Survival and long-term outcomes after concomitant mitral and aortic valve replacement in patients with rheumatic heart disease

INTRODUCTION: Double valve replacement (DVR) with a mechanical prosthesis is associated with a higher risk of mortality. We planned to study the survival rate, early and late mortality and major adverse cardiac and cerebrovascular events (MACCE) in patients undergoing DVR for rheumatic heart disease, with various generations of prosthetic valves ranging from ball in cage to bileaflet prosthesis and tilting disc valves. MATERIALS AND METHODOLOGY: We followed up 277 patients with rheumatic heart disease who underwent DVR between August 1999 and November 2009, retrospectively, at Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram. Two hundred and fifty-nine patients were followed up for a minimum period of 10 years, and the follow-up period varied between 10 and 20 years. Eighteen patients were lost to follow-up after the surgery and could not be contacted. Their data was included till the time they appeared for follow-up last, for survival analysis. Survival analysis was carried out using the life table method to calculate the freedom from reoperation, survival rates and freedom from MACCE at 1 year, 5 years and 10 years post-DVR. RESULTS: The median duration of hospital stay was 8 days. The number of patients with stroke was 11 (4.26%), 21 (8.7%) and 29 (12%) at the end of 1 year, 5 years, and 10 years, respectively. A total of 5 (2%) patients underwent reoperation by the end of 10 years. Seven patients died either in hospital or in the first 30 days following operation, making the early mortality 2.5%. At the end of 1 year, a total of 16 patients (5.8%) died. The mortality at the end of 5 years was 6.8% (19 patients), and at the end of 10 years, it was 7.2% (20 patients). The survival rate of the study population was 94.9%, 93.02% and 93.02% at the completion of 1 year, 5 years and 10 years, respectively. The freedom from MACCE was 93.8%, 88.6% and 85% at 1 year, 5 years and 10 years, respectively. The freedom from re-operation was 98% at 10 years. Kaplan-Meier analysis showed an overall survival time of 226.3 months in the entire study population. The mean survival time in males was 227.5 months and in females was 206.3 months, with no statistically significant difference between the two. Univariate logistic regression analysis revealed an association with mortality when DVR was combined with concomitant tricuspid valve repair procedures, with an odds ratio of 4.5 (p value 0.005). Multivariate logistic regression analysis also showed an association with mortality when tricuspid valve procedures were combined with DVR with an odds ratio of 5.25 (p value 0.003). CONCLUSION: The operative mortality and morbidity for DVR have been significantly reduced with advancements in operative techniques, myocardial preservation and postoperative care. Patients can have an improved functional status following surgery, with good rates of freedom from re-operation and MACCE.