Long-term Echocardiographic Outcomes of Patients after Mitral and Aortic Valve Replacement and their Clinical Significance_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

LIANGChun-shui ¹ , TANGHong ² , RENRong ¹ , HEFan ¹ , DENGYun-dan ¹ ,  XIAOXi-jun ¹

1. Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu 610041, P. R. China;
2. Department of Cardiology, West China Hospital, Sichuan University, Chengdu 610041, P. R. China;

Corresponding author：

XIAOXi-jun, Email: xijunxiao2009@hotmail.com

Keywords：

Double valve replacement; Postoperative follow-up; Echocardiography

DOI：

10.7507/1007-4848.20140093

Video：

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Objective To investigate long-term echocardiographic outcomes of patients after mitral and aortic valve replacement and their clinical significance. Methods A total of 204 patients who underwent mitral and aortic valve replacement from January 1999 to June 2008 in West China Hospital of Sichuan University, and had been followed up with echocardiography for longer than 5 years were enrolled in this study. There were 60 male and 144 female patients with their age ranging from 15 to 74 (48.42±11.00)years. Postoperative follow-up time was 5 to 13 (6.34±2.05)years. Preoperative and follow-up echocardiographic results were compared. Results Compared with preoperative results, postoperative left atrial diameter (LA)and left ventricular diameter (LV)significantly decreased (P < 0.05), while right ventricular diameter (RV), left ventricular ejection fraction (LVEF)and left ventricular fractional shortening (LVFS)significantly increased (P < 0.05). Right atrial diameter (RA)did not change significantly (P > 0.05). In the patients mainly with mitral stenosis preoperatively, postoperative LA, LV, left atrial area (LAA), left atrial volume (LAV), mitral mean pressure gradient (MPGmv), velocity time integral (VTImv)and pressure half time (PHTmv)significantly decreased (P < 0.05), while mitral effective orifice area (EOAmv)and effective orifice area index (EOAImv)increased significantly (P < 0.05), but peak E velocity (Emv)did not change significantly (P > 0.05). In the patients mainly with mitral regurgitation preoperatively, postoperative LA and LV decreased significantly (P < 0.05), while LAA, LAV, MPGmv, VTImv, PHTmv, EOAmv and EOAImv did not change significantly (P > 0.05). In the patients mainly with aortic stenosis preoperatively, postoperative LV, interventricular septal thickness (IVS), left ventricular mass (LVM), left ventricular mass index (LVMI), aortic peak forward flow velocity(Vav)and mean pressure gradient (MPGav)significantly decreased (P < 0.05), while aortic effective orifice area (EOAav)and effective orifice area index (EOAIav)significantly increased (P < 0.05), but left ventricular posterior wall thickness (LVPW)did not change significantly (P > 0.05). In the patients mainly with aortic regurgitation preoperatively, postoperative LV, LVM, LVMI, EOAav and EOAIav decreased significantly (P < 0.05), while Vav and MPGav increased significantly (P < 0.05), but IVS and LVPW did not change significantly (P > 0.05). In mitral position, compared with patients with 25 mm prosthesis, Emv, MPGmv and VTImv of patients with 27 mm prosthesis were significantly smaller (P < 0.05), but there was no statistical difference in PHTmv, EOAmv or EOAImv between the 2 groups (P > 0.05). In aortic position, compared with patients with 21mm prosthesis, Vav, MPGav and VTIav of patients with 23 mm prosthesis were significantly smaller (P < 0.05), while EOAav and EOAIav were significantly larger (P < 0.05). In mitral position, 38 patients (21.3%)had moderate prothesis-patient mismatch (PPM)and 4 patients (2.3%)had severe PPM. In aortic position, 50 patients (24.5%)had moderate PPM and 43 patients (21.1%)had severe PPM. Consti-tuent ratio of long-term tricuspid regurgitation (TR)degree of patients after tricuspid valvuloplasty (TVP)significantly improved (P < 0.05), but constituent ratio of long-term TR degree of patients without TVP significantly deteriorated (P < 0.05). Conclusions Left ventricular function and hemodynamic outcomes in the long term are significantly better than preoperative results after double valve replacement, but they are still far from normal. PPM in aortic position is more severe than that in mitral position. Since residual or aggravated TR is very common in the long term, concomitant TVP should be considered more positively for patients undergoing surgery for left-sided valvular disease.

Citation： LIANGChun-shui, TANGHong, RENRong, HEFan, DENGYun-dan, XIAOXi-jun. Long-term Echocardiographic Outcomes of Patients after Mitral and Aortic Valve Replacement and their Clinical Significance. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2014, 21(3): 336-343. doi: 10.7507/1007-4848.20140093 Copy

1.	王吉耀, 廖二元, 胡品津, 主编.内科学.北京:人民卫生出版社, 2010. 299-300.
2.	肖锡俊, 朱喜亮, 唐红, 等.二尖瓣置换术后患者远期超声心动图特征及其临床意义.中国胸心血管外科临床杂志, 2013, 20 (2):148-151.
3.	Bojar RM, Chief Editor. Adult cardiac surgery. Boston:Blackwell Scientific Publications, 1992. 155-156.
4.	马量, 叶丁生, 倪一鸣, 等.心瓣膜置换术1407例临床分析.中国胸心血管外科临床杂志, 2002, 9 (1):54-55.
5.	张宝仁, 邹良建, 徐志云, 等.风湿性瓣膜病二尖瓣与主动脉瓣置换术1154例长期效果分析.中华外科杂志, 2003, 41 (4):243-246.
6.	马瑞彦, 肖颖彬, 钟前进, 等.风湿性心瓣膜病伴心房颤动546例临床分析.中国胸心血管外科临床杂志, 2007, 14 (6):473-475.
7.	Pibarot P, Dumesnil JG. Prosthetic heart valves:selection of the optimal prosthesis and long-term management. Circulation, 2009, 119 (7):1034-1048.
8.	Colombo T, Russo C, Ciliberto GR, et al. Tricuspid regurgitation secondary to mitral valve disease:tricuspid annulus function as guide to tricuspid valve repair. Cardiovasc Surg, 2001, 9 (4):369-377.
9.	Huysmans HA, David TE, Westady S, Chief Editor. Stentless biop-rosthese. Oxford UK:Esis Medical Media Ltd, 1995. 727.
10.	唐红, 肖锡俊, 李嘉.风湿性二尖瓣狭窄患者左心房流体力学观察.中国胸心血管外科临床杂志, 2004, 11 (1):42-44.
11.	David S, Marc P, Goldbach M, et al. Hemodynamics and early clinical performance of the St. Jude medical regent mechanical aortic valve. Ann Thorac Surg, 2002, 74 (6):2003-2009.
12.	Minardi G, Pino PG, Manzara CC, et al. Early doppler-echocardiography evaluation of 597 prosthetic aortic valves. J Cardiovasc Med, 2010, 11 (4):229-233.
13.	Rahimtoola SH. The problem of valve prosthesis-patient mismatch. Circulation, 1978, 58 (1):20-24.
14.	Blais C, Dumesnil JG, Baillot R, et al. Impact of valve prosthesis-patient mismatch on short-term mortality after aortic valve replacement. Circulation, 2003, 108 (8):983-988.
15.	Mohty D, Malouf JF, Girard SE, et al. Impact of prosthesis-patient mismatch on long-term survival in patients with small St Jude Medical mechanical prostheses in the aortic position. Circulation, 2006, 113 (3):420-426.
16.	Ruel M, Al-Faleh H, Kulik A, et al. Prosthesis-patient mismatch after aortic valve replacement predominantly affects patients with preexisting left ventricular dysfunction:effect on survival, freedom from heart failure, and left ventricular mass regression. J Thorac Cardiovasc Surg, 2006, 131 (5):1036-1044.
17.	Tasca G, Brunelli F, Cirillo M, et al. Impact of valve prosthesis-patient mismatch on left ventricular mass regression following aortic valve replacement. Ann Thorac Surg, 2005, 79 (2):505-510.
18.	Milano AD, De Carlo M, Mecozzi G, et al. Clinical outcome in patients with 19-mm and 21-mm St. Jude aortic prostheses:compa-rison at long-term follow-up. Ann Thorac Surg, 2002, 73 (1):37-43.
19.	Pibarot P, Dumesnil JG, Lemieux M, et al. Impact of prosthesis-patient mismatch on hemodynamic and symptomatic status, morbidity and mortality after aortic valve replacement with a bioprosthetic heart valve. J Heart Valve Dis, 1998, 7 (2):211-218.
20.	Koene BM, Soliman Hamad MA, Bouma W, et al. Impact of prosthesis-patient mismatch on early and late mortality after aortic valve replacement. J Cardiothorac Surg, 2013, 8 (1):96.
21.	Li M, Dumesnil JG, Mathieu P, et al. Impact of valve prosthesis-patient mismatch on pulmonary arterial pressure after mitral valve replacement. J Am Coll Cardiol, 2005, 45 (7):1034-1040.
22.	Lam BK, Chan V, Hendry P, et al. The impact of patient-prosthesis mismatch on late outcomes after mitral valve replacement. J Thorac Cardiovasc Surg, 2007, 133 (6):1464-1473.
23.	Magne J, Mathieu P, Dumesnil JG, et al. Impact of prosthesis-patient mismatch on survival after mitral valve replacement. Circulation, 2007, 115 (11):1417-1425.
24.	Jamieson WR, Germann E, Ye J, et al. Effect of prosthesis-patient mismatch on long-term survival with mitral valve replacement:asse-ssment to 15 years. Ann Thorac Surg, 2009, 87 (4):1135-1141.
25.	Matsuura K, Mogi K, Aoki C, et al. Prosthesis-patient mismatch after mitral valve replacement stratified by referred and measured effective valve area. Ann Thorac Cardiovasc Surg, 2011, 17 (2):153-159.
26.	Aziz A, Lawton JS, Maniar HS, et al. Factors affecting survival after mitral valve replacement in patient with prosthesis-patient mism-atch. Ann Thorac Surg, 2010, 90 (4):1202-1210.
27.	Levinson JR, Akins CW, Buckley MJ, et al. Octogenarians with aortic stenosis. Outcome after aortic valve replacement. Circulation, 1989, 80 (31):149-156.
28.	Sakamoto Y, Hashimoto K, Okuyama H, et al. Prevalence and avoidance of prosthesis-patient mismatch in aortic valve replacement in small adults. Ann Thorac Surg, 2006, 81 (4):1305-1309.
29.	Braunwald NS, Ross J Jr, Morrow AG. Conservative management of tricuspid regurgitation in patients undergoing mitral valve replacement. Circulation, 1967, 35 (4 Suppl):I63-I69.
30.	Mccarthy PM, Bhudia SK, Rajeswaran J, et al. Tricuspid valve repair:durability and risk factor for failure. J Thorac Cardiavasc Surg, 2004, 127 (3):674-685.
31.	Rivera R, Duran E, Ajuria M, et al. Carpentier's flexible ring versus De Vega's annuloplasty:a prospective randomized study. J Thorac Cardiavasc Surg, 1985, 89 (2):196-203.
32.	McCarthy PM, Sales VL. Evolving indications for tricuspid valve surgery. Curr Treat Options Cardiovasc Med, 2010, 12 (6):587-597.
33.	Vahanian A, Baumgartner H, Bax J, et al. Guidelines on the manag-ement of valvular heart disease. Eur Heart J, 2007, 28 (2), 230-268.
34.	Robert O, Blase A, Chatterjee K, et al. ACC/AHA 2006 Guidelines for the management of patients with valvular heart disease. Circulation, 2006, 114 (5):84-231.
35.	Kim JB, Yoo DG, Kim GS, et al. Mild-to-moderate functional tricuspid regurgitation in patients undergoing valve replacement for rheumatic mitral disease:the influence of tricuspid valve repair on clinical and echocardiographic outcomes. Heart, 2012, 98 (1):24-30.
36.	Khoo JP, Davies JE, Ang KL, et al. Differences in performance of five types of aortic valve prostheses:haemodynamic assessment by dobutamine stress echocardiography. Heart, 2013, 99 (1):41-47.

1. 王吉耀, 廖二元, 胡品津, 主编.内科学.北京:人民卫生出版社, 2010. 299-300.
2. 肖锡俊, 朱喜亮, 唐红, 等.二尖瓣置换术后患者远期超声心动图特征及其临床意义.中国胸心血管外科临床杂志, 2013, 20 (2):148-151.
3. Bojar RM, Chief Editor. Adult cardiac surgery. Boston:Blackwell Scientific Publications, 1992. 155-156.
4. 马量, 叶丁生, 倪一鸣, 等.心瓣膜置换术1407例临床分析.中国胸心血管外科临床杂志, 2002, 9 (1):54-55.
5. 张宝仁, 邹良建, 徐志云, 等.风湿性瓣膜病二尖瓣与主动脉瓣置换术1154例长期效果分析.中华外科杂志, 2003, 41 (4):243-246.
6. 马瑞彦, 肖颖彬, 钟前进, 等.风湿性心瓣膜病伴心房颤动546例临床分析.中国胸心血管外科临床杂志, 2007, 14 (6):473-475.
7. Pibarot P, Dumesnil JG. Prosthetic heart valves:selection of the optimal prosthesis and long-term management. Circulation, 2009, 119 (7):1034-1048.
8. Colombo T, Russo C, Ciliberto GR, et al. Tricuspid regurgitation secondary to mitral valve disease:tricuspid annulus function as guide to tricuspid valve repair. Cardiovasc Surg, 2001, 9 (4):369-377.
9. Huysmans HA, David TE, Westady S, Chief Editor. Stentless biop-rosthese. Oxford UK:Esis Medical Media Ltd, 1995. 727.
10. 唐红, 肖锡俊, 李嘉.风湿性二尖瓣狭窄患者左心房流体力学观察.中国胸心血管外科临床杂志, 2004, 11 (1):42-44.
11. David S, Marc P, Goldbach M, et al. Hemodynamics and early clinical performance of the St. Jude medical regent mechanical aortic valve. Ann Thorac Surg, 2002, 74 (6):2003-2009.
12. Minardi G, Pino PG, Manzara CC, et al. Early doppler-echocardiography evaluation of 597 prosthetic aortic valves. J Cardiovasc Med, 2010, 11 (4):229-233.
13. Rahimtoola SH. The problem of valve prosthesis-patient mismatch. Circulation, 1978, 58 (1):20-24.
14. Blais C, Dumesnil JG, Baillot R, et al. Impact of valve prosthesis-patient mismatch on short-term mortality after aortic valve replacement. Circulation, 2003, 108 (8):983-988.
15. Mohty D, Malouf JF, Girard SE, et al. Impact of prosthesis-patient mismatch on long-term survival in patients with small St Jude Medical mechanical prostheses in the aortic position. Circulation, 2006, 113 (3):420-426.
16. Ruel M, Al-Faleh H, Kulik A, et al. Prosthesis-patient mismatch after aortic valve replacement predominantly affects patients with preexisting left ventricular dysfunction:effect on survival, freedom from heart failure, and left ventricular mass regression. J Thorac Cardiovasc Surg, 2006, 131 (5):1036-1044.
17. Tasca G, Brunelli F, Cirillo M, et al. Impact of valve prosthesis-patient mismatch on left ventricular mass regression following aortic valve replacement. Ann Thorac Surg, 2005, 79 (2):505-510.
18. Milano AD, De Carlo M, Mecozzi G, et al. Clinical outcome in patients with 19-mm and 21-mm St. Jude aortic prostheses:compa-rison at long-term follow-up. Ann Thorac Surg, 2002, 73 (1):37-43.
19. Pibarot P, Dumesnil JG, Lemieux M, et al. Impact of prosthesis-patient mismatch on hemodynamic and symptomatic status, morbidity and mortality after aortic valve replacement with a bioprosthetic heart valve. J Heart Valve Dis, 1998, 7 (2):211-218.
20. Koene BM, Soliman Hamad MA, Bouma W, et al. Impact of prosthesis-patient mismatch on early and late mortality after aortic valve replacement. J Cardiothorac Surg, 2013, 8 (1):96.
21. Li M, Dumesnil JG, Mathieu P, et al. Impact of valve prosthesis-patient mismatch on pulmonary arterial pressure after mitral valve replacement. J Am Coll Cardiol, 2005, 45 (7):1034-1040.
22. Lam BK, Chan V, Hendry P, et al. The impact of patient-prosthesis mismatch on late outcomes after mitral valve replacement. J Thorac Cardiovasc Surg, 2007, 133 (6):1464-1473.
23. Magne J, Mathieu P, Dumesnil JG, et al. Impact of prosthesis-patient mismatch on survival after mitral valve replacement. Circulation, 2007, 115 (11):1417-1425.
24. Jamieson WR, Germann E, Ye J, et al. Effect of prosthesis-patient mismatch on long-term survival with mitral valve replacement:asse-ssment to 15 years. Ann Thorac Surg, 2009, 87 (4):1135-1141.
25. Matsuura K, Mogi K, Aoki C, et al. Prosthesis-patient mismatch after mitral valve replacement stratified by referred and measured effective valve area. Ann Thorac Cardiovasc Surg, 2011, 17 (2):153-159.
26. Aziz A, Lawton JS, Maniar HS, et al. Factors affecting survival after mitral valve replacement in patient with prosthesis-patient mism-atch. Ann Thorac Surg, 2010, 90 (4):1202-1210.
27. Levinson JR, Akins CW, Buckley MJ, et al. Octogenarians with aortic stenosis. Outcome after aortic valve replacement. Circulation, 1989, 80 (31):149-156.
28. Sakamoto Y, Hashimoto K, Okuyama H, et al. Prevalence and avoidance of prosthesis-patient mismatch in aortic valve replacement in small adults. Ann Thorac Surg, 2006, 81 (4):1305-1309.
29. Braunwald NS, Ross J Jr, Morrow AG. Conservative management of tricuspid regurgitation in patients undergoing mitral valve replacement. Circulation, 1967, 35 (4 Suppl):I63-I69.
30. Mccarthy PM, Bhudia SK, Rajeswaran J, et al. Tricuspid valve repair:durability and risk factor for failure. J Thorac Cardiavasc Surg, 2004, 127 (3):674-685.
31. Rivera R, Duran E, Ajuria M, et al. Carpentier's flexible ring versus De Vega's annuloplasty:a prospective randomized study. J Thorac Cardiavasc Surg, 1985, 89 (2):196-203.
32. McCarthy PM, Sales VL. Evolving indications for tricuspid valve surgery. Curr Treat Options Cardiovasc Med, 2010, 12 (6):587-597.
33. Vahanian A, Baumgartner H, Bax J, et al. Guidelines on the manag-ement of valvular heart disease. Eur Heart J, 2007, 28 (2), 230-268.
34. Robert O, Blase A, Chatterjee K, et al. ACC/AHA 2006 Guidelines for the management of patients with valvular heart disease. Circulation, 2006, 114 (5):84-231.
35. Kim JB, Yoo DG, Kim GS, et al. Mild-to-moderate functional tricuspid regurgitation in patients undergoing valve replacement for rheumatic mitral disease:the influence of tricuspid valve repair on clinical and echocardiographic outcomes. Heart, 2012, 98 (1):24-30.
36. Khoo JP, Davies JE, Ang KL, et al. Differences in performance of five types of aortic valve prostheses:haemodynamic assessment by dobutamine stress echocardiography. Heart, 2013, 99 (1):41-47.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Long-term Echocardiographic Outcomes of Patients after Mitral and Aortic Valve Replacement and their Clinical Significance

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