Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 
Print this page Email this page Users Online: 387

 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 1  |  Page : 12-19

Outcomes of complete mitral valve excision and replacement with tilting disc (TTK Chitra) valve for rheumatic mitral valve stenosis


Department of Cardiothoracic Surgery, Katuri Medical College and Hospital, Guntur, Andhra Pradesh, India

Date of Submission09-Jul-2019
Date of Decision22-Sep-2019
Date of Acceptance28-Sep-2019
Date of Web Publication14-May-2020

Correspondence Address:
Dr. K Venkatavijay
Department of Cardiology, Katuri Medical College, Guntur, Andhra Pradesh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JDRNTRUHS.JDRNTRUHS_75_19

Rights and Permissions
  Abstract 


Background: Mitral valve (MV) disease is one of the earliest diseases of the heart, and rheumatic MV disease is one of the first discovered in the world dating back to the 19th century. Rheumatic heart disease (RHD) is declining in other countries, but it is still prevalent in the rural parts of India especially in lower economic group. In our hospital, we have operated 50 cases of rheumatic mitral stenosis for whom mitral valve replacement (MVR) with tilting disc (TTK Chitra valve) was done. Most of the MV cases have MV score >12 and the subvalvular apparatus was severely affected. In all the cases we have operated, we have excised complete valve and no posterior leaflet preservation or chordal tethering and repair was done.
Objectives of the study: To study MVR outcomes with tilting disc TTK Chitra valve and to compare pre- and postoperative valve gradient across tilting disc prosthetic valves and also study the left ventricular (LV) dimensions pre and post MVR and to study ejection fraction (EF) pre and post valve replacement and complications arising from posterior leaflet excision.
Materials and Methods: Fifty patients with chronic RHD Chronic Rheumatic heart Disease (CRHD) with severe mitral stenosis were taken up for the study who were operated in this department from May 2016 to April 2019. All the patients were evaluated with 2D echo, electrocardiogram, and coronary angiogram (when they were >35 years old).
Results: Out of 50 patients operated in our hospital, 34 were females, that is, 68% of the patients, and 16 patients were males, that is, 32%. As per age, 20 patients were between 41 and 50 years of age, that is, 40% belonged to 41–50 years of age; 39 patients were below 50 years, that is, 78% of patients were below 50 years; 4% are below 20 years; and 22% were above 50 years. As per the combined age and sex ratio also among both males and females, most Mitral Stenosis (MS) presumed below 50 years only. As per the valve area, the most common valve by preoperative echo was 66% below and equal to 1 cm[2] by Pressure half time (PHT) and Planimetry. About 60% of the patients had preoperative EF of more than 55% and less than 10% had between 36% and 40%. Preoperatively, 40% of the patients had severe pulmonary arterial hypertension (PAH), 30% of the patients had moderate PAH, and 30% of the patients had mild PAH. All these patients had been operated for MV where posterior leaflet was excised and no subvalvular apparatus was conserved and no chordal repair was done, but apparently no postoperative LV dysfunction was found in these patients. All these patients had taken up for MVR and TTK Chitra valve between 27 and 31 was used. In 70% of the patients, 29 and 31 TTK Chitra valve was used. This study is based on the echocardiographic analysis of the preoperative mean gradient across MV and postoperative mean gradient across MV which shows a considerable, comparable, and acceptable mean gradient postoperatively.
Conclusion: Whenever rheumatic mitral stenosis is present, complete valve can be reasonably excised without even sparing or preserving the subvalvular apparatus and it does not affect the EF and LV function. Native tilting disc valve, that is, TTK Chitra valve, can be safely used and it can give comparable results with the recent generation valves. Better outcomes are encountered with 29-mm size and above valves. Pulmonary artery hypertension decreases significantly if mitral stenosis is operated regardless of the advancement of disease process. There is no significant change in the LV parameters, and pre- and postoperatively EF remained the same.

Keywords: CRHD, MVR, PHT, TTK Chitra valve


How to cite this article:
Venkatavijay K, Vivekananda Y, Hemasundar K, L Rajitha N N. Outcomes of complete mitral valve excision and replacement with tilting disc (TTK Chitra) valve for rheumatic mitral valve stenosis. J NTR Univ Health Sci 2020;9:12-9

How to cite this URL:
Venkatavijay K, Vivekananda Y, Hemasundar K, L Rajitha N N. Outcomes of complete mitral valve excision and replacement with tilting disc (TTK Chitra) valve for rheumatic mitral valve stenosis. J NTR Univ Health Sci [serial online] 2020 [cited 2020 Nov 25];9:12-9. Available from: https://www.jdrntruhs.org/text.asp?2020/9/1/12/284319




  Introduction Top


While the incidence of acute Rheumatic Fever (RF) in the Western world had substantially declined over the past five decades, this trend is reversing due to immigration from nonindustrialized countries where rheumatic heart disease (RHD) is higher.

Mitral valve (MV) disease is one of the earliest diseases of the heart, and rheumatic MV disease is one of the first discovered in the world dating back to the 19th century.

RHD is declining in other countries, but it is still prevalent in the rural parts of India especially in lower economic group.

The complexity of rheumatic MV is varied in presentations and various permutations and combinations, and in India it is still present in the advanced stages with Wilkins scoring >12.

In our hospital, we have operated 50 cases of rheumatic mitral stenosis for whom mitral valve replacement (MVR) with tilting disc (TTK Chitra valve) was done.

Most of the MV cases have MV score >12 and the subvalvular apparatus was severely affected.

In all the cases we have operated, we have excised complete valve and no posterior leaflet preservation or chordal tethering and repair was done.


  Objectives of the Study Top


  1. To study MVR outcomes with tilting disc TTK Chitra valve.
  2. To compare pre- and postoperative valve gradient across tilting disc prosthetic valves.
  3. To know about the valve size preference and complications of prosthetic valves.
  4. To study the LV dimensions pre and post MVR and to study EF pre and post valve replacement and the complications arising from posterior leaflet excision.



  Materials and Methods Top


Fifty patients with CRHD with severe mitral stenosis were taken up for study who were operated in this department from May 2016 to April 2019.

Pure mitral regurgitation and Ischemic Heart Disease (IHD) with ischemic mitral regurgitation are excluded from the study.

All the patients are evaluated with 2D echo, electrocardiogram, and coronary angiogram (when they were >35 years of age) along with other preoperative investigations.

Operative steps

All these patients were approached through median sternotomy.

Routine aortic and bicaval canulation done and the patients was put on cardiopulmonary bypass, and cold blood cardioplegia was given and the heart was arrested in diastole and MV approached through left atrium.

For all these patients, complete excision of MV was done and no attempt was done to preserve the posterior leaflet or the subvalvular apparatus, and MVR was done using TTK Chitra valve from sizes 25 to 31 mm using intermittent pledgeted sutures.

Routinely, 2D echo in all these patients was done at the end of the first week at the time of discharge and evaluated.

The follow-up of these patients was done every 3 months till date.

Ethical Clearance

Ethical approval for this study was done by institutional ethical committee of katuri medical college and hospital and date and number as follows- F_NO9/IEC/FACULTY/KMCH/2016-17 dated 30 April 2016


  Results Top


Out of 50 patients operated in our hospital, 34 were females, that is, 68% of the patients, and 16 patients were males, that is, 32%.

As per age, 20 patients were between 41 and 50 years of age, that is, 40% belonged to 41–50 years of age; 39 patients were below 50 years, that is, 78% of patients were below 50 years; and % were below 20 years; and 22% were above 50 years.

As per the combined age and sex ratio also, both males and females were presumed below 50 years only.

As per the valve area, the most common valve by preoperative echo was 66% below and equal to 1 cm[2] by PHTs and planimetry [Table 1], [Table 2], [Table 3], [Table 4].
TABLE 1: Distribution according to sex

Click here to view
TABLE 2: Distribution according to age

Click here to view
TABLE 3: Valve area and size

Click here to view
TABLE 4: Valve gradient and number of patients

Click here to view


The preoperative maximum and the mean valve gradient in 90% of the patients were more than 15 mmHg and ≥10 mmHg, respectively [Table 4], [Table 5], [Table 6], [Table 7], [Table 8].
TABLE 5: Pre-Operative ejection fraction of patients

Click here to view
TABLE 6: LVIDS (preop)

Click here to view
TABLE 7: LVIDD preop

Click here to view
TABLE 8: RVSP (preop)

Click here to view


About 80% of the patients had preoperative ejection fraction (EF) of more than 55% and less than 10% were between 36% and 40%.

Around 60% of the patients were with 26–40 mm preoperative Left ventricle internal diameter in systole (LVIDs) and 60% of them were with more than 45 mm preoperative Left ventricle internal diameter in diastole (LVIDd).

Preoperatively, 40% of the patients had severe pulmonary arterial hypertension (PAH), 30% of the patients had moderate PAH, and 30% of the patients had mild PAH.

All these patients were taken up for MVR and TTK Chitra valve between 27 and 31 was used.

In 70% of the patients, 29 and 31 TTK Chitra valve was used [Table 9].
TABLE 9: TTK valve size

Click here to view


Regarding postoperative parameters, 80% of the postoperative patients had LVIDs of 26–35 mm and 90% of the patients had LVIDd less than 55 mm [Table 10] and [Table 11].
TABLE 10: LVIDS (postop

Click here to view
TABLE 11: LVIDD (postop)

Click here to view


Postoperatively, 78% of the patients improved themselves to moderate or mild PAH.

The postoperative mean valve gradient had decreased to 2–4 mmHg in 80% of the patients.

All these patients were operated for MV where the posterior leaflet was excised and no subvalvular apparatus was conserved and no chordal repair was done, but apparently no postoperative LV dysfunction was found in these patients.

This clearly indicates that posterior leaflet preservation and subvalvular apparatus preservation are not protective for LV function as far as rheumatic and stenotic MV are concerned.


  Discussion Top


MV had been the most commonly affected in the disease process of chronic RHD.

MV complex includes valve leaflets, annulus, commisures, and subvalvular apparatus which includes chorde tendinae and papillary muscles.

The speciality of rheumatic disease process is that it involves all these components in various degrees and the process continues to grow slowly.

The popular Wilkins score evaluates these and gives them a score as per the degree of involvement of each component (into four grades).

MV surgery started its origin from 1902 from digital commisurotomy to the present stage of percutaneous MVR, which is catering to the changing trends of MV disease from rheumatic to nonrheumatic disease in the Western world, and hence preservation of components of MV complex to preserve the left ventricular (LV) geometry and function became the major goal and target of MVR.

Contrary to the West, in India still rheumatic MV disease dominates the scenario accounting for more than 70% of the disease population, and especially in rural population still patients are presenting with advanced disease involving complete MV complex (Wilkins score >12), and preservation of posterior leaflet and subvalvular apparatus will not benefit the patient and the ongoing rheumatic process may endanger the prosthetic valve. A study conducted by Djukic PL and team from the Institute for Cardiovascular Diseases, Department of Cardiac Surgery, Clinical Centre of Serbia, Belgrade, proved the same.

Historical evolution of the prosthetic heart valves from the first attempts with the Hufnagel's valve in the treatment of aortic insufficiency to the Starr–Edwards' ball valve, and later the tilting disc valves (Bjork–Shiley, etc.), and finally the bileaflet valves (St. Jude) is discussed. The Indian contribution with Chitra valve is also described; TTK Chitra heart valve prosthesis (CHVP), a tilting disc mechanical heart valve of low cost and proven efficacy, has been in use for the past 15 years.

Chitra valve has an integrally machined cobalt-based alloy cage, an ultra-high molecular-weight polyethylene disc, and a polyester suture ring. The present valve is a fourth-generation valve. An important feature of this valve is its soft closing sound, by virtue of a plastic occlude.[1]

This study focused on two issues basically:

  • One is the secure use of native tilting disc valves in the current era of bileaflet valves.
  • The second is the effects of excision of posterior valve and subvalvular apparatus and its effects on LV function in rheumatic MV stenosis.


This study is based on echocardiographic analysis of the preoperative mean gradient across MV and postoperative mean gradient across MV which shows a considerable, comparable, and acceptable mean gradient postoperatively [Table 12].
TABLE 12: Mitral valve mean gradient - postop

Click here to view



Preoperatively, 90% of the maximum and mean gradients are more than 15 and 10 mmHg, respectively, and postoperatively, the same parameters have decreased to a mean gradient of 2–4 mmHg in 96% of patients and 70 of these patients have been implanted 29 (25) and 31 (10) TTK Chitra valve [Table 13].
TABLE 13: Comparsion of pre and post OP. LVIDS

Click here to view


In this study, the most favorable valve is 29-mm TTK Chitra valve even in stenotic patients which give acceptable mean gradients postoperatively.

The 31-mm TTK Chitra valve produces more acceptable gradients but less frequently implanted in stenotic patients due to fibrosed and contracted annulus in rheumatic disease.

Regarding the other parameters concerning the left ventricle such as EF, LVIDs, and LVIDd, there is no improvement or deterioration of LV function and we have not reported any LV dysfunction postoperatively [Table 14] and [Table 15].
TABLE 14: Comparsion of pre and post OP. LVIDD

Click here to view
TABLE 15: Comparsion of pre and post OP. ejection fraction

Click here to view


There is a significant decrease in the pulmonary artery pressures postoperatively as 78% of the patients turned down to mild to moderate PAH.

This is represented by Right ventricular Systolic pressure (RVSP) in the table, and complete valve excision and using of tilting disc valve did not affect the outcome of the patients and in fact the patients improved postoperatively [Table 16] and [Table 17].
TABLE 16: RVSP (Postop

Click here to view
TABLE 17: Comparsion of pre and post OP RVSP

Click here to view


Overall in our study, we had not encountered any mortality and morbidity associated with the procedure and there were no para valvular leaks postoperatively, and all the patients did well in the later period also.

The patient population encountered with us were of rural background and of lower economic group and had severe disease due to poor medical facilities.

Only rheumatic mitral stenosis was taken for the study, and hence in these situations still age-old complete valve excision and even native tilting disc valve TTK Chitra valve give equally good results than the recently invented valves and a large population can be benefitted.

We had studied various Results from Indian studies like Sankarkumar et al, Bhuvaneshwar GS, et al.,[2],[3],[4] (multicenter studies by clinical study. J Heart Valve Dis 2001;10:619-27). And we also had similar results eventough our study was limited.

The clinical course of our follow up even though it is very limited and limited period coordinates with RAO et al.[5]

Early results of Clinical trial mentioned by Valiathan, et al.,[6] had some morbidity and mortality but was due to first generation but in recent studies there is a lot of improvement which is we have found with our study

Even western studies related to tilting disc valves are also producing encouraging results Milano A, et al, Peter M, et al, Pellegrini A, et al.[7],[8],[9],[10],[11] The disease process in western scenario has changed from rheumatic to degeneration and ischemic disease but in India still Rheumatic disease dominates the rest.


  Limitations of the Study Top


Our patient sample size of study was limited with limited parameters of study.

This is majorly echocardiographic-based study only and other hematological and other investigations are not taken into consideration.


  Conclusion Top


Whenever rheumatic mitral stenosis is present, complete valve can be reasonably excised without even sparing or preserving the subvalvular apparatus and it does not affect the EF and LV function.

Native tilting disc valve, that is, TTK Chitra valve, can be safely used and gives comparable results with the recent generation valves, and better outcomes are encountered with 29-mm size and above size valves.

Pulmonary artery hypertension decreases significantly if mitral stenosis is operated regardless of the advancement of disease process.

There is no significant change in LV systolic and diastolic dimensions and no changes were found in EF postoperatively.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Li HH, Jeffrey RR, Davidson KG, Seifert D, Körfer R, Grunkemeier GL. The Ultracor tilting disc heart valve prosthesis: A seven-year study. J Heart Valve Dis 1998;7:647-54.  Back to cited text no. 1
    
2.
Sankarkumar R, Bhuvaneshwar GS, Magotra R, Muralidharan S, Rajan RS, Saha D, et al. Chitra heart valve: Results of a multicenter clinical study. J Heart Valve Dis 2001; 10:619-27.  Back to cited text no. 2
    
3.
Kumar P, Dalvi B, Chikkatur R, Kandhachar P, Parida R, Ahuja V, et al. TTK Chitra tilting disc valve: Hemodynamic evaluation. Indian J Thorac Cardiovasc Surg 2004;20:117-21. DOI: 10.1007/s12055-004-0060-5  Back to cited text no. 3
    
4.
Bhuvaneshwar GS, Muraleedharan CV, Arthun Vijayan C, Sankar Kumar R, Valiathan MS, Development of the Chitra tilting disc heart valve prosthesis. J Heart Valve Dis 1996;5:448-58.  Back to cited text no. 4
    
5.
Rao S, Kurian VM, Ghosh M, Sankar Kumar R, Mohan Singh MP, Valiathan MS. Clinical course after mitral valve replacement. Indian Heart J 1990;42:335-9.  Back to cited text no. 5
    
6.
Valiathan, Sankar Kumar, Balakrishnan, Venkitachalam, Bhuvaneshwar GS. Experience with the Chitra prosthetic valve: Early results of Clinical trial. Indian J Thorac Cardiovasc Surg 1991;7:105-8.  Back to cited text no. 6
    
7.
Sankarkumar R, Bhuvaneshwar GS, Magotra MS, Muralidharan S, Rajan RS, Saha D,et al. Chitra Heart valve: Results of a multicentre clinical study. J Heart Valve Dis 2001;10:619-27.  Back to cited text no. 7
    
8.
Milano A, Bortolotti U, Mazzucco A, Mossuto E, Testolin L, Thiene G,et al. Heart valve replacement with the Sorin tilting-disc prosthesis. A 10-year experience. J Thorac Cardiovasc Surg 1992;103:267-75.  Back to cited text no. 8
    
9.
Peter M, Weiss P, Jenzer HR, Hoffmann A, Dubach P, Roth J, et al. The Omnicarbon tilting-disc heart valve prosthesis. A clinical and Doppler echocardiographic follow-up. J Thorac Cardiovasc Surg 1993;106:599-608.  Back to cited text no. 9
    
10.
Pellegrini A, Colombo T, Quaini E, Russo C, Vitali E, Donatelli F. Mitral valve replacement with the SORIN valve. Long-term follow-up of 1,161 patients. Tex Heart Inst J 1991;18:16-23.  Back to cited text no. 10
    
11.
Strüber M, Campbell A, Richard G, Laas J. Hydrodynamic function of tilting disc prostheses and bileaflet valves in double valve replacement. Eur J Cardiothorac Surg 1996;10:422-7.  Back to cited text no. 11
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14], [Table 15], [Table 16], [Table 17]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Objectives of th...
Materials and Me...
Results
Discussion
Limitations of t...
Conclusion
References
Article Tables

 Article Access Statistics
    Viewed717    
    Printed46    
    Emailed0    
    PDF Downloaded110    
    Comments [Add]    

Recommend this journal