Title : Mechanical valve for isolated mitral stenoses complicated massive thromboses of left atrium: Is it necessary?
Abstract:
Objective: To analyzed main problems in surgery of mitral valve diseases (MVD) complicated by left atrium`s massive thromboses (LAMT) (thromboses more than 1/3 of left atrium`s volume).
Materials and Methods: 336 adult patients (pts) with MVD complicated LAMT were consequtive operated from 01.01.1984 till 01.01.2020 yy in Institute. Predominant genesis of MVD was rheumatism. Mitral stenoses was marked in all pts and all of them were in IV NYHA class. There were male 147 (43,7%) and females 189 (56,3%).The average age was 59,2±5,2 yy. Preoperative thromboembolic episodes were in 59 (17,6%) pts. Calcification of MV was in 197 (58,6%) pts. Previous closed mitral commissurotomy was occurred in 35(10,3%) pts. The following procedures were performed: MVR (n = 294) including plastic procedure on TV by De Vega (n = 35); open mitral commissurotomy (OMC) (n =42) including plastic procedure on TV (n = 7). Only mechanical valves were used. All operations were performed with CPB, moderate hypothermia, ante-retrograde crystalloid cardioplegia (Custadiol). All pts was devided on 2 groups; group A (n =162) maternal thrombotic basement was removal together with all thrombotic masses out of LA, group B (n =174) maternal thrombotic basement wasn`t removal. There were used bileaflet prosthesis (Saint Jude Medical, Carbomedics, On-X, ATS) (n=140); monodisc (n=98), Star-Edwards (ball) (n=38), Amosov`s model (hemiball) (n=18). Absence of applying donor blood product during all postoperative period was 19,5%.
Results: The hospital mortality (HM) at the period (1994-2014 yy) was 4,5% (n =9/198) for MVR and 0% (n = 0/29) for OMC. The reasons of deaths were: heart failure (n=4), brain damage (thrombemboli)(only group B) (n=3), MOF (n = 1), bleeding (n=1 group A). Traumatic rupture of LA`s wall during radical removing of maternal thrombotic basement as specific complication was marked in 2,5% (n=4/162) pts. At all period of experience thromboembolic events were marked: group A – 1,8% (n = 3/162) (lethal = 0), remote period - 3,6% (n = 5/140) (lethal -1,4%), group B – 5,8% (n = 10/174) (lethal- 3,4% ), remote period - 13,3% (n = 19/142) (lethal - 9,2%) (p < 0,05). At all period of experience thromboembolic events were marked: MVR in 4,1 % (n= 12/294), (lethal -1,0%), remote period - 8,9% (n = 22/245) (lethal -5,7%) and during OMC 2,4% (n= 1/42), (lethal -0), remote period - 5,4% (n = 2/37) (lethal -2,7%) (p < 0,05). 282 (95,5% alive) pts was followed-up at the remote period (average 16,2 ± 3,1 yy).At all period of experience thromboembolic events were marked for bileaflet prosthesis: Saint Jude - 1,5% (lethal = 0,7%), remote period - 3,6% (lethal – 0,9%), Carbomedics – 4,3% (lethal - 2,7%), remote period - 6,5% (lethal - 2,2%), On-X – 2,4% (lethal = 2,3%), remote period - 4,2% (lethal - 0), group ATS (n=32 pts) – 6,2% (lethal = 3,1%), remote period - 9,3% (lethal - 6,3%) (p < 0,05).
Conclusion: Thromboembolic events at postoperative period is specific complicated factor for LAMT. Maternal thrombotic basement must be removed with all thrombotic masses in all pts. Mechanical valve is independent risk-factor at postoperative period except model Saint Jude.
