The Journal of Thoracic and Cardiovascular Surgery
Volume 139, Issue 1 , Page 237, January 2010

Pulmonary autograft for mitral valve replacement: Making a simple procedure complex?

Department of Cardiothoracic Surgery, King Abduaziz University, Jeddah, Saudi Arabia

Article Outline

CTSNet classification: 35

 

To the Editor:

I read with interest the article by Kumar and colleagues1 about the use of pulmonary autografts for mitral valve replacement. I agree with the authors that cardiac surgeons working in Third World countries are faced with a major problem in the management of large numbers of patients with valvular disease. Most of those patients are of low socioeconomic and educational class, living in remote villages and mountains. There is no family practice or general practitioner system to provide early diagnosis and referral, postoperative follow-up, and anticoagulation control. Patients usually present late with advanced disease that makes repair impossible. The magnitude of the problem is escalated in children and women of childbearing age because we have no ideal valve substitute.

The pulmonary autograft concept is attractive but still has its drawbacks and complications. The procedure is complex and technically demanding, requiring at least double the usual crossclamp and bypass times. The procedure is not free of charge because there is a price for the homografts or preparation of the autografts, plus the added cost of complications. The mortality of approximately 15% reported by the authors is still high compared with single mitral valve replacement. Kabbani and colleagues2 reported 5% early mortality and 6% late mortality, but as they stated, it is “clearly related to the procedure,” which entails higher overall mortality. The issue of converting a single-valve into a double-valve disease is irritating because we have to expect long-term sequelae of pulmonary and mitral valve failures. The main concern with pulmonary autografts or homografts is early calcification. The removal of calcified grafts, as experienced in aortic homografts, is usually disastrous and has a high complication rate, including left ventricular rupture. The same complications are associated with the use of aortic or mitral homografts for mitral valve replacement. All of these autografts and homografts have to compete with the standard stented bioprostheses, which are improving and technically easier to insert, and require no anticoagulation. At the present time, bioprosthetic valves remain the standard in these patients, and manufacturers have shown us better preservation and longer durability.3

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References 

  1. Kumar AS, Talwar S, Gupta A. Mitral valve replacement with the pulmonary autograft: midterm results. J Thorac Cardiovasc Surg. 2009;138:359–364
  2. Kabbani SS, Jamil H, Hammoud A, Hatab JA, Nabhani F, Hariri R, et al. The mitral pulmonary autograft: assessment at midterm. Ann Thorac Surg. 2004;78:60–65
  3. Totaro P, Degno N, Zaidi A, Youhana A, Argano V. Carpentier Edwards Perimount Magna bioprostheses: a stented valve with stentless performance?. J Thorac Cardiovasc Surg. 2005;130:1668–1674

PII: S0022-5223(09)01156-8

doi:10.1016/j.jtcvs.2009.08.049

Refers to article:

  • Mitral valve replacement with the pulmonary autograft: Midterm results , 27 March 2009

    Arkalgud Sampath Kumar, Sachin Talwar, Anubhav Gupta
    The Journal of Thoracic and Cardiovascular Surgery August 2009 (Vol. 138, Issue 2, Pages 359-364)

The Journal of Thoracic and Cardiovascular Surgery
Volume 139, Issue 1 , Page 237, January 2010

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