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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 3, May/June 2021
AFRICA
151
the cardiothoracic surgeon. All valves displayed varying degrees
of rheumatic involvement as assessed by valve thickness and/or
calcification. Fifty two per cent of patients (
n
= 69) had features
of isolated chronic MR with no other findings. In addition to
chronic MR, the remaining subjects also had chordal rupture
(23%,
n
= 31), chordal elongation (16%,
n
= 21), active carditis
(1.5%,
n
= 2), and one subject had both chordal rupture and
elongation (1%).
Active carditis was diagnosed in the two patients who had
adhesions from fibrinous pericarditis. Chordal elongation was
also highly suggestive of ongoing active carditis in 21 patients.
Chordal rupture was presumed evidence of active carditis in
young subjects in the absence of infective endocarditis. Only
two patients had infective endocarditis, both of whom presented
in heart failure with EF > 55%. The first patient, a 23-year-old
male, was found to have grossly impaired LV function (EF =
18%) at the two-week, and six-week to three-month follow-
up visits, and was lost to follow up thereafter. The second, an
18-year-old female, had an EF of 70%, which fell to 40% at two
weeks, and she was well (NYHA I) with no clinical features of
cardiac failure at two years.
Despite being in heart failure, the majority of patients
underwent uneventful surgery with a median CPBT of 77 minutes
(
n
= 111, IQR 64–105 minutes). Most patients experienced
significant improvement in NYHA functional class (Table 3)
with resolution of heart failure. At six months following MVR
(
n
= 93), 1% of patients were in NYHA III–IV, 1% of patients
had heart failure and 7.6% had atrial fibrillation. The one patient
who remained in heart failure had a pre-operative EF of 56%,
which fell to 30% at two weeks postoperatively, and fell further
at the subsequent follow-up visits, with a concomitant increase
in left heart chamber dimensions. In total, there were 12 patients
with a persistently low EF (< 50%) at the six-month follow-
up visit; the median CPBT in this group was not significantly
different from the remaining patients (98 minutes, IQR 80–106,
p
= 0.07).
There were five postoperative deaths, yielding a mortality rate
of 4%. These deaths occurred in young patients with advanced
NYHA class, grossly dilated LA (
n
= 2) and PASP > 50 mmHg
(
n
= 3). There was no evidence of infective endocarditis or
active rheumatic carditis at surgery. One patient, who had a low
pre-operative EF of 40%, was HIV infected and died from lobar
pneumonia and cardiac failure two weeks after the operation.
Two patients were admitted
in extremis
pre-operatively, required
cardioversion in theatre and died from a low-cardiac output state.
A 21-year-old male whose EF fell from 68 to 35% at the two-week
post-operative visit, died from cardiac tamponade a month later.
The last patient was a nine-year-old child who died of massive air
embolism following removal of the aortic cross clamp.
Fourteen patients had a marked reduction in EF (to EF
< 30%) in the early postoperative period; eight of them had
received inotropic support at the end of mitral valve surgery.
Pre-operatively, nine of the 14 subjects had an EF < 60%, seven
had advanced heart failure (NHYA IV) and five were in atrial
fibrillation. The average CPBT in these patients was calculated
to be 101 minutes (range 40–180 minutes). The EF recovered
to > 50% in five of these 14 patients at the six-month follow up
(pre-operative EF 65, IQR 58–67); two patients died and seven
were lost to follow up.
Among the seven subjects with a pre-operative EF in the
40–49% range, only three recovered their EF to > 50% (EF:
52, 56 and 59%), with an accompanying fall in LVESD and
resolution of TR at the six-month visit (Table 4). In this group
there were two HIV-infected subjects: one had a pre-operative
EF of 40% and died two weeks after MVR, and the other, who
had a pre-operative EF of 55%, made an uneventful recovery.
The remaining two groups (EF 50–59% and > 60%) responded
similarly with an initial fall in the EF at two weeks and a steady
increase thereafter to over 55% in both groups, accompanied by
a decline in chamber dimensions and pulmonary artery pressure
Table 2. Baseline echocardiographic data across the different EF groups
EF group
40–49%
(n = 7)
50–59%
(n = 30)
> 60%
(n = 95)
p-value
LVEDD (mm)
62.6 ± 6.5 64.3 ± 8.3 59.4 ± 7.6 < 0.001
LVESD (mm)
49.0 ± 6.6 46.4 ± 5.8 37.5 ± 5.9 < 0.001
LA (mm)
56.3 ± 9.7 65.3 ± 13.8 60.2 ± 12.1
0.090
EF (%)*
42 (40–45)
56 (55–57)
65 (62–70)
< 0.001
PASP (mmHg)*
50 (38–53)
61 (35–79)
60 (47–80)
0.200
*Median (IQR). EF, ejection fraction; LA, left atrium; LVEDD, left ventricular
end-diastolic dimension; LVESD, left ventricular end-systolic dimension; PASP,
pulmonary artery systolic pressure. Ventricular dimensions were increased in
groups with EF < 60%.
Table 3. Pre- and postoperative functional class
Pre-surgery (n = 132)
6 months postsurgery (n = 93)
n
%
n
%
NYHA
I
10
7.6
79
84.9
II
35
26.5
13
14.0
III
39
29.5
1
1.1
IV
48
36.4
0
0.0
NYHA, New York Heart Association. Significant improvement was noted in
the functional class after surgery.
Table 4. Follow-up echocardiographic data
Postsurgery
Pre-surgery 2 weeks
6 weeks –
3 months
6 months
Pre-operative EF 40–49%
LVEDD (mm)
62.6 ± 6.5 57.3 ± 5.9 58.7 ± 15 59 ± 19.8
LVESD (mm)
49.0 ± 6.6
–
35.0 ± 1.4 40.5 ± 13.4
EF (%)*
42 (40–45)
43 (18–48) 52.0 (10–54) 56.0 (52–59)
LA (mm)
56.3 ± 9.7 42.4 ± 6.3 58.0 ± 0 61.5 ± 19
PASP (mmHg)*
50 (38–53)
45 (37–62) 62.0 (40–64) 43.5 (35–52)
Pre-operative EF 50–59%
LVEDD (mm)
64.3 ± 8.3 56.0 ± 8,7 55.3 ± 10.1 49.0 ± 9.6
LVESD (mm)
46.4 ± 5.8 41.5 ± 6,8 39.8 ± 10.4 36.0 ± 10.9
EF (%)*
56 (55–57)
40 (30–46) 50.0 (28–53) 56.0 (47–59)
LA (mm)
65.3 ± 13.8 51.0 ± 13,4 49.3 ± 11.8 44.6 ± 12.4
PAS (mmHg)*
61 (35–79) 46.5 (35–55) 43.0 (37–46) 34 (28.5–40)
Pre-operative EF > 60%
LVEDD (mm)
59.4 ± 7.6 51.3 ± 7.7 46.5 ± 7.4 48.2 ± 7.4
LVESD (mm)
37.5 ± 5.9 36.2 ± 9.8 32.5 ± 9.4 31.8 ± 6.4
EF (%)*
65 (62–70) 47.5 (40-57) 56.0 (48.5–60) 57.0 (43–65)
LA (mm)
60.2 ± 12.1 49.0 ± 11.4 43.9 ± 9.1 42.6 ± 8.7
PASP (mmHg)*
60 (47–80)
45 (38–55) 41.5 (36–49) 36.5 (31–41)
*Median (IQR). EF, ejection fraction; LA, left atrium; LVEDD, left ventricular
end-diastolic dimension; LVESD, left ventricular end-systolic dimension; PASP,
pulmonary artery systolic pressure. LA size and PA pressure remained elevated
in the group EF 40–49%. Most changes were complete at the six-week exami-
nation in the group with EF > 60%, while the group with EF 50–59% showed
ongoing improvement in echocardiographic parameters until six months.