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 Table of Contents  
Year : 2020  |  Volume : 15  |  Issue : 3  |  Page : 454-461

Early complications in patients undergoing mitral valve replacement surgery: An observational study

Department of Cardiac Vascular Thoracic Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed University), Wardha, Maharashtra, India

Date of Submission01-May-2017
Date of Acceptance02-May-2021
Date of Web Publication1-Feb-2021

Correspondence Address:
Dr. Imran Ali M. Khan
Department of Cardiac Vascular Thoracic Surgery, Acharya Vinoba Bhave Rural Hospital, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed University), Sawangi, Wardha - 442 004, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdmimsu.jdmimsu_7_17

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Background: Rheumatic fever(RF) & Rheumatic Heart disease(RHD) present a problem in all parts of the world especially in developing countries. In India RHD accounts for 12%-65% hospital admissions related to cardiovascular disease. It is the most common cause of Mitral valve disease with associated morbidity and mortality. Mitral valve replacement (MVR) is the surgical treatment when conservative approach fails.Mitral stenosis(MS), Mitral regurgitation (MR) or both MS+MR are main indications for MVR. Material and Method: Despite a rise in the rate of success of total valve replacement, the procedure has been associated with complications inherent to prosthesis as well as to any intra cardiac procedure. Majority of authors have defined complications occuring within thirty days in post operative period as early complications. Observations and Results: In this observational study of 85 patients at a rural cardiac surgery center, who underwent MVR for Mitral valve disease with concomittant Maze-III procedure(modified) for the surgical ablation of Atrialfibrillation (AF) if present, the early complications observed were General complications( AF, Post operative excessive bleeding, haemolysis,Neurological-psychiatric-Thromboembolic complications, wound infection,respiratory complications, Renal complications,prolonged inotropic support& Mechanical ventillation, Prolonged hospital stay & early mortality and Prosthesis specific complications of Paravulvular regugitation( PVR), Obstruction to valve by thrombus,valve endocarditis. Conclusion: AF was the most common post operative complication observed in 24.7% patients,Acute delirium(psychosis) was seen in 21.17% patients,prolonged hospital stay(more than 10 days) was observed in 17.7% of patients, prolonged inotropic support was needed in 12.9% patients, pulmonary complications were observed in 10.5% patients. The rate for other isolated complications was less than 10% each. Overall mortality rate was 1.17%. Prosthetic Valve related complicaio.

Keywords: Atrial fibrillation, cardiopulmonary bypass time, closed mitral commissurotomy, mitral regurgitation, mitral stenosis, mitral valve replacement, modified Maze III, American College of Cardiology/American Heart Association, paravalvular regurgitation, postanesthetic care unit, rheumatic fever, rheumatic heart disease, Wilkin's score

How to cite this article:
Khan IA, Patwardhan A. Early complications in patients undergoing mitral valve replacement surgery: An observational study. J Datta Meghe Inst Med Sci Univ 2020;15:454-61

How to cite this URL:
Khan IA, Patwardhan A. Early complications in patients undergoing mitral valve replacement surgery: An observational study. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2021 Feb 25];15:454-61. Available from: http://www.journaldmims.com/text.asp?2020/15/3/454/308574

  Introduction Top

In India, rheumatic heart disease (RHD) accounts for 12%–65% of hospital admissions related to cardiovascular disease.[1] A recent study by Yadav et al. has shown that in India, the prevalence of rheumatic fever/RHD is 4–6/1000 population.[2]

It is the most common cause of mitral valve disease rendering it incapable of performing its optimal functions affecting the heart adversely with associated morbidity and mortality. Mitral valve replacement (MVR) is the surgical treatment when conservative approach fails. Indications for MVR are mitral stenosis (MS), mitral regurgitation (MR), MS + MR, nonfeasibility of percutaneous techniques, nonfeasibility of satisfactory Mitral valve repair, restenosis after closed mitral commissurotomy (CMC), and Wilkins score >8/16.[3],[4],[5],[6]

Despite a rise in the rate of success of total valve replacement, the procedure has been associated with complications inherent to prosthesis as well as to any intracardiac procedure.[7] Majority of authors have defined complications occurring within 30 days in postoperative period as early complications.[7],[8]

In this study of 85 patients at a rural cardiac surgery center, who underwent MVR for mitral valve disease with concomitant Maze III procedure (modified) for the surgical ablation of atrial fibrillation (AF) if present, the early complications observed were as follows:

General complications (AF, postoperative excessive bleeding, hemolysis, neurological-psychiatric-thromboembolic complications, wound infection, respiratory complications, renal complications, prolonged inotropic support and mechanical ventilation, prolonged hospital stay, and early mortality) and prosthesis-specific complications of paravalvular regurgitation (PVR), obstruction to valve by thrombus, and valve endocarditis.

AF is the most common postoperative arrhythmia occurring in about 30% patients and is associated with increased rate of (1) cognitive changes, (2) renal dysfunction, (3) Infection, and (4) longer hospital stay.[9] Excessive postoperative mediastinal bleeding occurs in 2%–6% of cardiac surgery patients requiring re-exploration.[10] Cerebral strokes are the result of emboli to the cerebral circulation.[11],[12]

For adults, incidence of transient or permanent adverse cerebral outcomes including stroke, encephalopathy, and/or delirium may be as high as 10%–50%.[13],[14],[15]

Surgical wound infections are clearly an important contributor to the postoperative morbidity and mortality.[16],[17]

Postoperative renal insufficiency of some degree develops in 5%–30% of cardiac surgery patients, with approximately 1% requiring dialysis.[18],[19]

Radiographic evidence of atelectasis is present in most patients in early postoperative period.[8]

Most patients are extubated within 6 h after surgery, and more than 6 h of intubation is an evidence of respiratory insufficiency.[8]

In the current era, fast-track management in cardiac surgery is the gold standard of treatment and postanesthetic care unit rather than the Intensive Care Unit (ICU) are being utilized for early extubation and weaning from mechanical ventilation and inotropic support for shifting the patient to step-down unit.[7]

A 30-day postoperative mortality is considered the early mortality.[20],[21],[22]

Most of the early deaths are attributable to cardiac failure with risk factors such as old age, MR, left ventricular or atrial enlargement, advanced New York Heart Association (NYHA) class, and prolonged cardiopulmonary bypass time (CPB) and cross-clamp times.[3]

For isolated MVR, the mortality rate is <2%.[3]

Aim and objectives

  • To study the clinical profiles of patients for MVR surgery
  • To determine the early complications occurring after open cardiac surgery for MVR
  • To study the early postoperative mortality in patients undergoing MVR.

  Materials and Methods Top


The present work has been carried out at the Department of Cardiovascular and Thoracic Surgery (CVTS) surgery at Acharya Vinoba Bhave Rural Hospital at Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed University), Sawangi Meghe, Wardha, Maharashtra.

This is a cross-sectional observational study of 85 patients (both males and females) undergoing MVR surgery at the department of CVTS, during the period December 15, 2012–August 15, 2014.

Data were collected from the medical records of the patients (outpatient department [OPD] and indoor) and operation theater records.

Inclusion criteria

(1) All patients of RHD involving mainly the mitral valve, with or without AF, requiring MVR or MVR with concomitant Maze procedure, (2) Wilkins score >8/16, (3) presence of LA thrombus, (4) requiring tricuspid repair, (5) patients of restenosis of mitral valve after CMC (by thoracotomy), (6) emergency MVR with cardiac failure with normal renal function, and (7) emergency MVR for the complications arising out of balloon mitral Valvuloplasty.

Exclusion criteria

(1) Double valve replacement, (2) coronary artery disease, (3) Redo sternotomy, (4) presence of other intracardiac lesions, and (5) presence of diabetes mellitus (DM), renal dysfunction, infection, stroke, raised prothrombin time-internationally normalized ratio (PT-INR), and platelet deficiency.

Preoperative management

After selection of patients for MVR, who were diagnosed by two-dimensional echocardiogram on OPD basis following measures were taken.

All necessary laboratory and radiological investigations, essential for a cardiac procedure were done. Patients were explained in details about the prosthesis (mechanical/bioprosthesis), postoperative anticoagulation with its complications, dietary restrictions, etc.

All patients underwent median sternotomy MVR with CPB with or without concomitant modified Maze III procedure utilizing radiofrequency bipolar energy plus CryoProbe for AF.

Postoperative period

All operated cases were kept in ICU for first 2 days. Routine standard investigation. On 2nd postoperative day, anticoagulation started after PT-INR, which is repeated on alternate days.

On 5th day, routine transthoracic echocardiography is done by cardiologist/intensivist, as a routine to assess general cardiac and prosthesis status. Routine tests on 5th day and special tests were carried out as per requirement.

Following variables representing the early postoperative complications following mitral valve replacement were observed and hence studied in the present work

General complications

(1) Arrhythmias (AF, Bradycardia, supraventricular tachycardia (SVT), (2) postoperative excessive bleeding (surgical/Coagulopathy) (>4–5 ml/kg/h), (3) hemolysis (Hb% <8 g%), (4) neuropsychosis and thromboembolic (neurological + psychiatric and ischemia of limb/organ) under neurological complications such as stroke and under psychiatric-acute delirium., (5) wound complications (infective superficial, deep and noninfective superficial, deep), (6) respiratory complications (parenchymal atelectasis, pleural effusion, pneumothorax, hemothorax, etc.), (7) renal complications (serum creatinine 1.5 mg/100 ml or more), (8) inotropic support >24 h, (9) mechanical ventilation >24 h, (10) longer hospital stay >10 days due to any or combination of above factors, and (11) anticoagulation-related complications.

Valve-specific complications

(1) PVR or leak (2) obstruction due to thrombus or valve endocarditis.


Standard statistical analysis was done. Collected data were depicted in tabulated form.

Ethical clearance

The Institutional Ethics Committee of DMIMSDU has approved the Research work proposed to be carried out at Jawaharlal Nehru Medical College, Sawangi(M), Wardha. Date: 15th Sept 2012 with Reference no DMIMS(DU)/IEC/2012/512.

  Observations and Results Top

In total, 85 patients have undergone MVR surgery. Out of these, 65 (76.47%) were female and 20 (23.53%) were male [Table 1] (Age: 5 years to over 50 years).
Table 1: Gender distribution of patients undergoing mitral valve replacement

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[Table 2] and [Table 3] show general and valve-related postoperative complications, respectively, in patients undergoing MVR surgery. Postoperative arrhythmias were the most prominent early complication and mostly consisted of significant AF. AF was observed in 24.7% patients, and other insignificant self-limiting arrhythmias of short duration consisting of SVT and bradycardia were observed in 5.8% of patients. Significant postoperative bleeding was observed in 5.8% (five patients). Thromboembolic/neuropsychosis complications were observed in 22 patients, of which 2.35% (two patients) had stroke (hemiplegia), 1.17%[1] developed ischemia of limb in the form of gangrene of toes, and 21.17% (18) showed psychosis (acute delirium). Postoperative surgical wound complications were observed in 7% (6) patients. Hemolysis was seen in 7% (6) patients. Pulmonary complications comprising pleural and parenchymal lesions were present in 10.5% (9) patients. Prolonged stay in the ICU (more than 3 days) and consequently in hospital (more than 10 days) was observed in 17.7% (15) patients. Use of positive inotropic support of more than 24 h was seen in 12.9% (11) patients. Renal complications in the form of renal insufficiency with postoperative raised serum creatinine more than 1.5 were seen in 4.7% (4) patients. There was no complication related to the use of anticoagulants in the postoperative period. Use of mechanical ventilation of more than 24 h was observed in 8.23% (8) patients. The overall postoperative mortality was 1.17% (one patient). As far as valve-specific complications were concerned, they were observed in two patients (2.35%) as mild PVR/leak during the hospital stay. No patient had valve obstruction due to thrombus or valve endocarditis. No other valve-related events were noted.
Table 2: General complications observed in postoperative period

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Table 3: Prosthetic valve-related complications observed in postoperative period

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  Discussion Top

In this study of 85 patients who underwent MVR, 65 (76.4%) were female and 20 (23.6%) were male patients as per Table 1. The complications observed are depicted in Table 3. These observations can favorably be compared with the study of 99 patients done by Knott, who found overall rate of AF 32%, mortality 4%, and similar complications such as prolonged use of ventilators and thromboemboli, renal insufficiency, and strokes.[23]


Atrial fibrillation

Michelena et al. and majority of researchers found that AF is the most common arrhythmia in both males and females. Supraventricular arrhythmias, especially AF, are noted in about 25% of patients. It is usually benign.[6] In a large study of 4657 patients by Kaireviciute et al., who have undergone valvular surgery AF was found in 33%–49%. Patients.[24]

Postoperative arrhythmia was observed in 26 (30.58%) patients in the present study as depicted in Table 3. The overall incidence of arrhythmia including AF is in consistency with the majority of reports.[6],[9],[8],[25],[26]

The most prominent arrhythmia in the present study was AF which was found in 21 (24.7%) patients who have undergone MVR surgery. This is similar to percentage of AF reported in above and a majority of studies available in literature. There were 41 patients (48.23%) who had preoperative AF and underwent concomitant Maze procedure for surgical ablation of AF.

A proposed mechanism such as pericardial inflammation, autonomic imbalance during the postoperative period, excessive production of catecholamines, and fluid shift with resultant changes in volume and pressure is attributed to the development of AF.[27],[28]

In the present study, the most important risk factors are advanced age, valvular heart disease itself leading to enlarged left atrium, preexisting AF in 57.14% patients, and surgical trauma to left atrium in all cases.[9],[29]

Rheumatic valvular heart disease is commonly associated with AF which is the most common type of supraventricular arrhythmia. Cardiomyopathy due to tachycardia, systemic thromboembolism (stroke, peripheral ischemic), and altered life pattern are the results of AF.[30],[31],[32]

AF is an independent risk factor for morbidities such as stroke, heart failure, or death.[23],[33]

The risk of thromboembolic complications is approximately five to six times that of the population in sinus rhythm in chronic AF without rheumatic lesions, but the risk is about 17 folds in patients with RHD.[34],[35]


Concern is raised when the mediastinal tube output exceeds 4–5 ml/kg/h during first few hours after operation. Efforts must be made to determine the presence or absence of treatable conditions (e.g., coagulopathy) and whether re-exploration is needed. Mediastinal bleeding is categorized as surgical or medical (due to coagulopathy).

Re-exploration for bleeding is associated with increased morbidity and mortality.[10],[37]

There should be a low threshold for returning the patient to operating room early using the guidelines.[37]

Early exploration can (1) minimize the use of multiple transfusions associated with high risk of respiratory and renal failure, sepsis, and death and (2) lower the risk of wound complications.[38],[39]

Nonsurgical (microvascular bleeding) after cardiac surgery using CPB is a multifocal problem.

The central mediator in the process of clot formation is the generation of thrombin which acts to convert fibrinogen to fibrin, the basic building block of clot.

CPB also induces systemic inflammatory reaction, which opens up various pathways and destabilizes homeostasis including blood clotting.[8],[40]

In the present study, the postoperative bleeding was observed in five (5.85%) patients. This is in consistency with the other studies.[3],[10],[36]

In all the cases, the bleeding was turned out to be due to coagulopathy and none required re-exploration.


In the present study, the significant hemolysis (Hb < 8 g%) was observed in six (7%) patients necessitating blood transfusion in the postoperative period. This is in consistency with the majority of studies where a hematocrit below 22%–25% (Hb% <8) was considered a threshold for transfusion.[6],[41],[42]

Maraj et al. and other researchers showed that the primary mechanism and most common cause of hemolytic disease in patients with prosthetic heart valves are mechanical trauma to erythrocytes and paraprosthetic valvular regurgitation.[10],[43]

Neurological (neuropsychosis)/thromboembolic complications

In our series, we found cerebral stroke leading to hemiplegia in 2 (2.35%) patients. This is on the lower side in comparison with the reports of various authors.

McKhann et al. and Newman MF et al. and various other researchers in their studies reported 10%–50% incidence.[2],[13],[14]

Advanced age, DM, HT, female gender, cerebrovascular disease, previous cardiac surgery, emergency surgery, LA thrombus, and lack of careful De-airing are common risk factors for the development of stroke. Other recognized factors in adults are atherosclerotic disease of ascending aorta, increased CPB time, use of hemofiltration, and high blood transfusion.[8],[44],[45],[46],[47],[48],[49],[50]

The incidence of stroke in the present study is significantly low as compared to other studies (10% and above). Risk factors were the presence of AF and thrombus in one patient and AF and female gender in other patients. These findings are comparable with various studies reported.[13],[14],[49],[50]

One female (1.17%) patient had lower limb ischemia and developed gangrene of toes in the postoperative period. She also had AF in the postoperative period. It was not ascertained whether it was compartment syndrome leading to ischemia. Prolonged groin cannulation might be the cause.[6]

Acute delirium (psychosis)

Psychiatric problem (acute delirium) is a transient syndrome with impaired cognitive functions, reduced consciousness, and ability to maintain attention or hyperactiveness with combative loud behavior or quite behavior. It is a frequent postoperative problem found in 3%–50% of patients of cardiac surgery.[15]

Factors associated with the development of delirium include prior stroke or TIA, cerebrovascular disease, advanced age, preoperative cardiogenic shock, AF, DM, emergency surgery, postoperative blood transfusions, and low cardiac output. In this study, acute delirium or psychosis was found in 18 patients (21.17%). All the patients showed hyperactivity and combative loud behavior. All developed the complication on the next day of operation in ICU. This finding is in line with that reported by Koster et al. (3%–5%) and others.[51],[52]

Respiratory complications

Mistiaen et al. categorized respiratory failure, pneumonia, atelectasis under pulmonary complications and effusions, pneumothorax, empyema, and hemothorax under pleural complications.

The etiology of atelectasis is multifactorial: (1) conditions leading to hypoventilation, (2) conditions causing increased secretions, and (3) conditions causing abnormal clearance.

Pleural effusion is evident in up to 50% cases.[53]

In a largest reported series, large effusion occupying 25% of hemithorax was reported in <1% patients.[54],[55]

In this study, the respiratory complications (parenchymal + pleural) were 10.5% (9/85) patients. Five patients had atelectasis (5.8%]) and four developed pleural effusion (4.2%) in the postoperative period. There was no mortality observed. Similar findings were reported by Mistiaen et al. of 6% and 5% for pulmonary and pleural complications, respectively. This is within the range as reported various studies.[53],[56]

Wound complications

Sternal wound complications occur infrequently with an estimated incidence of 1%–5%, with a substantial morbidity and mortality. Minor complications include skin separation, soft tissue seroma, and infection without bone involvement. They are managed conservatively.

Major complications include sternal dehiscence (presence of peculiar click sound, discharge, unexplained fever, and leukocytosis), mediastinitis, and sternal osteomyelitis. These occur in 0.8% cases where closure with wires was done and in 0.9% cases when closure with Dacron was done.[57],[58],[59]

The predisposing factors for sternal complications are pre-, intra-, and postoperative factors.[60],[61]

Preoperative factors

Preoperative factors were obesity, diabetes, COAD, radiation, immunosuppressed state, renal failure, etc.

Intraoperative factors

Intraoperative factors were strict asepsis, proper hemostasis with discriminate use of electrocautery, precise midline sternotomy, meticulous atraumatic surgical technique, proper choice of closure material, and avoidance of prolonged operative time.

Postoperative factors

Postoperative factors were prolonged ventilator support, postoperative external cardiac compressions, and re-exploration for bleeding.

In the present study, none of the major wound complications was observed. Minor complication of serous discharge occurred in six patients (7%), all female in the age group between 40 and 50 years. This percentage nearly tallies with the occurrence reported in various series. Soakage was observed after 72 h. Culture and sensitivity reported nil for organism. They were managed conservatively. No patient was obese or diabetic or had renal insufficiency.

Renal complications

preoperative renal dysfunction is a major determinant of both operative and long-term mortality after cardiac surgery. Even patients with mild preoperative renal insufficiency are more likely to experience acute kidney injury (AKI) afterward with a compromised short- and long-term outcomes.[6]

Renal dysfunction is commonly defined as serum creatinine more than 1.5 mg/dl.

Etiology: The mechanisms include (1) renal hypoperfusion from low flow, (2) low-pressure nonpulsatile perfusion, (3) hemodilution, (4) hypothermia, (5) Systemic inflammatory response, (6) low cardiac output state, (and 7) intense peripheral vasoconstriction related to the use of alpha agents. The kidneys autoregulate and maintain RBF and GFR.[6]

However, a protracted period of ischemia will eventually cause tubular cell injury also called acute tubular necrosis or AKI.

Brown et al.,[62] Palomba et al.,[63] Thakar et al., and Mehta et al. concluded that the following risk factors are determinants for the development of postoperative renal insufficiency.

Risk factors for renal dysfunction

(1) Advanced age, (2) female gender, (3) DM, (4) Leukocytosis, (5) congestive heart failure, (6) hypertension, (7) emergency surgery, (8) NYHA Class III-IV, (9) CPB time more than 120 min, (10) nonwhite Race, (11) mitral valve surgery, (12) COPD, (13) severe anemia, and (14) re-operation.[6],[62]

The use of CPB for coronary artery bypass graft may result in more postoperative renal impairment as compared to conventional “off-pump” procedures.[64],[65]

Several studies suggest that the use of CPB prime of whole blood and high plasma Hb% level (more than 40/dl) during and early after CPB increases the risk of acute renal failure.

Postoperative renal insufficiency of some degree develops in 5%–30% of patients undergoing cardiac surgery. Approximately 1% require postoperative dialysis.[8]

In the present study, renal dysfunction occurred in 4.7% (4/85) of patients undergoing MVR. None required dialysis. There is no significant gender and age difference in the occurrence of renal dysfunction in this study. The overall incidence of renal dysfunction is in agreement with the incidence reported by Swaminathan et al.[19] and Ryckwaert et al.[18]

All the patients were treated by physician and no specific therapy was instituted. Before discharge, the serum creatinine levels returned to normal.

Preoperative risk factors were mitral valve surgery, NYHA-III-IV status, and nonwhite race.

Prolonged Intensive Care Unit and hospital stay

(ICU stay more than 48 h and hospital stay more than 10 days).

Advanced age, NYHA class above II, COPD, and increased cross-clamp time more than 90 min may be the reasons for longer stay of patients in ICU.

In the present study, the average length of ICU stay was 2.63 days (67 patients [78%] - 2 days and 18 patients [22%] - 5 days). Moreover, in majority 82% of cases, length of hospital stay was up to 10 days.

The length of hospital stay was 10 days in 70 (82.3%) patients and more than 10 days in 15 (17.7%) patients. Seventy (82.35%) patients were discharged within 10 days after operation and 15 (17.65%) stayed longer than 10 days in hospital due to various complications.

These observations are similar to reports available in literature.[20],[66]

Valve-related complications

In our study, we found mild paravalvular leak in two patients (2.35%).

Our incidence is within the range reported by Jindani et al. and Kastor et al. and others who blamed infection, friable annular tissue, annular calcification, use of monofilament sutures, Marfan syndrome, surface cutout, as possible contributory factors in 79% cases of paravalvular regurgitation in patients of MVR.[3],[6]

Joint Task Force agreed to the fact that replacement of a diseased heart valve with a prosthetic valve exchanges the native disease with prosthesis.[67],[68]


(Mortality during the stay and within 30 days of operation).

Most of the researchers considered mortality under 30 days of operation as early mortality.[2],[20]

A hospital mortality of 5.7% for isolated MVR has been reported from the Society of Thoracic Surgeons' adult cardiac surgery database during 2002–2006.[69]

In the present study, only one patient (i. 18%) died (on the 3rd postoperative day) due to acute cardiac failure. Patient was a female, over 65 years of age, with AF with left atrial enlargement with NYHA class IV as risk factors.[69],[70],[71]

This is in agreement with the rate, cause, and risk factors reported by Gilinov et al. and the textbook of cardiac surgery by Kirklin/Barratt-Boyes, fourth edition, vol-12,013.[70],[3]

  Summary and Conclusion Top

RHD with its associated complications is common in this part of the country. It is the most common cause of mitral valve disease (MS, MR, or both) in this area.

MVR is the surgical treatment when the native valve cannot be treated conservatively.

The operative approach in all cases in this study was through median sternotomy with CPB as in any other intracardiac procedure.

Valve replacement has been associated with certain complications inherent in the prosthesis; in addition to those encountered in any intracardiac operation, which can lead to increased morbidity, mortality, prolonged ICU and hospital stay, and the cost of treatment.

Complications occurring within first 30 postoperative days were defined as early complications. In this study, these complications were arrhythmias, excessive postoperative mediastinal, bleed, thromboembolic/neuropsychosis, sternal wound complications, hemolysis, pulmonary complications, prolonged ICU stay, use of inotropic support, renal- and prosthesis-specific complications, and death.

Postoperative arrhythmia was observed in nearly one–third of operated patients (30.5%), and out of these patients, 21 patients had AF.

AF was the most prominent early postoperative Arrhythmia observed in about one-fourth cases (24.7%) studied in this series. Acute delirium (Psychosis) was the next important complication associated with central nervous system observed in 21.17% patients in association with various other complications, leading to prolonged stay in the hospital for ten patients. No mortality was observed in association with acute delirium.

Eleven patients (12.9%) required the use of inotropic support of more than 24 h.

Pulmonary complications were seen in nine (10.5%) patients, in the form of atelectasis and pleural effusion. These were not associated with a longer hospital stay or any mortality.

Seven patients (8.23%) required mechanical ventilation for more than 24 h and had to stay in ICU for more than 24 h. This includes one death in ICU due to multiple problems.

Only one patient (1.17%) died after surgery due to multiple factors, of which AF was one important factor among them.

Our center is a rural cardiac surgery center and population of patients it caters to, is economically week, and majority of patients are illiterate.

The pattern of postoperative complications in the present study, with reference to incidence and risk factors, does not differ from those reported in various studies in the available literature. In fact, the mortality rate was on the lower side but comparable.

Concomitant Maze procedure along with MVR was found to be very useful in ablating AF.

We conclude that at our rural cardiac surgery center, the pattern of postoperative morbidity and mortality is comparable with other cardiac surgery centers elsewhere, signifying our adherence to standard cardiac surgery practice as prescribed by international guidelines.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

WHO. Report of the Director General: The World Health Report Changing History. Switzerland: WHO; 2004.  Back to cited text no. 1
Yadav P, Joshi P, Gupta J. Prevalence of Rf/RHD in school children in Malwa region of MP. Natl J Community Med 2010;1:156-1.  Back to cited text no. 2
Kirklin/Barratt-Boyes Cardiac Surgery. 4th ed., Vol. 1. Philadelphia: Elsevier Saunders Publication; 2013.  Back to cited text no. 3
Kaiser LR, Kron IL, Spray TL. Mastery of Thoracic Surgery. 2nd ed. Philadelphia: Lippincott Williams & Wilkins Publication; 2007.  Back to cited text no. 4
Complications of heart valve surgery. Ann Thorac Surg 1996;2:52-63.  Back to cited text no. 5
Bojar RM. Manual of Perioperative Care in Cardiac Surgery. 5th ed. Sussex, UK: Wiley Blackwell Publication; 2011.  Back to cited text no. 6
Attar S, Saunders E, McLaughlin JS, Scherlis L, Cowley RA. Prosthetic heart valve surgery. Evaluation of early and late complications. Ann Thorac Surg 1966;2:52-63.  Back to cited text no. 7
Lemmer JH Jr., VIahakes GJ. Handbook of Patient Care in Cardiac Surgery. 7th ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Publication; 2010.  Back to cited text no. 8
Mathew JP, Fontes ML, Tudor IC, Ramsay J, Duke P, Mazer CD, et al. A multicenter risk index for atrial fibrillation after cardiac surgery. JAMA 2004;291:1720-9.  Back to cited text no. 9
Choong CK, Gerrard C, Goldsmith KA, Dunningham H, Vuylsteke A. Delayed re-exploration for bleeding after coronary artery bypass surgery results in adverse outcomes. Eur J Cardiothorac Surg 2007;31:834-8.  Back to cited text no. 10
Barbut D, Lo YW, Gold JP, Trifiletti RR, Yao FS, Hager DN, et al. Impact of embolization during coronary artery bypass grafting on outcome and length of stay. Ann Thorac Surg 1997;63:998-1002.  Back to cited text no. 11
Salazar JD, Wityk RJ, Grega MA, Borowicz LM, Doty JR, Petrofski JA, et al. Stroke after cardiac surgery: Short- and long-term outcomes. Ann Thorac Surg 2001;72:1195-201.  Back to cited text no. 12
McKhann GM, Grega MA, Borowicz LM Jr., Baumgartner WA, Selnes OA. Stroke and encephalopathy after cardiac surgery: An update. Stroke 2006;37:562-71.  Back to cited text no. 13
Newman MF, Mathew JP, Grocott HP, Mackensen GB, Monk T, Welsh-Bohmer KA, et al. Central nervous system injury associated with cardiac surgery. Lancet 2006;368:694-703.  Back to cited text no. 14
Koster S, Hensens AG, van der Palen J. The long-term cognitive and functional outcomes of postoperative delirium after cardiac surgery. Ann Thorac Surg 2009;87:1469-74.  Back to cited text no. 15
Braxton JH, Marrin CA, McGrath PD, Morton JR, Norotsky M, Charlesworth DC, et al. 10-year follow-up of patients with and without mediastinitis. Semin Thorac Cardiovasc Surg 2004;16:70-6.  Back to cited text no. 16
Losanoff JE, Richman BW, Jones JW. Disruption and infection of median sternotomy: A comprehensive review. Eur J Cardiothorac Surg 2002;21:831-9.  Back to cited text no. 17
Ryckwaert F, Boccara G, Frappier JM, Colson PH. Incidence, risk factors, and prognosis of a moderate increase in plasma creatinine early after cardiac surgery. Crit Care Med 2002;30:1495-8.  Back to cited text no. 18
Swaminathan M, Shaw AD, Phillips-Bute BG, McGugan-Clark PL, Archer LE, Talbert S, et al. Trends in acute renal failure associated with coronary artery bypass graft surgery in the United States. Crit Care Med 2007;35:2286-91.  Back to cited text no. 19
Müller M, Junger A, Bräu M, Kwapisz MM, Schindler E, Akintürk H, et al. Incidence and risk calculation of inotropic support in patients undergoing cardiac surgery with cardiopulmonary bypass using an automated anaesthesia record-keeping system. Br J Anaesth 2002;89:398-404.  Back to cited text no. 20
Van Caenegem O, Jacquet LM, Goenen M. Outcome of cardiac surgery patients with complicated Intensive Care Unit stay. Curr Opin Crit Care 2002;8:404-10.  Back to cited text no. 21
Eltheni R, Giakoumidakis K, Brokalaki H, Galanis P, Nenekidis I, Fildissis G. Predictors of prolonged stay in ICU following cardiac surgery. ISRN Nurs 2012;2012:1-6.  Back to cited text no. 22
Knott HW. Clinical study of mitral valve repair: Short-term and long-term outcomes. South Med J 1999;92:33-40.  Back to cited text no. 23
Kaireviciute D, Aidietis A, Lip GY. Atrial fibrillation following cardiac surgery: Clinical features and preventative strategies. Eur Heart J 2009;30:410-25.  Back to cited text no. 24
Maisel WH, Rawn JD, Stevenson WG. Atrial fibrillation after cardiac surgery. Ann Intern Med 2001;135:1061-73.  Back to cited text no. 25
Feinberg WM, Blackshear JL, Laupacis A, Kronmal R, Hart RG. Prevalence, age distribution, and gender of patients with atrial fibrillation. Analysis and implications. Arch Intern Med 1995;155:469-73.  Back to cited text no. 26
Echahidi N, Pibarot P, O'Hara G, Mathieu P. Mechanisms, prevention, and treatment of atrial fibrillation after cardiac surgery. J Am Coll Cardiol 2008;51:793-801.  Back to cited text no. 27
Levy MN. Sympathetic-parasympathetic interactions in the heart. Circ Res 1971;29:437-45.  Back to cited text no. 28
Creswell LL, Schuessler RB, Rosenbloom M, Cox JL. Hazards of postoperative atrial arrhythmias. Ann Thorac Surg 1993;56:539-49.  Back to cited text no. 29
Go AS, Hylek EM, Phillips KA, Chang Y, Henault LE, Selby JV, et al. Prevalence of diagnosed atrial fibrillation in adults: National implications for rhythm management and stroke prevention: The AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA 2001;285:2370-5.  Back to cited text no. 30
Lönnerholm S, Blomström P, Nilsson L, Oxelbark S, Jideus L, Blomström-Lundqvist C. Effects of the maze operation on health-related quality of life in patients with atrial fibrillation. Circulation 2000;101:2607-11.  Back to cited text no. 31
Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: The Framingham Study. Stroke 1991;22:983-8.  Back to cited text no. 32
Task Force. Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation: Analysis of pooled data from five randomized controlled trials. Arch Intern Med 1994;154:1449-57.  Back to cited text no. 33
Schlepper M. Identification of patients with atrial fibrillation at risk for thromboembolism. In: Olsson SB, Allessie MA, Campbell RW, editors. Atrial Fibrillation: Mechanism and Therapeutic Strategies. Vol. 15. Armonk, NY: Futura; 1994.  Back to cited text no. 34
Khan IA, Sancheti A, Paddalwar S, Potwar SA, Marghade S, Patwardhan AM. An update on concomitant modified Maze-III procedure for atrial fibrillation in patients undergoing mitral valve replacement in a rural cardiac surgery center. J Datta Meghe Inst Med Sci Univ 2013;8:91-4.  Back to cited text no. 35
Karthik S, Grayson AD, McCarron EE, Pullan DM, Desmond MJ. Reexploration for bleeding after coronary artery bypass surgery: Risk factors, outcomes, and the effect of time delay. Ann Thorac Surg 2004;78:527-34.  Back to cited text no. 36
Dunning J, Fabbri A, Kolh PH, Levine A, Lockowandt U, Mackay J, et al. Guideline for resuscitation in cardiac arrest after cardiac surgery. Eur J Cardiothorac Surg 2009;36:3-28.  Back to cited text no. 37
Ranucci M, Bozzetti G, Ditta A, Cotza M, Carboni G, Ballotta A. Surgical reexploration after cardiac operations: Why a worse outcome? Ann Thorac Surg 2008;86:1557-62.  Back to cited text no. 38
Talamonti MS, LoCicero J 3rd, Hoyne WP, Sanders JH, Michaelis LL. Early reexploration for excessive postoperative bleeding lowers wound complication rates in open heart surgery. Am Surg 1987;53:102-4.  Back to cited text no. 39
Despotis G, Eby C, Lublin DM. A review of transfusion risks and optimal management of perioperative bleeding with cardiac surgery. Transfusion 2008;48 1 Suppl:2S-30S.  Back to cited text no. 40
Ismeno G, Renzulli A, Carozza A, De Feo M, Iannuzzi M, Sante P, et al. Intravascular hemolysis after mitral and aortic valve replacement with different types of mechanical prostheses. Int J Cardiol 1999;69:179-83.  Back to cited text no. 41
Kloster FE. Diagnosis and management of complications of prosthetic heart valves. Am J Cardiol 1975;35:872-85.  Back to cited text no. 42
Maraj R, Jacobs LE, Ioli A, Kotler MN. Evaluation of hemolysis in patients with prosthetic heart valves. Clin Cardiol 1998;21:387-92.  Back to cited text no. 43
Bucerius J, Gummert JF, Borger MA, Walther T, Doll N, Onnasch JF, et al. Stroke after cardiac surgery: A risk factor analysis of 16,184 consecutive adult patients. Ann Thorac Surg 2003;75:472-8.  Back to cited text no. 44
John R, Chaudhri AF, Weinberg AD, Ting W, Rose EA, Smith CR, et al. Multricentric review of post operative risk factors for stroke after CABG. Ann Thorac Surg 2000;69:30-6.  Back to cited text no. 45
Liddicoat JR, Redmond JM, Vassileva CM, Baumgartner WA, Cameron DE. Hypothermic circulatory arrest in octogenarians: Risk of stroke and mortality. Ann Thorac Surg 2000;69:1048-51.  Back to cited text no. 46
Svenarud P, Persson M, Van Der Linden J. Effects of CO@ insufflation on number and behaviour of microemboli in open heart surgery. A RCT. Circulation 2004;109:1127-32.  Back to cited text no. 47
Martens S, Neumann K, Sodemann C, Deschka H, Wimmer-Greinecker G, Moritz A. Carbon dioxide field flooding reduces neurologic impairment after open heart surgery. Ann Thorac Surg 2008;85:543-7.  Back to cited text no. 48
Filsoufi F, Rahmanian PB, Castillo JG, Bronster D, Adams DH. Incidence, topography, predictors and long-term survival after stroke in patients undergoing coronary artery bypass grafting. Ann Thorac Surg 2008;85:862-70.  Back to cited text no. 49
Nishiyama K, Horiguchi M, Shizuta S, Doi T, Ehara N, Tanuguchi R, et al. Temporal pattern of strokes after on-pump and off-pump coronary artery bypass graft surgery. Ann Thorac Surg 2009;87:1839-44.  Back to cited text no. 50
Rothenhäusler HB, Grieser B, Nollert G, Reichart B, Schelling G, Kapfhammer HP. Psychiatric and psychosocial outcome of cardiac surgery with cardiopulmonary bypass: A prospective 12-month follow-up study. Gen Hosp Psychiatry 2005;27:18-28.  Back to cited text no. 51
Ho PM, Masoudi FA, Spertus JA, Peterson PN, Shroyer AL, McCarthy M Jr., et al. Depression predicts mortality following cardiac valve surgery. Ann Thorac Surg 2005;79:1255-9.  Back to cited text no. 52
Mistiaen W, Vissers D. The risk of postoperative pulmonary or pleural complications after aortic valve replacement is low in elderly patients: An observational study. Aust J Physiother 2008;54:119-24.  Back to cited text no. 53
Light RW, Rogers JT, Cheng D, Rodriguez RM. Large pleural effusions occurring after coronary artery bypass grafting. Cardiovascular Surgery Associates, PC. Ann Intern Med 1999;130:891-6.  Back to cited text no. 54
Little AG, editor. Complications in Cardiothoracic Surgery. Avoidance and Treatment. 1st ed. USA: Futura, Blackwell Publishing; 2004. Available from: http://www.blackwellfutura.com. [Last accessed on 2017 Dec 18].  Back to cited text no. 55
Al-Qubati FA, Damag AK, Noman T. Egypt J Chest Dis Tuberc 2013;62:775-80.  Back to cited text no. 56
Little AG, editor. Complications in Cardiothoracic Surgery. Avoidance and Treatment. 1st ed. USA: Futura, Blackwell Publishing; 2004. Available from: http://www.blackwellfutura.com. [Last accessed on 2017 Dec 18].  Back to cited text no. 57
Stoney WS, Alford WC Jr., Burrus GR, Frist RA, Thomas CS Jr. Median sternotomy dehiscence. Ann Thorac Surg 1978;26:421-6.  Back to cited text no. 58
Breyer RH, Mills SA, Hudspeth AS, Johnston FR, Cordell AR. A prospective study of sternal wound complications. Ann Thorac Surg 1984;37:412-6.  Back to cited text no. 59
Kontos GJ, Starr MG, Orszulak TA. Etiology of mediastinal infection after cardiac surgery. In: Salem TJ, editor. Mediastinal and Sterna Infections, Cardiac Surgery: State of Art Review. Philadelphia: Hanley and Belfus Inc.; 1998. p. 519-30.  Back to cited text no. 60
Nishida H, Grooters RK, Soltanzadeh H, Thieman KC, Schneider RF, PaKim W, et al. Discriminate use of electrocautery in median sternotomy incision. A 0.6% wound infection rate. J Thorac Cardiovasc Surg 1991;101:488-94.  Back to cited text no. 61
Brown JR, Cochran RP, Leavitt BJ, Dacey LJ, Ross CS, MacKenzie TA, et al. Multivariable prediction of renal insufficiency developing after cardiac surgery. Circulation 2007;116 11 Suppl: I139-43.  Back to cited text no. 62
Palomba H, de Castro I, Neto AL, Lage S, Yu L. Acute kidney injury prediction following elective cardiac surgery: AKICS Score. Kidney Int 2007;72:624-31.  Back to cited text no. 63
Ascione R, Lloyd CT, Underwood MJ, Gomes WJ, Angelini GD. On-pump versus off-pump coronary revascularization: Evaluation of renal function. Ann Thorac Surg 1999;68:493-8.  Back to cited text no. 64
Di Mauro M, Gagliardi M, Iacò AL, Contini M, Bivona A, Bosco P, et al. Does off-pump coronary surgery reduce postoperative acute renal failure? The importance of preoperative renal function. Ann Thorac Surg 2007;84:1496-502.  Back to cited text no. 65
Australasian Society of Cardiothoracic Surgery. Victoria Cardiac Surgery Database Project. Report to the Public on Cardiac Surgery in Victoria Public Hospital; 2002.  Back to cited text no. 66
Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC); European Association for Cardio-Thoracic Surgery (EACTS), Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Barón-Esquivias G, et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012;33:2451-96.  Back to cited text no. 67
Whitlock RP, Sun JC, Fremes SE, Rubens FD, Teoh KH; American College of Chest Physicians. Antithrombotic and thrombolytic therapy for valvular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141 2 Suppl: e576S-600S.  Back to cited text no. 68
O'Brien SM, Shahian DM, Filardo G, Ferraris VA, Haan CK, Rich JB, et al. The Society of Thoracic Surgeons 2008 cardiac surgery risk models: Part 2 – Isolated valve surgery. Ann Thorac Surg 2009;88 1 Suppl:S23-42.  Back to cited text no. 69
Gillinov AM, Cosgrove DM. Minimally invasive mitral valve surgery: Mini-sternotomy with extended transseptal approach. Semin Thorac Cardiovasc Surg 1999;11:206-11.  Back to cited text no. 70
El-Kholey KE, El-Shenaway H. Role Of Diode Laser In Preservation Of The Marginal Bone Around Early Loaded Endosseous Implant. Life Sci J2012;9:940-943. (ISSN: 1097-8135).  Back to cited text no. 71


  [Table 1], [Table 2], [Table 3]


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