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23
MITRAL AND AORTIC VALVE OPERATIONS IN QATAR
AMERCHAIKHOUNI, MD, FACC, FICS; ALIHIJAZI, MD, FRCS, FACS
QATAR'S first aortic valve operation was performed
at Hamad General Hospital on June 27, 1983, and the
hospital's first mitral valve operation was performed
a month later on July 25, 1983. A computerized
record of each cardiac operation, performed at the
hospital, was utilized in the periodical revision and
critical evaluation of the growth and development of
the new cardiac surgery program in Qatar.
In this report our experience in mitral and aortic
valve operations, performed during the period
between June 1983 to June 1988, is reviewed. During
this 5-year period, there was a total of 82 mitral and
aortic valve operations; the characteristics of these
patients and the results of their operations are
described in this retrospective study.
Patients and Methods
Mitral and aortic valve operations amounted to
25% of all cardiopulmonary bypass cardiac operations performed at Hamad General Hospital during
this 5-year period, while 65% ofthe operations were
performed for myocardial revascularization and 10%
for congenital heart diseases. Of the valve operations,
24 (29%) were done during the last year of the study
period, while an average of 15 valve operations was
carried out in each of the previous years.
All patients were evaluated by echocardiography,
Doppler, and cardiac catheterization. The left
ventricular function and NYHA clinical functional
class of the patients are listed in Table 1. Operative
therapy was recommended in symptomatic patients
or in patients with
________________________________
From the Department of Cardiothoracic Surgery, Hamad General
Hospital, Doha, Qatar.
Address reprint requests and correspondence to Dr. Chaikhouni:
Department of Cardiothoracic Surgery, Hamad General Hospital,
P.O. Box 3050, Doha, Qatar.
Journal of the Saudi Heart Association Vol . 2, No. 1, 1990
deteriorating left ventricular function as demonstrated
by echocardiography or cardiac catheterization. All of
the cardiac valve operations were performed using
cardiopulmonary bypass, hemodilution, hypothermia,
aortic cross clamp, and myocardial protection with
repeated doses of cold potassium cardioplegia through
the ascending aorta.
Table 1. NYHA functional class of patients who had aortic or mitral
valve operation at Hamad General Hospital, 1983
1988.
Functional class
No.
(%)
I
12
34
29
7
(15.0)
(41.5)
(35.0)
(8.5)
11
III
IV
The mean age of the patients was 33 years, with a
range of 7 to 55 years; 56 of the patients were males
and 26 were females (M:F = 2:1). The distribution of
patients according to sex and types of cardiac valve
disease is illustrated in Figure 1.
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CHAIKHOUNI AND HIJAZI
Results
In aortic valve disease, we found that the maletofemale ratio was 8:1, while in mitral valve disease the
male-to-female ratio was 2:1. In female patients, the
possibilities were 6:1 and 3:1 of having a mitral or
aortic valve disease and mitral stenosis or
regurgitation, respectively. In male patients, the
possibilities were 1.5:1 and 1.7:1 of having a mitral or
aortic valve disease and mitral stenosis or
regurgitation, respectively. Mitral stenosis was present
in 49 patients, mitral regurgitation in 18, aortic
regurgitation in 21, and aortic stenosis in 11.
Seventeen patients had more than one type of valve
disease. The patients' symptoms are listed in Table 2.
26
MVR
Mitral Valvuloplasty
CMC
AVR
AVR + MVR
Table 2. Symptoms of patients who had aortic or mitral valve
operation at Hamad General Hospital, 1983 - 1988.
Valve + ACB
Symptoms
No.
(%)
Dyspnea
70
(85)
Poor exercise tolerance
61
(74)
Palpitation
Chest pain
Thromboemboli
Hemoptysis
Asymptomatic
33
21
5
3
12
(40)
(26)
(6)
(3.5)
(15)
Mitral valve replacement was done in 26 patients,
mitral valvuloplasty in 23, aortic valve replacement in
17, double valve replacement (mitral and aortic) in 11,
closed mitral commissurotomy in 3, and valve
replacement with myocardial revascularization in 2
(Figure 2).
All patients who needed cardiac valve replacement
received a mechanical valve (St. Jude or BjorkShiley). Most ofthe prosthetic valves in the mitral
position were placed with continuous sutures, while
most of the prosthetic aortic valves were placed with
interrupted pledgeted sutures. (We kept track of the
frequently used sizes because the importance of
having these sizes in stock reduces the cost of keeping
unnecessary large stock of valve sizes that are less
commonly used. )
Most of the mitral valvuloplasty operations were
performed because of mitral stenosis. In mitral valve
disease, valvuloplasty was always attempted first, and
valve replacement was
Journal of the Saudi Heart Association Vol . 2, No. 1, 1990
5
10
15
20
25
Number of Operations
Figure 2. Types of cardiac valve operations. MVR = mitral valve
replacement; CMC = closed mitral commissurotomy; A VR =
aortic valve replacement; ACB = aorto-coronary bypass.
carried out if valvuloplasty was not feasible when
judged intraoperatively by the surgeon. The possibilities of performing valvuloplasty were 40% in
mitral stenosis and 16% in mitral regurgitation.
De Vega tricuspid valve annuloplasty was needed in
5 patients who required mitral valve replacement.
Puig-Massana mitral annuloplasty ring was used in all
mitral valvuloplasty operations when regurgitation was
the major component of the mitral valve disease.
The arithmetic mean (average) aortic cross clamp
time, cardiopulmonary bypass time (pump time) and
the range of these items are illustrated in Figure 3.
Major morbidity was encountered in 12% of the
patients (Table 3). Re-exploration for bleeding was
needed in only 2 patients (2.4%), and severe
postpericardiotomy syndrome, requiring steroid
therapy, also occurred in 2 (2.4%). Another two
patients who had cerebrovascular accidents had
emergency operations for severe mitral stenosis which
was complicated preoperatively by cerebral emboli,
both of these patients died postoperatively within three
days. A 21-year-old female patient who had open
mitral commissurotomy for
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A-V AL VE SURGERY IN QATAR
mitral stenosis, nine months later, developed a
significant mitral regurgitation and deterioration of
aortic regurgitation which were estimated to be mild
in the initial evaluation; this patient had successful
mitral and aortic valves replacement and De Vega
tricuspid annuloplasty. Another patient, a 39-yearold obese man, required rewiring of the sternum 5
days after operation because of mechanical failure of
sternal closure with no evidence of mediastinitis; he
was discharged in good condition on the 14th
postoperative day. None of the patients developed
perivalvular leak, wound infection, or any major
thromboembolic episode, other than what is
mentioned during this study period (1983-1988).
However, we must emphasize that our follow-up is
accurate only for patients who remained in Qatar,
because we do not have a
good follow-up system for our patients living abroad.
_
"",.,
Vllvulopl..tr
PumpTI....
MV
R
AV
R
(64-140) 81
w ~ ~ 40 ~ ~ ro ~ ~ ~
T'...... ln M'nut..
Figure 3. Aortic cross clamp and total pump times in cardiac valve
operations. MVR = mitral valve replacement; A VR = aortic valve replacement.
Table 3. Cardiac valve operations at Hamad General Hospital, 1983 1988.
Complications
No.
(%)
Postoperative bleeding
2
(2.4)
Postpericardiotomy syndrome
Cerebrovascular accident
Prosthetic valve thrombosis
Failure of commissurotomy
2
2
2
1
1
(2.4)
(2.4)
(2.4)
(4.3)
(1.2)
Sternal dehiscence
Journal of the Saudi Heart Association Vol . 2, No. 1, 1990
The mortality rate in this series of consecutive
valve operations was 3.7%. Three patients died within
30 days of the operation (this total includes the two
patients who had the preoperative embolic
cerebrovascular accidents mentioned earlier). The
third patient was a 32-year-old man who needed
double valve replacement (mitral and aortic). St. Jude
prosthetic valves were used, and the patient was lost
to follow-up until he presented 7 months
postoperatively with cardiogenic shock in the
emergency room. The echocardiogram showed
thrombosis of both prosthetic valves. Emergency
declotting of the mitral valve and replacement of the
aortic valve were done, but the patient expired about 6
h later due to profound shock in spite of intraaortic
balloon pump support.
Discussion
When the cardiac surgery program first began,
there was an expectation that there would be more
valve operations than myocardial revasculariza
tion. On the contrary, we were impressed by the
unexpected high percentage of myocardial revascularization operations (65 %) taking place in a young
developing country such as Qatar. We expe.cted
rheumatic heart disease to be more common than
coronary artery disease, but our actual experience
showed that coronary artery disease is much more
common in this society. The other unexpected
observations were that most of our valve patients
were men and that more men than women were
affected with mitral stenosis.
The male:to-female ratio in valve patients was 2: 1.
Mitral stenosis was the commonest valve disease in
our patients, and the male-to-female ratio in mitral
stenosis was also 2: 1. These observations do not
necessarily indicate that valve diseases in Qatar are
different from the valve diseases as described in the
standard textbooks.!
A more careful evaluation of these observations in
relation to the population of Qatar may explain these
differences. The male-to-female ratio in the general
population in Qatar is 2:1 which is different from the
expected male-to-female ratio of 1: 1 in other
societies.2This unusually high percentage of males in
Qatar is largely due to the expatriate male workers
who are recruited for employment services.