261) | 110 (45–515)‡ |
| Aox time | 80 (5–319) | 78 (5–225) | 80.5 (27–319) | 76 (12–467)* | 72.50 (12–235) | 82 (25–467)‡ |
| Cardiac condition (echo parameters) | ||||||
| LVEF (%) | 60 (20–82) | 60 (22–80) | 60 (20–82) | 66 (25–89)* | 67 (27–89) | 65 (25–82)‡ |
| TAPSE (mm) | 18 (6–37) | 19 (8–36) | 18 (6.0–37.0)† | 23 (5.3–40)* | 24.0 (6.2–39.4) | 22 (5.3–40) |
| TVG | 41 (0–156) | 37 (0–100) | 42 (0–156) | 31 (0–111)* | 30 (0–108) | 33 (0–111)‡ |
| Mitral stenosis | 342 (42%) | 69 (41.3%) | 273 (42.2%) | 0 (0%)* | 0 (0%) | 0 (0%) |
| Mitral regurgitation | 166 (20.4%) | 52 (31.1%) | 114 (17.6%)† | 568 (100%)* | 353 (100%) | 215 (100%) |
| Mixed mitral valve disease | 306 (37.6%) | 46 (27.5%) | 260 (40.2%)† | 0 (0%)* | 0 (0%) | 0 (0%) |
| Risk Assessment for Mortality | ||||||
| Euroscore II | 2.0 (0.5–19.5) | 1.9 (0.5–19.5) | 2.1 (0.5–16.2) † | 1.6 (0.5–21.3)* | 1.4 (0.5–14.0) | 2.2 (0.5–21.3)‡ |
[i] DM: diabetes mellitus, COPD: Chronic Obstructive Pulmonary Disease, CKD: chronic kidney disease, NYHA fc: New York Heart Association functional class, CABG: Coronary Artery Bypass Grafting, PTMC: percutaneous transvenous mitral commissurotomy, CPB: cardiopulmonary bypass, AoX: aortic cross-clamp, LVEF: left ventricular ejection fraction, TAPSE: tricuspid annular plane systolic excursion, TVG: tricuspid valve gradient.
*Comparing RHD and non-RHD, p < 0.05.
†Comparing repair and replacement in RHD, p < 0.05.
‡Comparing repair and replacement in non-RHD repair, p < 0.05.
Figure 2
The echocardiographic pictures of rheumatic mitral valve disease pre (above picture) and post repaired (below picture).
Figure 3
The echocardiographic pictures of rheumatic mitral valve disease pre (above picture) and post replacement with mechanical prosthetic valve (below picture).
Table 2
Outcome following mitral valve surgery based on aetiology and surgical approach.
| VARIABLES | RHEUMATIC HEART DISEASE | NON-RHEUMATIC HEART DISEASE | ||||
|---|---|---|---|---|---|---|
| TOTAL n = 814 | MITRAL REPAIR n = 167 | MITRAL REPLACE n = 647 | TOTAL n = 568 | MITRAL REPAIR n = 353 | MITRAL REPLACE n = 215 | |
| Early outcome | ||||||
| 30-day mortality | 71 (8.7%) | 14 (8.4%) | 57 (8.8%) | 25 (4.4%)* | 12 (3.4%) | 13 (6.0%) |
| 30-day reoperation | 15 (1.8%) | 4 (2.4%) | 11 (1.7%) | 9 (1.6%) | 6 (1.7%) | 3 (1.4%) |
| Late outcome | ||||||
| Late all-cause mortality | 136 (16.7%) | 22 (13.2%) | 114 (17.6%) | 92 (16.2%) | 46 (13%) | 46 (21.4%)‡ |
| Late MV reoperation | 3 (0.4%) | 0 (0%) | 3 (0.5%) | 5 (0.9%) | 4 (1.1%) | 1 (0.5%) |
[i] MV: mitral valve.
* Comparing RHD and non-RHD, p < 0.05.
† Comparing repair and replacement in RHD, p < 0.05.
‡ Comparing repair and replacement in non-RHD repair, p < 0.05.
Table 3
Factors associated with 30-day mortality after rheumatic mitral valve surgery.
| VARIABLE | UNIVARIATE | MULTIVARIATE | ||||
|---|---|---|---|---|---|---|
| OR | 95%CI | p-VALUE | OR | 95%CI | p-VALUE | |
| Age > 60 Years | 2.82 | 1.25–6.38 | 0.018* | |||
| Female | 0.60 | 0.37–0.98 | 0.056 | 0.55 | 0.33–0.91 | 0.020* |
| BMI > 25.0 kg/m2 | 0.53 | 0.28–1.04 | 0.082 | 0.53 | 0.27–1.04 | 0.064 |
| Atrial Fibrillation | 2.86 | 1.40–5.86 | 0.004* | 2.86 | 1.39–5.89 | 0.004* |
| Hypertension | 0.99 | 0.44–2.24 | 1.00 | |||
| NYHA fc III–IV | 1.75 | 1.06–2.89 | 0.036* | |||
| Infective Endocarditis | 1.05 | 0.24–4.58 | 1.00 | |||
| Concomitant AVR | 1.26 | 0.75–2.12 | 0.454 | |||
| Concomitant TVr | 1.37 | 0.82–2.28 | 0.276 | |||
| Concomitant CABG | 2.48 | 0.91–6.77 | 0.078 | |||
| ≥3 surgical procedures | 1.41 | 0.77–2.57 | 0.346 | |||
| History of PTMC | 1.93 | 0.42–8.88 | 0.316 | |||
| LVEF < 30% | 1.76 | 0.21–14.78 | 0.473 | |||
| TAPSE < 17 mm | 1.47 | 0.90–2.39 | 0.155 | |||
| TVG ≥ 50 mmHg | 0.91 | 0.55–1.51 | 0.811 | |||
| Mitral Stenosis | 1.47 | 0.90–2.39 | 0.154 | |||
| Mitral Regurgitation | 0.70 | 0.36–1.36 | 0.358 | |||
| Mixed MV Disease | 0.84 | 0.50–1.40 | 0.574 | |||
| Mitral valve Repair | 0.95 | 0.51–1.75 | 0.984 | |||
| Euroscore II > 4 | 3.32 | 1.70–6.49 | 0.001* | 3.86 | 1.93–7.74 | <0.0001* |
[i] BMI: body mass index, AVR: Aortic Valve Replacement, TVr: Tricuspid Valve repair, CABG: Coronary Artery Bypass Grafting, PTMC: percutaneous transvenous mitral commissurotomy, LVEF: Left Ventricular Ejection Fraction, TVG: Tricuspid Valve Gradient. Data were analysed using the Chi-Square Test and Logistic Regression for the multivariate analysis. * Statistically significant (p < 0.05).
Table 4
Factors associated with 30-day mortality after non-rheumatic mitral valve surgery.
| VARIABLE | UNIVARIATE | MULTIVARIATE | ||||
|---|---|---|---|---|---|---|
| OR | 95%CI | p-VALUE | OR | 95%CI | p-VALUE | |
| Age > 60 Years | 3.36 | 1.48–7.61 | 0.005* | 3.06 | 1.24–7.53 | 0.015* |
| Female | 0.52 | 0.19–1.40 | 0.271 | |||
| BMI > 25.0 kg/m2 | 0.17 | 0.04–0.72 | 0.012* | 0.22 | 0.05–0.95 | 0.042* |
| Atrial Fibrillation | 4.11 | 1.78–9.49 | 0.001* | 3.06 | 1.25–7.48 | 0.014* |
| COPD | 22.58 | 1.37–372.04 | 0.086 | |||
| CKD (CCL < 50 ml/m2) | 2.38 | 1.05–5.36 | 0.057 | |||
| NYHA fc III-IV | 2.28 | 0.99–5.25 | 0.075 | 2.65 | 1.06–6.65 | 0.038* |
| Infective Endocarditis | 1.04 | 0.24–4.55 | 1.000 | |||
| Concomitant AVR | 1.87 | 0.53–6.52 | 0.409 | |||
| Concomitant TVr | 2.96 | 1.32–6.65 | 0.012* | |||
| Concomitant CABG | 2.07 | 0.84–5.10 | 0.160 | |||
| ≥3 surgical procedures | 16.83 | 5.54–51.11 | <0.001* | 15.57 | 4.46–54.31 | <0.001* |
| TAPSE < 17 mm | 1.31 | 0.44–3.93 | 0.548 | |||
| TVG ≥ 50 mmHg | 1.75 | 0.74–4.16 | 0.300 | |||
| Mitral valve Repair | 0.55 | 0.25–1.22 | 0.200 | |||
| Euroscore II > 4 | 3.86 | 1.36–10.95 | 0.020* | |||
[i] BMI: body mass index, AVR: Aortic Valve Replacement, TVr: Tricuspid Valve repair, CABG: Coronary Artery Bypass Grafting, PTMC: percutaneous transvenous mitral commissurotomy, LVEF: Left Ventricular Ejection Fraction, TVG: Tricuspid Valve Gradient. Data were analysed using the Chi-Square Test and Logistic Regression for the multivariate analysis. * Statistically significant (p < 0.05).
Table 5
Factors associated with late mortality in patients with rheumatic MV surgery.
| VARIABLE | UNIVARIATE | MULTIVARIATE | ||||
|---|---|---|---|---|---|---|
| HR | 95%CI | p-VALUE | HR | 95%CI | p-VALUE | |
| Age > 60 Years | 2.72 | 1.56–4.74 | <0.001* | 2.17 | 1.23–3.81 | 0.007* |
| Female | 0.57 | 0.41–0.80 | <0.001* | 0.58 | 0.41–0.83 | 0.002* |
| BMI > 25.0 kg/m2 | 0.91 | 0.61–1.35 | 0.633 | |||
| Atrial Fibrillation | 3.27 | 1.91–5.59 | <0.001* | 3.42 | 2.0–5.87 | <0.001* |
| DM with Insulin. n (%) | 1.99 | 0.49–8.03 | 0.335 | |||
| Hypertension | 0.96 | 0.54–1.70 | 0.881 | |||
| NYHA fc III-IV | 1.78 | 1.25–2.54 | 0.001* | 1.62 | 1.13–2.32 | 0.008* |
| Infective Endocarditis | 0.74 | 0.24–2.32 | 0.602 | |||
| Concomitant AVR | 1.59 | 1.13–2.25 | 0.008* | 1.60 | 1.12–2.28 | 0.010 * |
| Concomitant TVr | 1.03 | 0.74–1.45 | 0.850 | |||
| Concomitant CABG | 1.19 | 0.49–2.91 | 0.702 | |||
| ≥3 surgical procedures | 1.56 | 1.04–2.35 | 0.031* | |||
| History of PTMC | 1.97 | 0.73–5.32 | 0.182 | 2.70 | 0.99–7.39 | 0.053 |
| LVEF < 30% | 2.17 | 0.54–8.79 | 0.276 | |||
| TAPSE < 17 mm | 1.34 | 0.96–1.88 | 0.086 | |||
| TVG ≥ 50 mmHg | 0.93 | 0.65–1.32 | 0.687 | |||
| Mitral Stenosis | 1.22 | 0.87–1.70 | 0.258 | |||
| Mitral Regurgitation | 0.85 | 0.55–1.32 | 0.470 | |||
| Mixed mitral Valve Disease | 0.91 | 0.64–1.29 | 0.586 | |||
| Mitral valve Repair | 0.77 | 0.49–1.22 | 0.266 | |||
| Euroscore II > 4.0 | 2.56 | 1.59–4.12 | <0.001* | 2.08 | 1.26–3.44 | 0.004* |
[i] BMI: body mass index, AVR: Aortic Valve Replacement, TVr: Tricuspid Valve repair, CABG: Coronary Artery Bypass Grafting, PTMC: percutaneous transvenous mitral commissurotomy, LVEF: Left Ventricular Ejection Fraction, TVG: Tricuspid Valve Gradient. Data were analysed by Cox Regression. *Statistically significant (p-value < 0.05).
Table 6
Factors associated with late mortality in patients with non-rheumatic MV surgery.
| VARIABLE | UNIVARIATE | MULTIVARIATE | ||||
|---|---|---|---|---|---|---|
| HR | 95%CI | p-VALUE | HR | 95%CI | p-VALUE | |
| Age > 60 Years | 1.86 | 1.19–2.90 | 0.006* | 1.50 | 0.95–2.38 | 0.085 |
| Female | 0.55 | 0.33–0.91 | 0.020* | 0.56 | 0.33–0.94 | 0.029* |
| BMI > 25.0 kg/m2 | 0.68 | 0.42–1.07 | 0.097 | |||
| Atrial Fibrillation | 2.75 | 1.82–4.14 | <0.001* | 2.31 | 1.51–3.52 | <0.001* |
| COPD | 3.50 | 0.49–25.19 | 0.214 | |||
| CKD (CCL < 50 ml/m2) | 1.92 | 1.26–2.92 | 0.002* | 1.58 | 1.01–2.48 | 0.046* |
| NYHA fc III-IV | 2.12 | 1.38–3.27 | 0.001* | 2.27 | 1.47–3.53 | <0.0001* |
| Infective Endocarditis | 0.38 | 0.12–1.18 | 0.094 | 0.37 | 0.11–1.18 | 0.092 |
| Concomitant AVR | 1.86 | 0.99–3.49 | 0.054 | |||
| Concomitant TVr | 1.86 | 1.20–2.87 | 0.005* | |||
| Concomitant CABG | 1.66 | 1.03–2.67 | 0.039* | |||
| ≥3 surgical procedures | 6.06 | 3.03–12.13 | <0.001* | 3.97 | 1.93–8.18 | <0.001* |
| TAPSE < 17 mm | 1.86 | 1.13–3.09 | 0.016* | |||
| TVG ≥ 50 mmHg | 1.15 | 0.71–1.88 | 0.566 | |||
| Mitral valve Repair | 0.58 | 0.38–0.87 | 0.009* | 0.65 | 0.42–0.99 | 0.047* |
| Euroscore II > 4 | 2.76 | 1.53–4.96 | 0.001* | |||
[i] BMI: body mass index, AVR: Aortic Valve Replacement, TVr: Tricuspid Valve repair, CABG: Coronary Artery Bypass Grafting, PTMC: percutaneous transvenous mitral commissurotomy, LVEF: Left Ventricular Ejection Fraction, TVG: Tricuspid Valve Gradient. Data were analysed by Cox Regression. *Statistically significant (p-value < 0.05).
Figure 4
Cumulative survival, comparison between MVr and MVR in the RHD group.
Figure 5
Cumulative survival, comparison between MVr and MVR in the non-RHD group.