Conservative mitral valve surgery: has the progress changed the indications?

Abstract

Cardiac valve replacement still means replacement of one disease by another. Thromboembolic complications in the case of mechanical valves, as well as restenosing and calcification of bioprostheses, are major causes of further morbidity and mortality. Hence valve reconstruction, where indicated, represents an attractive alternative. In the late 1960s mitral valve reconstruction received new impetus from Carpentier through a number of techniques based on a multifactorial concept of mitral valve pathology. Although initially other surgery groups showed little enthusiasm for this approach, more recently a marked trend towards valve-preserving surgery has been observable. The experience of Carpentier and others, including our own, has provided better medium and long-term results with mitral reconstruction compared to valve replacement, in regard to all indices of valve function except the reoperation rate, which is higher after valve reconstruction. It can also be shown that the results of reconstruction of rheumatically damaged valves are less good than in non-rheumatic valve diseases and in particular myxomatous mitral valves. On the other hand, rheumatic populations are as a rule young and show poor compliance in taking medication, especially anticoagulants, which is why in these cases valve replacement is even less attractive. Although valve reconstruction is subject to a marked learning curve, it is possible to take advantage of others' experience. Several new surgical techniques have been developed and others are being adapted to new needs. Together these two factors have helped to make valve reconstruction a more reliable and reproducible method. The improved results have changed the indication for valve replacement, in that nowadays an attempt is made to reconstruct the valve before left ventricular hemodynamics are irreversibly damaged.(ABSTRACT TRUNCATED AT 250 WORDS)