Influencing Factors Of The Progression Of Neighbouring Valve Lesion After Mitral Valve Replacement In Rheumatic Heart Disease

Background:Rheumatic heart disease is a very common disease in most developing countries,which is often involving the mitral valve,leads to fibrosis of the valve tissue,result in stenosis or incomplete closure.Valvular disease can cause changes in hemodynamics,lead to serious complications such as cardiac insufficiency and atrial fibrillation,which can endanger the life of the patient.Due to the complex surrounding structure and hemodynamics of the mitral valve,mitral valve replacement is still the mainstream of clinical treatment.However,some patients with rheumatic heart disease who underwent mitral valve replacement may develop the progression of neighbouring valve disease such as aortic valve or tricuspid valve over time,and even need to receive secondary surgical treatment.Objective:This is a single-center retrospective study.We investigated the influencing factors of adjacent valves(aortic valve and tricuspid valve)disease progression after mitral valve replacement in rheumatic heart disease.The aim of this study is to develop appropriate clinical diagnosis and treatment strategies for such patients.Methods:The clinical data of patients who received mitral valve replacement in Zhujiang Hospital of Southern Medical University from 2010 to 2016 were collected.Patients were divided into two groups according to the progression of aortic or tricuspid valve disease after surgery,then the grouped data were statistically analyzed.Results:(1)Influencing factors of the progression of aortic valve lesion after mitral valve replacement in rheumatic heart disease:We screened the collected medical records,144 eligible patients were included and divided into two groups by endpoint events.Those who had significant aortic valve disease progression after mitral valve replacement were classified into the progression group,and the other patients were classified into the non-progression group.Multivariate analysis showed 5 significant significant factors:Tricuspid ring implantation(P=0.008,OR=0.10),left ventricular diameter(P=0.011,OR=0.27),preoperative mild to moderate aortic valve disease(P=0.009,OR=7.28),prosthesis mitral valve size(P=0.032,OR=2.51),aortic valve peak velocity(P=0.011,OR=3.70).(2)Influencing factors of the progression of tricuspid regurgitation after mitral valve replacement in rheumatic heart disease:We screened the collected medical records,103 eligible patients were included and divided into two groups by endpoint events..Those who had significant tricuspid regurgitation progression after mitral valve replacement were classified into the progression group,and the other patients were classified into the non-progression group.The multivariate analysis showed two significant factors:gender(P=0.050,OR=2.85)and atrial fibrillation(P=0.018,OR=3.95).Conclusions:(1)The progression of aortic valve lesions of the patients with rheumatic heart disease who underwent mitral valve replacement is related to a variety of factors.It may be mainly due to the increase of left ventricular preload and a series of hemodynamic changes after mitral valve surgery.According to the statistical analysis results,it is suggested that patients with preoperative mild to moderate aortic valve lesion,high aortic valve velocity(peak velocity>1.7m/s)or small left ventricular diameter(<35mm)should be considered as potential candidates for rapid progression of aortic valve lesion,which need cardiotonic and diuresis treatment to reduce the load for a long time after the operation and closely followed up.At the same time,it is suggested to relax the indications for concomitant tricuspid annuloplasty during mitral valve replacement.In contrast,the selection of valve size should be as accurate and conservative as possible according to the patient’s condition to avoid the prosthesis valve mismatch.(2)As shown by the result of statistical analysis,atrial fibrillation is one of the independent risk factors for progression of tricuspid regurgitation after mitral valve replacement in rheumatic heart disease.Combined with previous reports,It is suggested that we should actively correct tricuspid regurgitation in such patients,so as to prevent their progression.We also observed that women are more likely to have increased tricuspid regurgitation than men,which may be related to the rheumatism.In addition,we found that the presence of mild tricuspid regurgitation before surgery may not correlate with the progression of postoperative tricuspid.Therefore,for patients with rheumatic mitral valve disease complicated with mild to moderate adjacent valve lesion,a comprehensive consideration should be taken to formulate a reasonable surgical plan,rather than simply taking the severity of valve lesion as the sole criterion for surgery.