11.13.5 Multiple valve corrections

The risk of double valve replacement is significantly higher than that of a single prosthesis, with operative mortality averaging 6.5% compared with 0.9-3.9% for single valve replacement, and rising to 8-14% for triple valve replacement. Survival at 5 years without reoperation is 72% [4,7]. When feasible, mitral, aortic or tricuspid valve repair has a better prognosis than prosthesis implantation, reducing mortality by 40% but with some risk of recurrence [8]. The worst survival of all combinations is the MI-AI combination, probably because of the irreversible damage suffered by the LV in this condition when the patient becomes symptomatic. The indication for intervention on the second valve is justified if the insufficiency or stenosis is severe; if it is moderate to severe, intervention is justified if the operative risk is low or intermediate (< 8%), if the lesion is structural and if the valvular disease shows signs of rapid progression [1,5].

The alternative is re-intervention to treat the condition that appeared to be waiting to be treated at the time of the initial operation. This approach depends on the rate of progression of the disease. Degenerative aortic stenosis progresses more rapidly than rheumatic or congenital stenosis, and a high degree of aortic calcification is associated with a poor prognosis [2,6]. Aortic insufficiency progresses more slowly than stenosis [3].

European and American guidelines provide the following general recommendations for polyvalvular surgery [1,2,5,8].

• Two severe valve diseases: simultaneous surgery on both valves if the surgical risk is low or moderate (Class I recommendation); if the risk is high, double surgery is recommended for symptomatic patients. If the risk is prohibitive, the double operation can be replaced by a subsequent non-invasive procedure (TAVI for aortic stenosis, MitraClip for mitral regurgitation, balloon dilatation for mitral stenosis).
• Severe valve disease (indication for surgery) + moderate to severe symptomatic valve disease: If the risk of surgery is low or moderate, it is reasonable to correct AI, AS,TI and structural MI simultaneously (class IIa).
• Severe valve disease (indication for surgery) + moderate-to-severe valve disease in an asymptomatic patient: The increased risk of surgery means that the second operation should be postponed or a non-invasive percutaneous procedure should be performed.
• Severe left-sided valve disease + severe TI: concomitant tricuspid repair (usually ring surgery) (Class I).
• Severe left heart valve disease + moderate TI: simultaneous correction of the TI is reasonable if the annulus is dilated, if the RV is failing or if the pulmonary hypertension is severe (Class IIa).
• Two non-severe valvular diseases: the combination of two diseases of moderate importance can lead to a serious situation with significant symptoms, severe ventricular dysfunction/dilatation and pulmonary hypertension. Surgery may be indicated if the exercise test, fine indices of right and left myocardial function, natriuretic peptides and pulmonary pressure are abnormal (class IIb).

In the elderly, it is more important to improve quality of life than to extend life, because  the long term no longer really exists. This observation suggests that we should not be maximalist in these surgical indications. In case of double valve replacement, using the same type of prosthesis for both valves avoids superimposing the risks of anticoagulation of mechanical valves on those of bioprosthetic deterioration [7].

 

Double valve repair

The risk of double valve replacement is significantly higher than that of a single prosthesis: average operative mortality of 6.5% instead of 0.9-3.9%; this rises to 8-14% for triple replacement.

 

© CHASSOT PG, BETTEX D, August 2011, last update November 2019