Acute phase of rheumatic fever
During the acute phase of rheumatic fever, most patients with valvulitis and mitral regurgitation can be managed medically. In rare occasions, the persistence of an intense inflammatory syndrome associated with severe valvular regurgitation refractory to medical therapy may necessitate a surgical intervention. In 1970's, our group was the first to perform reconstructive mitral valve surgery in patients with acute rheumatic valvulitis. The surprising fact was that surgical intervention not only corrected valvular regurgitation, but postoperatively there was a significant reduction in the intensity of the inflammatory syndrome. Two other important findings were: 1) we were able to reconstruct effectively the mitral valve during the acute phase of the disease and 2) the surgical intervention was associated with low mortality. Subsequently other groups confirmed our results.
Chronic phase of rheumatic fever
During the last few decades the percutaneous mitral valve balloon dilatation has become the first line therapy for many patients with mitral stenosis. This procedure is indicated in symptomatic patients (NYHA II, III and IV) with isolated moderate to severe mitral stenosis (valve area <1.5cm2) and favorable valve morphology. Asymptomatic patients with moderate to severe mitral stenosis and pulmonary hypertension at rest (pulmonary artery systolic pressure >50 mm Hg) may also be considered for percutaneous therapy. The latter technique is, however, contraindicated in several circumstances: the presence of at least moderate mitral regurgitation, the existence of left atrial thrombus on echocardiography, and inadequate valve morphology (e.g. leaflet calcification, extensive subvalvular lesions). Percutaneous mitral balloon dilatation is associated with a finite incidence of recurrent stenosis, particularly in patients undergoing repeat procedures and with iatrogenic mitral regurgitation in patients with high Wilkins valve score.
Surgical intervention is the treatment of choice in symptomatic patients (NYHA class III or IV), with moderate to severe mitral stenosis (valve area <1.5cm2), who are not appropriate for, or who have failed percutaneous balloon dilatation. There is also a subgroup of asymptomatic patients with severe mitral stenosis and severe pulmonary hypertension with unfavorable morphology for percutaneous balloon dilatation. Mitral valve surgery is recommended in this subgroup in order to prevent right ventricular failure.
In patients with mild asymptomatic mitral stenosis (valve area >1.5 cm2 and mean gradient <5 mm Hg), no further intervention is necessary after the initial workup. These patients are likely to remain stable for years and should be treated medically with a close follow-up.
In symptomatic patients with moderate to severe mitral regurgitation, surgical intervention is indicated before ventricular dilatation or dysfunction occurs. Similarly, it is preferable to proceed with surgery while the patient is in NYHA I and II and before atrial fibrillation takes place.
In asymptomatic patients with severe mitral regurgitation, the timing of surgery depends greatly on the likelihood of valve reconstruction. The extent of valvular lesions and surgeon's experience are the two most important variables predicting the feasibility of valve reconstruction. In this context, only asymptomatic patients who can be guaranteed a reconstructive procedure should be considered for surgery.
Bonow RO, Carabello BA, Chatterjee K, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008;118(15):e523-661.
Carpentier A, Adams DH, Filsoufi F. Carpentier's reconstructive valve surgery. Saunders (Elsevier), 2010