Double Valve Replacement (Mitral and Aortic) for Rheumatic Heart Disease: A 20-year experience with 300 patients.

Document Type: Original Article


1 Cardiovascular and Thoracic Surgeon, Department of CVTS, LTMMC and GH, Sion, Mumbai, India

2 Resident of Cardiovascular and Thoracic Surgeon, Department of CVTS, LTMMC and GH, Sion, Mumbai, India.

3 Cardiovascular and Thoracic Surgeon, Department of CVTS, LTMMC and GH, Sion, Mumbai, India.

4 Resident of Cardiovascular and Thoracic Surgeon, Department of CVTS, LTMMC and GH, Sion, Mumbai, India

5 Cardiovascular And Thoracic Surgeon, Department Of CVTS, LTMMC And GH, Sion, Mumbai, India.


Introduction: Rheumatic heart disease still remains one of the leading causes of congestive heart failure and death owing to valvular pathologies, in developing countries. Valve replacement still remains the treatment of choice in such patients.The aim of this study wasto analyze the postoperative outcome of  double valve replacement (Mitral and Aortic ) in patients of rheumatic heart disease.
Materials and Methods: Between 1988 and 2008, 300 patients of rheumatic heart disease underwent double (Mitral and Aortic) valve replacement with Starr Edwards valve or St Jude mechanical valve prosthesis were implanted. These patients were studied retrospectively for preoperative data and postoperative outcome including causes of early and late deaths and the data was analyzed statistically.
Results: The 30-day hospital death rate was 11.3% andlate death occurred in 11.6%. Anticoagulant regimen was followed to maintain the target pro-thrombin time at 1.5 times the control value. The actuarial survival (exclusive of hospital mortality) was 92.4%, 84.6%, and 84.4%, per year at 5, 10, and 20 years, respectively
Conclusions: In view of the acknowledged advantageof superior durability, increased thromboresistance in our patient population, and its cost effectiveness the Starr-Edwards ball valve or St. Jude valve is the mechanical prosthesis of choice for advanced combined valvular disease. The low-intensity anticoagulant regimen has offered suffcient protection against thromboembolism as well as hemorrhage.


1. Robbins S L, Cotran R S. The Heart. Kumar V, Abbas A K, Fausto N. Pathologic basis of disease. 7th ed Philadelphia: Saunders; 2006. P,592-594.

 2. Kaplan M, Bolande R, Rakita L, Blair J. Presence of Bound Immunoglobulins and Complement in the Myocardium in Acute Rheumatic Fever. New England Journal of Medicine. 1964;271(13):637-645.

3. Grover FL, Hammermeister KE, Burchfiel C. Initial report of the Veterans Administration preoperative risk assessment study for cardiac surgery. Ann ThoracSurg 1990; 50:12-28.

4.Christakis GT, Weisel RD, David TE, Salerno TA, Ivanov J.Predictors of operative survival of valve replacement.Circulation 1988;78 (Suppl. I):25–34.

5. Milano A, Bortolotti U, Mazucco A, Guerra F, Magni A, Gallucci V. Aortic valve replacement with the Hancock standard, Björk-Shiley and Lillehei-Kaster prostheses. A comparison based on follow-up from 1±15 years. J ThoracCardiovascSurg 1989;98:37-47.

6. Duncan J M, Cooley D A, Livesay J J, Ott D A, Reul G A, Walker W E, etal. The St. Jude Medical Valve: Early Clinical Results in 253 Patients.Tex Heart Inst J. 1983 March; 10(1): 11–16.

7. Holper K, Haehnel J, Augustin N, Sebening F. Surgery for Tricuspid Insufficiency: Long-Term Follow-Up After De Vega Annuloplasty. The Thoracic and Cardiovascular Surgeon. 1993;41(01):1-

8. Edmunds L, Clark R, Cohn L, Grunkemeier G, Miller D, Weisel R. Guidelines for Reporting Morbidity and Mortality after Cardiac Valvular Operations. Asian Cardiovascular and Thoracic Annals. 1996;4(2):126-129.

9. Brown P, Roberts C, McIntosh C, Swain J, Clark R. Relation between choice of prostheses and late outcome in double-valve replacement. The Annals of Thoracic Surgery. 1993;55(3):631-640.

10.  Emery RW, Palmquist WE, Metther E, Nicoloff DM; A new cardiac valve prosthesis: in vitro results.Trans Am Soc Artif Intern Organs. 24 1978:550-556.

11. Bortolotti U, Milano A, Testolin L, Tursi V, Mazzucco A, Gallucci V. Influence of type of prosthesis on late results after combined mitral-aortic valve replacement. The Annals of Thoracic Surgery. 1991;52(1):84-91.

12. Litmathe J, Boeken U, Kurt M, Feindt P, Gams E. Predictive Risk Factors in Double-Valve Replacement (AVR and MVR) Compared to Isolated Aortic Valve Replacement. The Thoracic and Cardiovascular Surgeon. 2006;54(7):459-463.

 13. Teoh KH, Christakis GT, Weisel RD, Tong CP, Mickleborough LL, Scully HE, et al. The Determinants of Mortality and Morbidity after Multiple-Valve Operations. The Annals of Thoracic Surgery. 1987;43(4):353-358.

14. Karp RB, Cyrus RJ, Blackstone EH, Kirklin JW, Kouchoukos NT, Pacifico AD. The Björk-Shiley valve: intermediate-term follow-up. J Thorac Cardiovasc Surg.1981 Apr;81(4):602–614.

15.  Bernal J, Rabasa J, Gutierrez-Garcia F, Morales C, Nistal J, Revuelta J. The CarboMedics Valve: Experience With 1,049 Implants. The Annals of Thoracic Surgery. 1998;65(1):137-143.

16.  Taylor K. The United Kingdom Heart Valve Registry: the first 10 years. Heart. 1997;77(4):295-296.

17. Malouf J, Enriquez-Sarano M, Pellikka P, Oh J, Bailey K, Chandrasekaran K et al. Severe pulmonary hypertension in patients with severe aortic valve stenosis: clinical profile and prognostic implications. Journal of the American College of Cardiology. 2002;40(4):789-795.

18. Galloway A, Grossi E, Baumann F et al. Multiple valve operation for advanced valvular heart disease: Results and risk factors in 513 patients. Journal of the American College of Cardiology. 1992;19(4):725-732.

 19. Talwar S, Jayanthkumar H, Kumar A. Chordal preservation during mitral valve replacement: basis, techniques and results. Indian J Thorac Cardiovasc Surg. 2005;21(1):45-52.

 20. Kopf GSHammond GLGeha ASElefteriades JHashim SW. Long-term performance of the St. Jude Medical valve: low incidence of thromboembolism and hemorrhagic complications with modest doses of warfarin. Circulation. 1987 Sep;76(3 Pt 2):III132-6

21. Iyer KS, Reddy KS, Rao IM, Bhatia ML, Gopinath N, Venugopal P. Valve replacement in children under 20 years of age. Experience with Björk-Shiley valve. J ThoracCardiovascSurg 1984;88:217-24.

22. Salazar, E., Zajarias, A., Gutierrez, N., Iturbe, I. The problem of cardiac valve prosthesis anticoagulants and pregnancy. Circulation. 1984;70:69–77. 

23. Corcos T, Gandjbakch I, Pavie A, et al. Long term results of valve replacement with Starr-Edwards silicone ball valve prosthesis. Circulation 1987;71(Suppl 4):446.

24. Armenti F, Stephenson LW, Edmunds LH Jr. Simultaneous implantation of St. Jude medical aortic and mitral prostheses. J ThoracCardiovascSurg 1987;94:733-9.

25. Sethia B, Turner MA, Lewis S, Rodger RA, Bain WH. Fourteen years experience with the Björk-Shiley tilting disc prosthesis. J ThoracCardiovasc Surg 1986;91:350-361.

26.Dhasmana JP, Blackstone EH, Kirklin JW, Kouchoukos NT. Factors associated with periprosthetic leakage following pri-mary mitral valve replacement with special consideration of the suture technique. Ann ThoracSurg 1983;35:170-178.