Management of asymptomatic patients with severe non-ischaemic mitral regurgitation. Are practices consistent with guidelines? (original) (raw)
Related papers
2010
Background-The optimal timing of surgical intervention in asymptomatic patients with severe mitral regurgitation is unclear. We therefore compared the long-term results of early surgery with a conventional treatment strategy. Methods and Results-From 1996 to 2005, 447 consecutive asymptomatic patients (253 men, age 50Ϯ15 years) with severe degenerative mitral regurgitation and preserved left ventricular function were evaluated prospectively. The end point was defined as the composite of operative mortality, cardiac death, repeat mitral valve surgery, and urgent admission due to congestive heart failure during follow-up. Early surgery was performed on 161 patients (operated group), and the conventional treatment strategy was used for 286 patients (conventional treatment group). There were no significant differences between the 2 groups in terms of age, gender, euroSCORE (European System for Cardiac Operative Risk Evaluation), or ejection fraction. During a median follow-up of 1988 days, there were 2 repeat surgeries and no cardiac deaths or operative mortality in the operated group compared with 12 cardiac deaths, 1 repeat surgery, and 22 admissions for congestive heart failure in the conventional treatment group. The estimated actuarial 7-year cardiac mortality rate was 0% in the operated group and 5Ϯ2% in the conventional treatment group (Pϭ0.008), and for 127 propensity score-matched pairs, the estimated actuarial 7-year event-free survival rate was significantly higher in the operated than in the conventional treatment group (99Ϯ1% versus 85Ϯ4%, Pϭ0.007). In the conventional treatment group, baseline grade of pulmonary hypertension (hazard ratio 1.87, 95% CI 1.22 to 2.87, Pϭ0.003), age (hazard ratio 1.02, 95% CI 1.01 to 1.04, Pϭ0.005), and effective regurgitant orifice area (hazard ratio 2.06, 95% CI 1.11 to 3.82, Pϭ0.02) were independent variables that predicted late development of surgical indications or congestive heart failure on Cox multivariate analysis. Conclusions-Compared with conservative management, the strategy of early surgery was associated with an improved long-term event rate by decreasing cardiac mortality and congestive heart failure hospitalization more effectively in patients with severe degenerative mitral regurgitation. Early surgery may therefore further improve clinical outcomes in asymptomatic severe mitral regurgitation with preserved left ventricular systolic function and a high likelihood of mitral valve repair. (Circulation. 2009;119:797-804.)
European Journal of Cardio-Thoracic Surgery, 2011
Objective: It is well accepted that patients with severe mitral regurgitation (MR) benefit from mitral valve repair; however, the management of those with less than severe leakage is controversial. Watchful waiting is often advocated and considered safe, but the risk of developing left ventricular (LV) dysfunction under medical management is unknown. Methods: Using a population-based County-wide study database, we analyzed echocardiograms during clinical follow-up and medical management of 204 patients with mitral valve prolapse and less-than-severe MR. LV dysfunction was defined per American Heart Association guidelines as an ejection fraction (EF) <60% or LV end-systolic dimension >40 mm. Results: At index examination, mean age was 57 years and 121 (59%) were women. The mean EF was 62%, and 62 (30%) had evidence of LV dysfunction. MR severity was mild in 121 (59%), mild-moderate in 23 (11%), moderate in 36 (18%) and moderate-severe in 24 (12%). During followup (mean 8.6 years), 79 patients (39%) demonstrated progression of MR by at least one grade. Greater degrees of regurgitation at index echocardiogram were associated with greater progression during follow-up (P = 0.0001). After adjusting for age, sex, body surface area (BSA), and baseline regurgitation grade, multivariable modeling revealed that larger LV end-diastolic dimension (odds ratio (OR) = 1.14; P = 0.0018) and greater diastolic septal thickness (OR = 1.40; P = 0.0211) predicted greater progression of MR with time. From initial diagnosis to follow-up echocardiography, EF declined, while left-heart dimensions and pulmonary arterial pressure increased. Of the 142 patients with normal baseline LV function, 52% developed either worsening MR or de novo LV dysfunction. Importantly, even in the 87 patients with stable regurgitation, 18 (21%) developed new LV dysfunction during follow-up. Fifty-two patients (25%) eventually underwent mitral valve repair. Following surgery, there were significant decreases in EF, LV end-diastolic dimensions and LV mass; while 11 developed de novo LV dysfunction. Conclusions: Over half of patients with chronic persistent, but sub-severe MR due to mitral leaflet prolapse develop LV dysfunction or worsening regurgitation despite optimal medical management. LV deterioration can occur even in the absence of MR progression. These data advocate for the development of detailed guidelines supporting frequent echocardiographic monitoring and the identification of earlier triggers for surgical consideration prior to the development of LV dysfunction in this patient population. #
Surgical results for mitral regurgitation from coronary artery disease
The Journal of Thoracic and Cardiovascular Surgery, 1986
Surgical results for mitral regurgitation from coronary artery disease Results of coronary artery bypass grafting with and without mitral valve replacement were analyzed retrospectively in 101 patients with preoperative ischemicmitral regurgitation to determine the effects of severity and surgical treatment of mitral regurgitation on survival. Between 1980 and 1984, a total of 1,475 patients (mean age 59, 77% male) underwent coronary bypass. These patients were divided into three groups: (1)patients without ischemicmitral regurgitation who underwent isolated coronary bypass (1,374; 93%), (2) patients with ischemic mitral regurgitation who underwent isolated coronary bypass without valve replacenient (85; 6 %), and (3) patients with ischemic mitral regurgitation who underwent combined mitral valve replacementandcoronary bypass (16; 1 %). Preoperatively, patients with ischemic mitral regurgitation compared to those without regurgitation were significantly older (+6 years, P < 0.001), had more severe coronary artery disease (p < 0.001), a higher incidence of congestive heart failure (24% versus 5%, p < 0.001) andrecent myocardial infarction (16% versus 8%, p < 0.01), and a lower mean ejection fraction (45% versus 61 %, p < 0.001). Operative mortality was significantly increasedin patients with ischemicmitral regurgitation who underwent coronary bypass alone (p < 0.01) and in those who underwent coronary bypass and mitral valve replacement(p < 0.01)-11 % and 19%, respectively-than in the coronary bypass patients without ischemic mitral regurgitation (3.7%). The severity of mitral regurgitation(0 to 4+) proved to bethe most significant predictorof operativemortality. Theactuarial survival rate at 5 years for the coronary bypass patients with ischemicmitral regurgitation was 85% compared to 91 % (p < 0.05) for the coronary bypass patients without ischemic mitral regurgitation. These results indicate that patients with ischemic mitral regurgitation have a higher prevalence of cardiac risk factors and are at an increased risk of operative mortality. Although the severity of the ischemicmitral regurgitation was strongly predictive of early survival, it proved to havean unexpectedly modest effect on long-term survival after surgical treatment.
Surgical treatment of asymptomatic and mildly symptomatic mitral regurgitation
The Journal of Thoracic and Cardiovascular Surgery, 1996
The purpose of this study was to review the risk-benefit ratio of mitral valve repair in patients with severe mitral regurgitation and no or mild symptoms. From January 1989 to December 1994, 584 patients were operated on for mitral regurgitation. Of these, 175 patients were in New York Heart Association class I or II with grade 3 to 4 isolated chronic mitral regurgitation. They comprise our study population. Mean age was 51.3 +/- 14.3 years. Principal causes of mitral regurgitation were degenerative in 128 (73%) and rheumatic in 26 patients (15%). Leaflet prolapse was the mechanism responsible for regurgitation in 152 patients (86%). Mitral valve repair was performed in 174 patients, and one patient required initial valve replacement. Mean follow-up was 34.3 +/- 18.8 months. Three patients died, for an overall mortality of 1.7%. Five patients were reoperated on, for an actuarial freedom from reoperation of 97.0% +/- 0.8% at 5 years. Actuarial freedom from thromboembolism and endocarditis was 96.3% +/- 1.7% and 99.4% +/- 0.6%, respectively, for an event-free survival of 91.0% +/- 2.0% at 5 years. Left atrial diameter decreased from 54.3 +/- 11.6 mm to 43.6 +/- 10.5 mm (p < 0.001). Left ventricular end-systolic and end-diastolic diameters decreased from 40.0 +/- 6.8 mm and 64.8 +/- 7.0 mm to 34.6 +/- 6.7 mm (p < 0.001) and 52.7 +/- 7.4 mm (p < 0.001), respectively. Mean residual mitral regurgitation was 0.44 +/- 0.6. Mitral valve repair for chronic mitral regurgitation in patients having mild or no symptoms was performed with low mortality and morbidity, good valve function, and preserved late left ventricular performance. Early repair may be advocated on the basis of severity of regurgitation and valve repairability, regardless of symptoms.
Non-ischemic Severe Mitral Regurgitation: When and How to Operate? The Role of Echocardiography
Journal of Medical Ultrasound, 2008
Mitral regurgitation is a common but complex valvular heart disease. In severe mitral regurgitation, the regurgitant volume increases by about 7.5 mL per year and the effective regurgitant orifice increases by about 5.9 mm 2 per year. Severe mitral regurgitation can produce left ventricular remodeling and finally irreversible left ventricular dysfunction. Ninety percent of patients with severe mitral regurgitation caused by flail mitral valve undergo surgery or die. The optimal timing of mitral valve surgery in patients with severe mitral regurgitation is crucial. In recent years, mitral valve repair has been shown to be better than mitral valve replacement for both short-and long-term outcome. Important issues such as reducing operative mortality, improving long-term survival and improving the rate of mitral valve repair are crucial when considering mitral valve surgery. Echocardiography allows the reliable identification of the presence, severity, etiology and mechanisms as well as the pathologic lesions of mitral regurgitation. The following questions relating to echocardiography should be asked before patients undergo surgery: (1) Is the mitral regurgitation organic or functional? (2) When is the optimal time for surgery? (3) What is the etiology of mitral regurgitation? (4) Where is the lesion(s)? (5) Can the mitral valve be repaired? (6) Which surgical technique is most appropriate? Quantitative assessment of the severity of mitral regurgitation is essential for the optimal timing of surgery. Transesophageal echocardiography as well as three-dimensional echocardiography can help to identify the etiology, mechanisms and pathologic lesions prior to possible mitral valve repair.
Moderate Mitral Regurgitation and Coronary Disease: Treatment with Coronary Bypass Alone?
2006
Background: In cases of moderate(2 or 3+ on a scale of 0 to 4+) nonorganic mitral regurgitation (MR) and coronary artery disease, operative strategy continues to be debated between coronary artery bypass grafting alone (CABG) or concomitant valve repair. To clarify the optimal management of these patients, we evaluated the mid-term results of isolated CABG in the study group.
2010
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was, 'Does severe asymptomatic mitral regurgitation (MR) require surgery or is watch and wait the optimal strategy?'. Over 103 papers were found using the reported search, and 10 represented the best evidence to answer this clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. No studies in the modern era have shown significant survival benefit for patients undergoing surgery for asymptomatic severe MR if they have good left ventricular (LV) function. The progression rate to surgery on developing symptoms is 10% per year in these patients. Ling et al. reported a 63% incidence of congestive heart failure and 30% incidence of chronic atrial fibrillation (AF) at 10 years for conservative treatment, during which period 90% either underwent surgery or died. In addition, one study of 478 patients with good LV operated on in the 1980s showed a 76% 10-year survival in patients who were NYHA IyII but only a 48% 10-year survival in patients with NYHA IIIyIV although this group was older and had more AF. Early surgery has very good peri-and postoperative survival rates, and the American Heart Association currently recommend that these patients may be operated on if the chance of repair is)90%. Patients may, therefore, be reassured that either strategy is acceptable.
Clinical Epidemiology and Global Health, 2021
Background: Non valvular, ischemic regurgitation (MR) occurs secondary to myocardial infarction or acute ischemia. The presence of ischaemic MR is associated with increased morbidity and mortality. The severity of ischaemic MR is directly proportional to the severity of the LV dysfunction causing the MR. The present study was carried out to estimate the burden, clinical presentation and prognosis of non valvular MR among patients with coronary artery disease. Methods: This cohort study was carried out among 75 adults aged over 25 years with electrocardiographic evidence of coronary artery disease. Clinical examination and periodic electrocardiography was done for evaluating the ischemic status and echocardiogram was done to assess the status of mitral regurgitation. Ejection fraction was measured by Simpsons method and regional wall motion abnormality was qualitatively evaluated. Results: In this study, 60% of the participants had mild MR while 22.9% had moderate MR. In correlation with STEMI, inferior/posterior wall MI with right ventricular extension showed presence of MR in 100% of the cases. There was a statistically significant difference in the incidence of congestive cardiac failure among the patients with severe MR (66.7%) and mild MR (25%) compared to those without CCF (p < 0.01). Conclusion: Ischemic MR is characteristically dynamic and can change substantially with changes in loading conditions. This study has laid down the basis for evaluating future role of new adjunctive surgical techniques and of percutaneous interventions.
When to Intervene for Asymptomatic Mitral Valve Regurgitation
Seminars in Thoracic and Cardiovascular Surgery, 2010
Mitral regurgitation (MR), currently the most frequent valvular heart disease, is mostly degenerative, linked to aging and of increasing prevalence. Indications of mitral surgery, the only current approved treatment of MR, are disputed. Coherent cumulative evidence obtained worldwide show that early surgery in asymptomatic patients is the preferred approach. Waiting for symptoms or left ventricular dysfunction is a failed strategy in that these characteristics are insensitive markers of risk, are often unrecognized in a timely manner and, even after successful surgery, are associated with poor outcome. Furthermore, in patients with severe organic MR, surgery is almost unavoidable and early mitral repair before the appearance of symptoms or overt LV dysfunction may restore life expectancy as long as valve repair is performed. New objective markers of adverse outcome under medical management have recently been described, allowing selection of patients for performance of restorative surgery that reestablishes life expectancy. This approach of early surgery provides improved outcomes in observational studies and is conceivable in centers that provide low risk, high repair rates, high quality of repairs and of Doppler-Echocardiographic assessment. Semin Thoracic Surg 22:216-224
Impact of Severe Mitral Regurgitation on Postoperative Outcomes After Noncardiac Surgery
The American Journal of Medicine, 2013
OBJECTIVE: Preoperative cardiac risk assessment scoring systems traditionally do not include valvular regurgitation as a criterion for adverse outcome prediction. We sought to determine the impact of significant mitral regurgitation on postoperative outcomes after planned noncardiac surgeries. METHODS: Patients with significant mitral regurgitation (moderate-severe or severe) undergoing noncardiac surgery were identified using surgical and echocardiographic databases at the Cleveland Clinic. The mechanism of mitral regurgitation was identified and classified as ischemic or nonischemic. By using propensity score analysis, we obtained 4 matched controls (patients undergoing noncardiac surgery without mitral regurgitation) for each case. The primary outcome was defined as a composite of 30-day mortality, myocardial infarction, heart failure, and stroke. Secondary outcomes included 30-day mortality, myocardial infarction, heart failure, stroke, and atrial fibrillation. RESULTS: A total of 298 cases and 1172 controls were included in the study. The incidence of primary outcome was significantly higher among patients with mitral regurgitation (22.2%) compared with controls (16.4%, P ϭ .02). Analysis of the secondary outcomes revealed significant differences in perioperative heart failure (odds ratio, 1.4; 95% confidence interval, 1.02-2.0) and perioperative myocardial infarction (odds ratio, 2.9; 95% confidence interval, 1.2-7.3). Of patients with mitral regurgitation, those with ischemic mitral regurgitation had significantly more events than those with nonischemic mitral regurgitation (39.2% vs 13.3%, P Ͻ .001). CONCLUSIONS: Patients undergoing noncardiac surgery with significant ischemic mitral regurgitation are at higher risk of a composite adverse postoperative outcome, including short-term mortality, heart failure, myocardial infarction, and stroke.