Watchful waiting for severe mitral regurgitation

Long-Term Results of Mitral Valve Repair

Introduction

Current guidelines state that patients with severe mitral regurgitation should be treated in reference centers with a high reparability rate, low mortality rate, and durable results.

Objective

To analyze our global experience with the treatment of organic mitral regurgitation from various etiologies operated in a single center.

Methods

We evaluated all surgically treated patients with organic mitral regurgitation from 2004-2017. Patients were evaluated clinically and by echocardiography every year. We determined early and late survival rates, valve related events and freedom from recurrent mitral regurgitation and tricuspid regurgitation. Valve failure was defined as any mitral regurgitation ≥ moderate degree or the need for reoperation for any reason.

Results

Out of 133 patients with organic mitral regurgitation, 125 (93.9%) were submitted to valve repair. Mean age was 57±15 years and 52 patients were males. The most common etiologies were degenerative disease (73 patients) and rheumatic disease (34 patients). Early mortality was 2.4% and late survival was 84.3% at 10 years, which are similar to the age- and gender-matched general population. Only two patients developed severe mitral regurgitation, and both were reoperated (95.6% at 10 years). Freedom from mitral valve failure was 84.5% at 10 years, with no difference between degenerative and rheumatic valves. Overall, late ≥ moderate tricuspid regurgitation was present in 34% of the patients, being more common in the rheumatic ones. The use of tricuspid annuloplasty abolished this complication.

Conclusion

We have demonstrated that mitral regurgitation due to organic mitral valve disease from various etiologies can be surgically treated with a high repair rate, low early mortality and long-term survival that are comparable to the matched general population. Concomitant treatment of atrial fibrillation and tricuspid valve may be important adjuncts to optimize long-term results.

Forward Left Ventricular Ejection Fraction: A Simple Risk Marker in Patients With Primary Mitral Regurgitation

Background

The timing of mitral valve surgery in asymptomatic patients with primary mitral regurgitation (MR) is controversial. We hypothesized that the forward left ventricular (LV) ejection fraction (LVEF; ie, LV outflow tract stroke volume divided by LV end‐diastolic volume) is superior to the total LVEF to predict outcomes in MR. The objective of this study was to examine the association between echocardiographic parameters of MR severity and LV function and outcomes in patients with MR.

Methods and Results

The clinical and Doppler‐echocardiographic data of 278 patients with ≥mild MR and no class I indication of mitral valve surgery at baseline were retrospectively analyzed. The primary study end point was the composite of mitral valve surgery or death. During a mean follow‐up of 5.4±3.2 years, there were 147 (53%) events: 96 (35%) MV surgeries and 66 (24%) deaths. Total LVEF and global longitudinal strain were not associated with the occurrence of events, whereas forward LVEF (P<0.0001) and LV end‐systolic diameter (P=0.0003) were. After adjustment for age, sex, MR severity, Charlson probability, coronary artery disease, and atrial fibrillation, forward LVEF remained independently associated with the occurrence of events (adjusted hazard ratio: 1.09, [95% confidence interval]: 1.02–1.17 per 5% decrease; P=0.01), whereas LV end‐systolic diameter was not (P=0.48).

Conclusions

The results of this study suggest that the forward LVEF may be superior to the total LVEF and LV end‐systolic diameter to predict outcomes in patients with primary MR. This simple and easily measurable parameter may be useful to improve risk stratification and select the best timing for intervention in patients with primary MR.

Role of a heart valve clinic programme in the management of patients with aortic stenosis

AIMS

We sought to assess the efficacy of a heart valve clinic (HVC) follow-up programme for patients with severe aortic stenosis (AS).

METHODS AND RESULTS

Three hundred and eighty-eight consecutive patients with AS (age 71 ± 10 years; aortic-jet velocity 5.1 ± 0.6 m/s) and an indication for aortic valve replacement (AVR) were included. Of these, 290 patients presented with an indication for surgery at their first visit at the HVC and 98 asymptomatic patients who had been enrolled in an HVC monitoring programme developed indications for surgery during follow-up. Time to symptom detection was significantly longer in patients that presented with symptoms at baseline (352 ± 471 days) than in patients followed in the HVC (76 ± 75 days, P < 0.001). Despite being educated to recognize and promptly report new symptoms, 77 of the 98 patients in the HVC programme waited until the next scheduled consultation to report them. Severe symptom onset (NYHA or CCS Class ≥III) was present in 61% of patients being symptomatic at the initial visit and in 34% of patients in the HVC programme (P < 0.001).

CONCLUSION

Delays in referral and symptom reporting as well as symptom denial are common in patients with AS. These findings support the concept of risk stratification to identify patients who may benefit from elective surgery. A structured HVC programme results in the detection of symptoms at an earlier and less severe stage and thus in an optimized timing of surgery.

Mitral Valve Repair Outcomes in a Community Hospital: A Retrospective Analysis

BACKGROUND

The results of mitral valve repair operations conducted at community hospitals in rural states are not well studied or reported in the literature.

METHODS

We retrospectively assessed consecutive patients who underwent isolated mitral valve repair operations performed by a single experienced cardiothoracic surgeon at a large community hospital from May 1, 2006 - April 30, 2010. Patients were monitored for up to three years (average 2.2 years) following surgery for a variety of surgical variables, including morbidity, mortality, and serial two-dimensional transthoracic echocardiographic findings. Comparisons were made with the Society of Thoracic Surgeons Adult Cardiac Surgery Database (ACSD).

RESULTS

Sixty-three consecutive patients underwent isolated complex mitral repair operations. Echocardiographic and morbidity data demonstrated successful outcomes, with no operative mortality and a single cardiac-related death within three years postoperatively. Other variables, especially those that relate to post-repair outcomes, showed no significant differences between our patients and comparison data from the ASCD.

CONCLUSIONS

Our study demonstrates equivalent risks and outcomes for complex mitral valve repair performed in a community hospital setting as those found in a national database. The appropriate institutional setting for performing highly complex procedures has substantial implications for health policy, especially regarding access and quality issues.

Early surgical intervention or watchful waiting for the management of asymptomatic mitral regurgitation: a systematic review and meta-analysis

BACKGROUND

Discordance between studies drives continued debate regarding the best management of asymptomatic severe mitral regurgitation (MR). The aim of the present study was to conduct a systematic review and meta-analysis of management plans for asymptomatic severe MR, and compare the effectiveness of a strategy of early surgery to watchful waiting.

METHODS

A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Studies were excluded if they: (I) lacked a watchful waiting cohort; (II) included symptomatic patients; or (III) included etiologies other than degenerative mitral valve disease. The primary outcome of the study was all-cause mortality at 10 years. Secondary outcomes included operative mortality, repair rate, repeat mitral valve surgery, and development of new atrial fibrillation.

RESULTS

Five observational studies were eligible for review and three were included in the pooled analysis. In asymptomatic patients without class I triggers (symptoms or ventricular dysfunction), pooled analysis revealed a significant reduction in long-term mortality with an early surgery approach [hazard ratio (HR) =0.38; 95% confidence interval (CI): 0.21-0.71]. This survival benefit persisted in a sub-group analysis limited to patients without class II triggers (atrial fibrillation or pulmonary hypertension) [relative risk (RR) =0.85; 95% CI: 0.75-0.98]. Aggregate rates of operative mortality did not differ between treatment arms (0.7% vs. 0.7% for early surgery vs. watchful waiting). However, significantly higher repair rates were achieved in the early surgery cohorts (RR =1.10; 95% CI: 1.02-1.18).

CONCLUSIONS

Despite disagreement between individual studies, the present meta-analysis demonstrates that a strategy of early surgery may improve survival and increase the likelihood of mitral valve repair compared with watchful waiting. Early surgery may also benefit patients when instituted prior to the development of class II triggers.

How has robotic repair changed the landscape of mitral valve surgery?

The introduction of robotic technology has revolutionized the performance of certain cardiac surgical procedures such as mitral valve (MV) repair. The foundation of modern MV repair was laid by Dr. Dwight C. McGoon in 1958. The operation was first performed with robotic assistance by Carpentier in 1998 using rudimentary motion-assisted equipment. Today, four generations later, telemanipulation technology enables surgeons to carry out all known methods of MV repair traditionally performed by conventional sternotomy; utilizing tiny port access incisions to safely and reliably eliminate mitral regurgitation. Extubation in the operating room following robotic MV repair is now routine and its benefits are well-documented, including transfer to the step-down from the intensive care unit several hours after surgery. This, in turn, translates into diminished usage of blood products, decreased need for pain medication, earlier dismissal from hospital, more rapid return to work and improved patient satisfaction. In addition, smaller, more cosmetically appealing scars and comparable short and mid-term outcomes of robotic and open MV repair have made the robotic approach a preferred option for many patients who meet appropriate safety criteria. As these procedures become more commonplace in large structural heart practices, it is important to reflect upon how the robotic approach has changed the landscape of MV surgery. We discuss the evolution and current status of robotic MV repair founded upon the principles of safe and effective open mitral valvuloplasty techniques. We will explore the potential of the robotic platform to improve both early referral and patient acceptance of interventions to eliminate severe degenerative mitral regurgitation.

Impact of duration of mitral regurgitation on outcomes in asymptomatic patients with myxomatous mitral valve undergoing exercise stress echocardiography

Background

Significant mitral regurgitation (MR) typically occurs as holosystolic (HS) or mid‐late systolic (MLS), with differences in volumetric impact on the left ventricle (LV). We sought to assess outcomes of degenerative MR patients undergoing exercise echocardiography, separated based on MR duration (MLS versus HS).

Methods and Results

We included 609 consecutive patients with ≥III+myxomatous MR undergoing exercise echocardiography: HS (n=487) and MLS (n=122). MLS MR was defined as delayed appearance of MR signal during mid‐late systole on continuous‐wave Doppler while HS MR occurred throughout systole. Composite events of death and congestive heart failure were recorded. Compared to MLS MR, HS MR patients were older (60±14 versus 53±14 years), more were males (72% versus 53%), and had greater prevalence of atrial fibrillation (16% versus 7%; all P<0.01). HS MR patients had higher right ventricular systolic pressure (RVSP) at rest (33±11 versus 27±9 mm Hg), more flail leaflets (36% versus 6%), and a lower number of metabolic equivalents (METs) achieved (9.5±3 versus 10.5±3), compared to the MLS MR group (all P<0.05). There were 54 events during 7.1±3 years of follow‐up. On step‐wise multivariable analysis, HS versus MLS MR (HR 4.99 [1.21 to 20.14]), higher LV ejection fraction (hazard ratio [HR], 0.94 [0.89 to 0.98]), atrial fibrillation (HR, 2.59 [1.33 to 5.11]), higher RVSP (HR, 1.05 [1.03 to 1.09]), and higher percentage of age‐ and gender‐predicted METs (HR, 0.98 [0.97 to 0.99]) were independently associated with adverse outcomes (all P<0.05).

Conclusion

In patients with ≥III+myxomatous MR undergoing exercise echocardiography, holosystolic MR is associated with adverse outcomes, independent of other predictors.

Importance of exercise capacity in predicting outcomes and determining optimal timing of surgery in significant primary mitral regurgitation

BACKGROUND

In primary mitral regurgitation (MR), exercise echocardiography aids in symptom evaluation and timing of mitral valve (MV) surgery. In patients with grade ≥3 primary MR undergoing exercise echocardiography followed by MV surgery, we sought to assess predictors of outcomes and whether delaying MV surgery adversely affects outcomes.

METHODS AND RESULTS

We studied 576 consecutive such patients (aged 57±13 years, 70% men, excluding prior valve surgery and functional MR). Clinical, echocardiographic (MR, LVEF, indexed LV dimensions, RV systolic pressure) and exercise data (metabolic equivalents) were recorded. Composite events of death, MI, stroke, and congestive heart failure were recorded. Mean LVEF was 58±5%, indexed LV end-systolic dimension was 1.7±0.5 mm/m(2), rest RV systolic pressure was 32±13 mm Hg, peak-stress RV systolic pressure was 47±17 mm Hg, and percentage of age- and gender-predicted metabolic equivalents was 113±27. Median time between exercise and MV surgery was 3 months (MV surgery delayed ≥1 year in 28%). At 6.6±4 years, there were 53 events (no deaths at 30 days). On stepwise multivariable survival analysis, increasing age (hazard ratio of 1.07 [95% confidence interval, 1.03 to 1.12], P<0.01), lower percentage of age- and gender-predicted metabolic equivalents (hazard ratio of 0.82 [95% confidence interval, 0.71 to 0.94], P=0.007), and lower LVEF (0.94 [0.89 to 0.99], P=0.04) independently predicted outcomes. In patients achieving >100% predicted metabolic equivalents (n=399), delaying surgery by ≥1 year (median of 28 months) did not adversely affect outcomes (P=0.8).

CONCLUSION

In patients with primary MR that underwent exercise echocardiography followed by MV surgery, lower achieved metabolic equivalents were associated with worse long-term outcomes. In those with preserved exercise capacity, delaying MV surgery by ≥1 year did not adversely affect outcomes.

Mitral valve repair in asymptomatic patients with severe mitral regurgitation: pushing past the tipping point

Degenerative mitral valve regurgitation (MR) is the one of the most frequent valvular heart conditions in the Western world and is increasingly recognized as an important preventable cause of chronic heart failure. This condition also represents the most common indication for mitral surgery and is of particular interest because the mitral valve can be repaired in most patients with very low surgical risk. Historical single-center studies have supported the performance of "early mitral valve repair" in asymptomatic patients with severe degenerative MR to normalize survival and improve late outcomes. Emerging recent evidence further indicates for the first time that the prompt surgical correction of severe MR due to flail mitral leaflets within 3 months following diagnosis in asymptomatic patients without classical Class I indications (symptoms or left ventricular dysfunction) conveys a 40% decrease in the risk of late death and a 60% diminution in heart failure incidence. A 10-point rationale based on the weight of rapidly accumulating clinical data, supports the performance of early mitral valve repair even in the absence of symptoms, left ventricular dysfunction, or guideline-based triggers; when effective operations can be provided using conventional or minimally invasive techniques at very low surgical risk.

Almanac 2012: adult cardiac surgery: the national society journals present selected research that has driven recent advances in clinical cardiology

This review covers the important publications in adult cardiac surgery in the last few years, including the current evidence base for surgical revascularisation and the use of off-pump surgery, bilateral internal mammary arteries and endoscopic vein harvesting. The changes in conventional aortic valve surgery are described alongside the outcomes of clinical trials and registries for transcatheter aortic valve implantation, and the introduction of less invasive and novel approaches of conventional aortic valve replacement surgery. Surgery for mitral valve disease is also considered, with particular reference to surgery for asymptomatic degenerative mitral regurgitation.

Mitral valve surgery: wait and see vs. early operation

Mitral valve repair represents the optimal surgical treatment for severe degenerative mitral regurgitation. According to the current guidelines, mitral repair is indicated in the presence of symptoms and/or signs of left ventricular (LV) dysfunction. In asymptomatic patients with preserved LV function, surgery should be considered in the presence of atrial fibrillation (AF) and/or pulmonary hypertension. In asymptomatic patients with preserved LV function, normal pulmonary artery pressure, and no episodes of AF, surgical timing is still an object of debate. The controversial issue is whether, in those circumstances, a 'wait and see (watchful waiting)' approach should be followed or an 'early repair' policy should be preferred. Indeed, a randomized trial comparing the two strategies has never been performed. In the absence of evidence-based arguments definitely supporting any particular course of action, advantages, drawbacks, and requirements for both strategies will be discussed in this review on the basis of the most significant observational studies which have focused on this issue.