The fate of aortic valve after rheumatic mitral valve surgery



      Deterioration of the native aortic valve function by a late progression of rheumatic disease is not infrequent in patients who underwent rheumatic mitral valve surgery; however, this phenomenon has not been clearly quantified.


      A total of 1155 consecutive patients (age 52.0 ± 12.9 years; 807 female) who underwent rheumatic mitral valve surgery without concomitant aortic valve surgery from 1997 to 2015 were enrolled. The primary end point was the composite of progression to severe aortic valve dysfunction or a requirement of subsequent aortic valve replacements during follow-up. To determine the risk factors of the primary outcome, we performed the generalized linear mixed model.


      The baseline severities of aortic valve were none to trivial in 880 patients (76.2%), mild in 256 patients (22.2%), and moderate in 19 patients (1.6%). The latest 1062 echocardiographic assessments (91.9%; median, 81.2 postoperative months; interquartile range, 37.3-132.1 months) demonstrated 26 cases (0.33%/patient-year) meeting the primary end point during follow-up. Cumulative incidence of the primary end point at 10 years was 0.4% ± 0.3% and 7.4% ± 2.5% depending on the presence of mild or greater aortic valve dysfunction at baseline (P < .01). In multivariable analyses, aortic valve peak pressure gradient (odds ratio, 1.14; 95% confidence interval, 1.10-1.20), aortic regurgitation degree (mild over none: odds ratio, 3.26; 95% confidence interval, 1.15-9.23), and time (odds ratio, 1.30; 95% confidence interval 1.19-1.41) were significantly associated with the occurrence of the primary end point.


      Progression of severe aortic valve dysfunction and the need for aortic valve replacement are uncommon in patients undergoing rheumatic mitral valve surgery. However, such events were relatively common among those with mild or greater aortic valve dysfunction at the time of mitral valve surgery.

      Graphical abstract

      Key Words

      Abbreviations and Acronyms:

      AR (aortic regurgitation), AS (aortic stenosis), AV (aortic valve), AVD (aortic valve dysfunction), AVR (aortic valve replacement), CI (confidence interval), MV (mitral valve), OR (odds ratio)
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      Linked Article

      • Commentary: The aortic valve after rheumatic mitral valve surgery. Remarkably stable!
        The Journal of Thoracic and Cardiovascular SurgeryVol. 165Issue 2
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          Acute rheumatic fever is still endemic in most low- and middle-income countries, and rheumatic heart valve disease, one of the most important causes of mortality, is especially prevalent in young patients, with a mean age of 20 to 25 years in patients who reach surgery. The disease is much rarer in developed countries of the Western world and some parts of Asia, but in these regions, there remain many patients who have late consequences of the acute phase of rheumatic fever that occurred in their infancy or youth 4 or 5 decades ago.
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      • Commentary: Methods in observational studies in valve surgery, when time matters
        The Journal of Thoracic and Cardiovascular SurgeryVol. 165Issue 2
        • Preview
          In this issue of the Journal, Kim and colleagues1 provide insightful information on the fate of the aortic valve in patients with rheumatic disease undergoing surgery of the mitral valve. Their main finding is that progression of aortic valve disease and the need for aortic valve replacement are relatively uncommon in these patients, with the risk correlated with the severity of the aortic valve dysfunction at the time of the mitral operation.
        • Full-Text
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