SURGERY FOR RHEUMATIC MITRAL REGURGITATION IN PATIENTS BELOW 20 YEARSOF AGE - AN ANALYSIS OF FAILURES

Background and aim of the study: Mitral valve repair is less stable in rheumatic than in degenerative disease. This failure rate is inversel y related to the age of the patient. Based on our clinical experience, we selected the group of patients with the worst results for this stu dy: (i) rheumatic, (ii) age 20 or under, (iii) pure mitral regurgitati on (MR), and, (iv) no aortic disease. Materials and methods: Between 1 988 and 1995, 83 consecutive patients complied with these characterist ics. No patient was excluded. Replacement (MVR) was performed in 26 an d repair (MRp) in 57 (69%). Results: There was one hospital death (1%) with an actuarial survival at 48 months of 74.8% +/- 19% for MVR and of 97.9% +/- 2.1% at 78 months for MRp. There were no thromboembolic e vents. Reoperation was required in one MVR (4%) and in 21 MRp (37%), w ithin same admission in six, within three months in eight, under one y ear in three, and beyond in four cases. Severe MR appeared in five fur ther cases. No statistical difference was found between the preoperati ve clinical data, operative findings and surgical maneuvers of those p atients with successful and unsuccessful repair. The rate of failure w as similar after Kay (14/29) and Duran (12/28) annuloplasty. All patie nts showed a rapid decrease in Left ventricular dimensions. Early fail ures showed elongation of previously shortened chordae at reoperation, together with more reduction in systolic dimension than the other gro ups. Late failures were more related to progression of the rheumatic p rocess. No clear relationship between rheumatic activity and failure r ate was found. Conclusion: Rheumatic mitral regurgitation in the young remains a serious problem. The treatment of this frequent pathology i n the developing countries needs a new approach based on the knowledge that it starts at the annulus. Earlier surgery at this level might pr event its further progression, avoiding the problems of secondary chor dal elongation.