Combined Mitral and Aortic Valve Replacement for Rheumatic Heart Disease: Fifteen-Year Follow Up and Long-Term Results

Background and aim of the study: Rheumatic heart disease is the most common cause of multivalvular disease in developing countries. Unless aggressive and timely intervention in the form of valve replacement is pursued, the condition progresses rapidly to disability and death. Combined mitral-aortic valve replacement represents a major technical challenge, and carries high early and late mortality rates. Methods: The course of 382 consecutive hospital survivors of combined mitral-aortic valve replacement, operated on between January 1992 and December 2006, was reviewed. The valve of choice for the mitral position was the Starr-Edwards (98%), while Medtronic-Hall and St. Jude Medical valves were favored for the aortic position (81%). Results: The mean postoperative follow up was 64.8 ± 53.9 months, with a total cumulative follow up of 1,792 patient-years (pt-yr); the follow up was 87% complete (n = 332). Late death occurred in 29 patients (8.7%). Long-term survival at five, 10 and 15 years was 92%, 78% and 45%, respectively, with a mean survival of 153 months. The linearized rates of thromboembolism, anticoagulation-related hemorrhage and prosthetic valve endocarditis were 1.06, 2.41 and 0.334% per pt-yr, respectively. Conclusion: Among the rheumatic population, double valve replacement offers excellent symptomatic improvement and favorable late survival. Hemodynamic superiority and thromboresistance are the normal selection criteria for these prostheses, although the surgeon’s experience, and the ease of insertion, availability and cost of the valve also play important roles. A strict adherence to optimal anticoagulation levels optimizes protection against thromboembolism and anticoagulation-related hemorrhage, and helps to provide the patient with a good quality life.