Study Shows Benefits to Early Mitral Surgery in Patients With Mitral Valve Regurgitation

In patients with mitral valve regurgitation due to flail mitral leaflets, performance of early mitral surgery compared to initial medical management was found to be associated with greater long-term survival and lower risk of heart failure, according to a study published Aug. 13 in the Journal of the American Medical Association .

“Intriguing data to say that perhaps there’s an additional group where early surgery may be indicated,” said Christopher Cannon, MD, FACC.

The study looked at 2,097 patients with flail mitral valve regurgitation receiving routine cardiac care from six tertiary centers in France, Italy, Belgium and the U.S. enrolled in the Mitral Regurgitation International Database registry.  Of these, 1021 did not have guideline recommended indications for early surgery (new or worsening symptoms or left ventricular dysfunction). In those without another indication for surgery, the authors compared those who underwent surgery in the first three months to those initially managed medically. In the latter group, 59 percent did undergo mitral valve surgery at an average of 1.65 years post enrollment.

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Results showed no significant difference between treatment strategies at three months, but long-term survival rates were higher for patients with early surgery (86 percent vs. 69 percent at 10 years, P < .001), which was confirmed in adjusted models, a propensity-matched cohort, and an inverse probability–weighted analysis, associated with a five-year reduction in mortality of 52.6 percent (P < .001). Similar results were observed in relative reduction in mortality following early surgery in the subset with class II triggers (59.3 after five years, P = .002).

Further, long-term heart failure risk was also lower with early surgery (7 percent vs. 23 percent at 10 years, P < .001), which was confirmed in risk-adjusted models, a propensity-matched cohort, and in an inverse probability–weighted analysis. Reduction in late-onset atrial fibrillation was not observed.

“The advantages associated with early surgical correction of mitral valve regurgitation were confirmed in both unmatched and matched populations, using multiple statistical methods,” note the authors. They add that prompt surgical intervention was associated with “greater long-term survival and lower heart failure risk, even in the absence of traditional class I triggers for surgery.”

In an editorial comment, Catherine M. Otto, MD, FACC, of the University of Washington School of Medicine, Seattle, notes, “clinical decisions for patients with valve disease are based on imperfect evidence. Currently, there are no data from randomized clinical trials for the optimal timing of surgery for patients with asymptomatic severe mitral regurgitation.” She adds that “referral of patients with significant valve dysfunction to a heart valve center is recommended so that options for the restoration of normal valve function, procedural risks, long-term outcomes, and patient preferences can be discussed in a team approach that includes valve experts, imaging specialist, interventional cardiologists and cardiac surgeons.”

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Valvular Heart Disease, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Mitral Regurgitation

Keywords: France, Survival Rate, Mitral Valve Insufficiency, Referral and Consultation, Belgium, Heart Failure, Atrial Fibrillation, Probability, Ventricular Dysfunction, Left, United States, Italy

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