Rheumatic mitral repair versus replacement in a threshold country: the impact of commissural fusion.

BACKGROUND AND AIM OF THE STUDY: In developing countries rheumatic heart disease is the predominant indication for cardiac surgery. As the disease tends to progress, reoperation rates for mitral valve repairs are high. Against this background, the predictors of failure were assessed and the overall performance of repairs compared with replacements in a 10-year cohort of rheumatic single mitral valve procedures. METHODS: Between 2000 and 2010, a total of 646 consecutive adult (aged >15 years) patients underwent primary, single mitral valve procedures. All 87 percutaneous balloon valvuloplasties (100%) were rheumatic, compared to 280 of the 345 primary mitral valve replacements (81%) and 69 of the 215 primary mitral valve repairs (32%). As the study aim was to compare the outcome of mitral valve repair versus replacement in rheumatic patients of a threshold country, all 69 repair patients were propensity-matched with 69 of the replacement patients. Based on propensity score analysis, Kaplan-Meier actuarial analysis with log-rank testing was used to evaluate survival and morbidity. RESULTS: The follow up was 100% complete (n = 138), and ranged from 0.6 to 132 months (mean 53.3 +/- 36.5 months). Actuarial freedom from valve-related mortality was 96 +/- 3% and 92 +/- 4% at five years, and 96 +/- 3% and 80 +/- 11% at 10 years for repairs and replacements, respectively (p = NS). Actuarial freedom from all valve-related events (deaths, reoperations and morbidity) was 80 +/- 6% and 86 +/- 5% at five years, and 70 +/- 8% and 69 +/- 11% at 10 years (p = NS). Actuarial freedom from all valve-related events was 57 +/- 11% and 96 +/- 3% at five years (p = 0.0008), and 42 +/- 12% and 96 +/- 3% at 10 years (p < 0.001) for those mitral valve repairs with and without commissural fusion, respectively (p = 0.0002 overall). CONCLUSION: The long-term results for mitral valve replacement in an indigent, rheumatic heart disease population of a developing country were better than generally perceived. Notwithstanding, mitral valve repair has a superior long-term outcome in those patients who do not show commissural fusion at operation.

Heart transplantation: the contributions of Christiaan Barnard and the University of Cape Town/Groote Schuur Hospital.

Christiaan (Chris) Neethling Barnard was born in South Africa and qualified in medicine at the University of Cape Town in 1946. Following surgical training in South Africa and the USA, Barnard established a successful open-heart surgery program at Groote Schuur Hospital and the University of Cape Town in 1958. In 1967, he led the team that performed the world's first human-to-human heart transplant. Although the first heart transplant patient survived only 18 days, four of Groote Schuur hospital's first 10 patients survived for more than one year, two living for 13 and 23 years, respectively. This relative success amid many failures worldwide did much to generate guarded optimism that heart transplantation would eventually become a viable therapeutic option, Barnard then developed the operation of heterotopic heart transplantation (the socalled "piggy-back" transplant), which had some advantages in the pre-cyclosporine era when immunosuppressive therapy was limited. His group was the first to successfully transport donor hearts using a hypothermic perfusion storage device in 1981. Several studies on the haemodynamic and metabolic sequelae of brain death were carried out in his Department's cardiovascular research laboratories at the University of Cape Town, and the concept of hormonal replacement therapy in organ donors was developed. An active heart transplant program still continues in the Chris Barnard Division of Cardiothoracic Surgery at Groote Schuur Hospital and the University of Cape Town, but the thrust of clinical activity within the Division and the research within its state-of-the-art cardiovascular research laboratories is now directed towards valvular and ischaemic heart diseases, which are common in the African population.