Comparison of Early Surgery Versus Conventional Treatment in Asymptomatic Severe Mitral Regurgitation

Abstract

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.)

Early mitral valve repair versus watchful waiting in patients with severe asymptomatic organic mitral regurgitation; rationale and design of the Dutch AMR trial, a multicenter, randomised trial

“…Sample size calculation The expected 5-year event rate is 38%, which is the median of the published literature, and involves the composite of cardiac death, heart failure and hospitalisation for atrial fibrillation [7][8][9]. From results of non-randomised studies, we make a conservative estimate for the relative reduction in risk due to surgical repair as being 45%, thus reducing the absolute risk of events down to 21%.…”

“…A total number of 529 entries were screened of which 522 could be excluded because they were case reports, not trials, reviews, or off-topic. In 7 trials the effect of surgery versus staying conservative was monitored (Table 1) [6][7][8][9][10][11][12]. In one of the trials there was no control group mentioned for survival [10].…”

Primary mitral valve regurgitation: Update and review

“…They showed that the group treated with early surgery had an improved 7-year event free survival (99% ± 1% versus 85% ± 4% for the watchful waiting group, p = 0.001) and less hospitalization for heart failure. 102 Montant et al showed similar results following prospectively 192 asymptomatic patients with severe degenerative mitral regurgitation. 103 67 patients were managed with the conservative approach, while 125 patients underwent early surgical intervention.…”

“…102 161 patients were referred for early surgery and 286 were managed with the ''wait and see'' strategy. They showed that the group treated with early surgery had an improved 7-year event free survival (99% ± 1% versus 85% ± 4% for the watchful waiting group, p = 0.001) and less hospitalization for heart failure.…”

Feasibility and Efficacy of Mitral Valve Repair for Degenerative Mitral Regurgitation in the Elderly

“…Previous reports also demonstrated high operative mortality and morbidity after mitral valve surgery in the elderly. [1][2][3][4][5][6] Mitral valve repair is the treatment of choice for severe MR in the general population because it provides a significant survival advantage over both medical treatment 7,8) and mitral valve replacement. 9) However, its feasibility and efficacy in elderly patients are unclear.…”