Pathologic changes in the cardiac valves requiring surgical correction of more than one valve can result from rheumatic heart disease, degenerative valve diseases, infective endocarditis, and a number of miscellaneous causes. Further, valve dysfunction may be primary; that is, a direct result of a disease process, or secondary; that is, caused by cardiac enlargement and/or pulmonary hypertension. Surgical management is influenced both by the underlying cause of valve dysfunction and, when valves are involved secondarily, by the anticipated response to replacement or repair of the primary valve lesion. In addition, the consequences of various combinations of diseased valves on left and right ventricular geometry and function frequently are different from the remodeling as a result of single-valve disease. This chapter addresses pathophysiologic considerations in multivalvular heart disease, surgical techniques, and management of commonly encountered etiologies.
Repair of multiple lesions was necessary even in the early development of operative management of valvular heart disease (Table 47-1). The first triple-valve replacement during a single operation was reported in 1960, and simultaneous replacement of all four valves was reported in 1992.1
Table 47-1 History of Multiple Valve Operations |Favorite Table|Download (.pdf)
Table 47-1 History of Multiple Valve Operations
|Staged mitral then tricuspid commissurotomy||1952||Doctor's Hospital, Philadelphia, PA164|
|Simultaneous mitral and tricuspid commissurotomy||1953||Cleveland, OH165|
|Simultaneous mitral commissurotomy and aortic valvuloplasty using cardiopulmonary bypass||1956||University of Minnesota, Minneapolis, MN166|
|Simultaneous mitral and aortic valve replacement||1961||St. Francis General Hospital, Pittsburgh, PA123|
|Simultaneous triple-valve replacement||1963||University of Oregon, Portland, OR|
|Simultaneous quadruple valve replacement||1992||Mayo Clinic, Rochester, MN120|
Experience from clinical practice indicates that multiple valve disease requiring surgical correction occurs in a few common combinations. As seen in Table 47-2, multiple procedures account for approximately 15% of all operations on cardiac valves; 80% of these operations involve the aortic and mitral positions. Replacement of the mitral and tricuspid valves (with or without aortic replacement) accounts for 20% of operations. Only rarely is the combination of aortic and tricuspid disease encountered.
Table 47-2 Prevalence of Multiple Cardiac Valve Replacement According to Institution |Favorite Table|Download (.pdf)
Table 47-2 Prevalence of Multiple Cardiac Valve Replacement According to Institution
|University of Alabama||Mayo Clinic||Texas Heart Institute||University of Oregon||Percentage of all valve surgery (11,026 cases)||Percentage of multiple valve surgery (1662 cases)|
|Total number of all valve operations||2555||2166||4170||2135|
|All multiple valve procedures||383 (15%)||437 (20%)||541 (13%)||301 (14%)||15 (1662)||100|
|M-A||298 (11.6%)||320 (14.7%)||459 (11%)||253 (11.8%)||12 (1330)||80|
|M-A-T||40 (1.6%)||55 (2.5%)||55 (2.5%)||48 (2.2%)||2 (198)||12|
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