Results
Between January 2010 and February 2020, 556 female patients underwent
mitral valve surgery at our center, of whom 355 (64%) were subjected
to MVR and were included in the study, and 201 (36%) were subjected
to mitral valve repair. Among those subjected to MVR,
174 (49%) received MBP (Group I) and 181 (51%) received MMP (Group
II). In the overall included population, 266 (75%) patients were in
child- bearing period [Group I: 134(77%); Group II:
132 (73%)]. Moreover, 263 (74%) patients had rheumatic mitral valve
disease [243 (74%) severe mitral
regurgitation grade (≥V); 220 (62%) annular dilatation], and 128
(36%) had AF.
Comparison of preoperative patient demographics, socioeconomic status,
mitral valve pathology, and echocardiographic data showed no
statistically significant differences between groups (Table 1).
Operative parameters were also not significantly different between
groups, except cardiopulmonary bypass
time that was significantly shorter in Group I than
in Group II (p = 0.0001; Table 2). Moreover, the postoperative
ICU and clinical follow-up course were better and hospital and ICU stays
were significantly shorter in Group I than in Group II (p< 0.0001) (Table 3), probably because patients in Group
II needed to wait for the target therapeutic international normalized
ratio (INR) (range 2.5-3 folds the normal value) and had more
postoperative complications than those than those in Group I.
Postoperative NYHA-class status was much
improved in Group I compared to that in
Group II (p = 0.04). Notably, the frequency of mitral valve
re-replacement was higher in Group II than in Group I (3.7%
vs. 0.6 %; p = 0.02).
Postoperative complications, including wound
infection, pericardial tamponade, AF, pneumothorax, pneumonia,
and ARF, showed no significant differences between groups. Immediate
operative death was only seen in 0.6% of the patients in
Group II. After 10years of follow-up, the postoperative transvalvular
pressure gradient was significantly lower and the vena contracta was
significantly wider in Group I than in Group II (p <
0.0001and p = 0.006, respectively).
At 30days postoperatively, 3 (0.8%) patients in the overall
population died [one in Group I (0.6%) and two in Group
II (1.2%)]. The most common complication at 30 days after surgery was
AF [68 patients (19%)].Moreover, 36 (10%) patients experienced
pneumonia, 5 (1.4%) wound infection, 28 (7.9%) pericardial tamponade,
13 (3.7%) pneumothorax, 9 (2.5%) pleural effusion, and 14 (3.9%)
stroke. Additionally, 34 (9.6%) patients had ARF, with only 10 (2.8%)
requiring temporary hemodialysis, while 29 (8.2%) patients suffered
from A-V block grade III, and 27 (7.6%) had pacemaker implantation.
Re-exploration for postoperative bleeding occurred in 22 (6.2%)
patients and was significantly more frequent among Group II [18
(10%)] than in Group I [4 (2.4%)] patients (p <
0.0001). Abortion occurred in 32 (9%) women in child-bearing period and
was significantly more frequent among Group II [27 (15%)] than in
Group I [5 (3%)] patients (p = 0.0001). Anticoagulant
complication-free pregnancy occurred in 242 (68.2%) women in
child-bearing period, and the rate was significantly higher in Group I
[141 patients (81%)] than in Group II [101 (56%)] (p
< 0.0001; Table 4).
Oral anticoagulants such as coumadin were available at all times for
all patients, but compliance to these drugs was 81%. The INR of Group
II patient was in the therapeutic target most of the times. Moreover, 5
out of 7 patients in this group who had mitral valve re-replacement
due to poor oral anticoagulant compliance or failure of coumadin
treatment to reach the INR therapeutic target in pregnant
woman resulting in life-threatening mechanical valve thrombosis in a
pregnant woman who received MMP (5 ± 2) years before
pregnancy. However, all a majority of them were successfully
treated with MBP re-replacement but had a significant risk of
miscarriage. In contrast, there was only one case for mitral
valve re-replacement in Group I due to structural valve
deterioration. Additionally, 18 (10%) Group II patients aborted due
to teratogenicity related to coumadin, representing about 67% (18/27)
of all abortion cases in this group.
The Kaplan–Meier curves of postoperative complications and survival
rate over the 10-year follow-up period are presented in Figure 1.
The survival rate was significantly higher in Group I than in Group II
(88%vs 63% p < 0.0001).The 95% confidence interval
of Cox hazards survival regression ratio was significantly different
between groups [0.1926 (0.0759–0.4889), p = 0.0001], whereas
the adjusted 95% confidence interval for preoperative variables (age,
logistic EuroScore-I, mitral regurgitation grade 4) was not
[0.5581(0.3254–0.9581), p = 0.059670].