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‘CLAS’ score: an objective tool to standardize and predict mitral valve repairability

  • Amber Malhotra
  • Sumbul Siddiqui
  • Vivek Wadhawa
  • Himani Pandya
  • Kartik Patel
  • Komal Shah
  • Hemang Gandhi
  • Pankaj Garg
  • Sudhir Adalti
  • Kamal Sharma
Original Article
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Abstract

Purpose

Carpentier’s classification has been used to classify both stenotic and regurgitant lesions. However, given the extreme variability of lesions, a universal nomenclature suggestive of the complexity and the prognosis of the repair procedure for the entire spectrum of the mitral valve disease still remains elusive. We present the predictors of mitral valve repairability with the help of a four-level-based ‘CLAS’ scoring system.

Methods

A total of 394 patients undergoing mitral valve procedure were prospectively studied. The valvular apparatus was divided into four sub-units, namely Commissures (C), Leaflet (L), Annulus (A), and Subvalvular apparatus (S), and the components were scored individually and the summation scores were calculated. Based on our results, three CLAS groups were formulated.

Results

A total of 376 (n = 394) patients underwent successful MVRep (95.43%; on-table failure in 18 patients). A total of 276 were rheumatic, 51 degenerative, 28 congenital, and 16 had infective endocarditis. Thirty-day mortality was 14 (3.72%) while delayed re-intervention rate was 8 (2.12%). The mean follow-up period was 30 months. One hundred percent patients with a CLAS score ≤ 8 had a successful repair as compared to 93.33 and 69.69%, respectively, for patients with scores between 9 and 12 and > 12, respectively. The cardio pulmonary bypass time, aortic-cross-clamp time, and ICU stay also showed a significant correlation with the patient’s ‘CLAS’ groups.

Conclusion

The CLAS score is highly predictive of a successful repair. We thus propose that, in the patients with a score of ≤ 8, repair should always be attempted irrespective of the pathology. The patients expected to be scored > 8 should be referred to a repair reference center.

Keywords

Mitral valve repair Rheumatic heart disease Mitral regurgitation 

Notes

Compliance with ethical standards

The research protocol was approved by the Institutional Review Board and Ethics Committee. A written informed consent for participation was obtained, follow-up data was collected as a part of the valvular repair registry of the institute and was 96% complete.

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

Study does not involve the use of any animal.

And in case of patients, all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Written informed consent has been taken from patients and none have been forced to be a part of study.

References

  1. 1.
    Rothenbühler M, O'Sullivan CJ, Stortecky S, et al. Active surveillance for rheumatic heart disease in endemic regions: a systematic review and meta-analysis of prevalence among children and adolescents. Lancet Glob Health. 2014;2:e717–26.CrossRefGoogle Scholar
  2. 2.
    Choudhary SK, Talwar S, Dubey B, Chopra A, Saxena A, Kumar AS. Mitral valve repair in a predominantly rheumatic population: long-term results. Tex Heart Inst J. 2001;28:8–15.PubMedPubMedCentralGoogle Scholar
  3. 3.
    Carpentier A. Cardiac valve surgery—the “French correction”. J Thorac Cardiovasc Surg. 1983;86:323–37.Google Scholar
  4. 4.
    Wheeler R, Steeds R, Rana B, et al. A minimum dataset for a standard transoesophageal echocardiogram: a guideline protocol from the British Society of Echocardiography. Echo Res Pract. 2015;2:G29–45.CrossRefGoogle Scholar
  5. 5.
    Guiraudon GM, Ofiesh JG, Kaushik R. Extended vertical transatrial septal approach to the mitral valve. Ann Thorac Surg. 1991;52:1058–62.CrossRefGoogle Scholar
  6. 6.
    Sampath Kumar A, Talwar S, Saxena A, Singh R, Velayoudam D. Results of mitral valve repair in rheumatic mitral regurgitation. Interact Cardiovasc Thorac Surg. 2006;5:356–61.CrossRefGoogle Scholar
  7. 7.
    Pomerantzeff PM, Brandão CM, Leite Filho OA, et al. Mitral valve repair in rheumatic patients with mitral insuficiency: twenty years of techniques and results. Rev Bras Cir Cardiovasc. 2009;24:485–9.CrossRefGoogle Scholar
  8. 8.
    Castillo JG, Anyanwu AC, Fuster V. Adams DH. A near 100% repair rate for mitral valve prolapse is achievable in a reference center: implications for future guidelines. J Thorac Cardiovasc Surg. 2012;144:308–12.CrossRefGoogle Scholar
  9. 9.
    Chauvaud S, Fuzellier JF, Berrebi A, Deloche A, Fabiani JN, Carpentier A. Long-term (29 years) results of reconstructive surgery in rheumatic mitral valve insufficiency. Circulation. 2001;104:112–5.CrossRefGoogle Scholar
  10. 10.
    Dillon J, Yakub MA, Kong PK, Ramli MF, Jaffar N, Gaffar IF. Comparative long-term results of mitral valve repair in adults with chronic rheumatic disease and degenerative disease: Is repair for “burnt-out” rheumatic disease still inferior to repair for degenerative disease in the current era? J Thorac Cardiovasc Surg. 2015;149:771–9.CrossRefGoogle Scholar
  11. 11.
    Acar C, de Ibarra JS, Lansac E. Anterior leaflet augmentation with autologous pericardium for mitral repair in rheumatic valve insufficiency. J Heart Valve Dis. 2004;13:741–6.PubMedGoogle Scholar
  12. 12.
    Chotivatanapong T, Lerdsomboon P, Sungkahapong V. Rheumatic mitral valve repair: experience of 221 cases from Central Chest Institute of Thailand. J Med Assoc Thai. 2012;95:S51–7.PubMedGoogle Scholar
  13. 13.
    Adams DH, Anyanwu AC, Rahmanian PB, Abascal V, Salzberg SP, Filsoufi F. Large annuloplasty rings facilitate mitral valve repair in Barlow’s disease. Ann Thorac Surg. 2006;82:2096–100.CrossRefGoogle Scholar
  14. 14.
    David TE, Armstrong S, Ivanov J. Chordal replacement with polytetrafluoroethylene sutures for mitral valve repair: a 25-year experience. J Thorac Cardiovasc Surg. 2013;145:1563–9.CrossRefGoogle Scholar
  15. 15.
    David TE. Artificial chordae. Semin Thorac Cardiovasc Surg. 2004;16:161–8.CrossRefGoogle Scholar
  16. 16.
    Calafiore AM, Scandura S, Iacò AL, et al. A simple method to obtain the correct length of the artificial chordae in complex chordal replacement. J Card Surg. 2008;23:204–6.CrossRefGoogle Scholar

Copyright information

© Indian Association of Cardiovascular-Thoracic Surgeons 2018

Authors and Affiliations

  • Amber Malhotra
    • 1
  • Sumbul Siddiqui
    • 1
  • Vivek Wadhawa
    • 1
  • Himani Pandya
    • 2
  • Kartik Patel
    • 1
  • Komal Shah
    • 2
  • Hemang Gandhi
    • 3
  • Pankaj Garg
    • 1
  • Sudhir Adalti
    • 1
  • Kamal Sharma
    • 4
  1. 1.Department of Cardio Vascular and Thoracic SurgeryU. N. Mehta Institute of Cardiology and Research Center (affiliated to BJ Medical College, Ahmedabad)AhmedabadIndia
  2. 2.Department of ResearchU. N. Mehta Institute of Cardiology and Research Center (affiliated to BJ Medical College, Ahmedabad)AhmedabadIndia
  3. 3.Department of Cardiac AnesthesiaU. N. Mehta Institute of Cardiology and Research Center (affiliated to BJ Medical College, Ahmedabad)AhmedabadIndia
  4. 4.Department of CardiologyU. N. Mehta Institute of Cardiology and Research Center (affiliated to BJ Medical College, Ahmedabad)AhmedabadIndia

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