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Post-Surgical Survival in Degenerative Mitral Regurgitation
Quick Takes
- Patients with degenerative mitral regurgitation (DMR) undergoing mitral valve surgery have increased mortality if they have any of the following secondary outcome determinants: 1) left atrial volume index ≥60 mL/m2, 2) right ventricular systolic pressure ≥50 mm Hg, 3) atrial fibrillation, or 4) at least moderate tricuspid regurgitation.
- A greater number of these secondary outcome determinants is associated with incrementally higher rates of mortality.
Study Questions:
What factors are associated with survival following mitral valve surgery for degenerative mitral regurgitation (DMR)?
Methods:
This multicenter registry examined patients with isolated DMR (due to mitral valve prolapse and/or flail leaflet) who underwent mitral valve surgery and examined the prognostic value of four secondary outcome determinants: left atrial volume index ≥60 mL/m2, right ventricular systolic pressure ≥50 mm Hg, atrial fibrillation, and at least moderate tricuspid regurgitation. The relationship between the presence and number of these findings to all-cause mortality was evaluated on multivariate analysis, which adjusted for age, EuroSCORE II, symptoms, ejection fraction, left ventricular end-systolic diameter, and DMR severity. Only patients who had surgery within 1 year of registry enrollment were included.
Results:
There were 2,276 individuals in the study. Median age was 65 years and 32% were male. Median follow-up was 5.6 years, with deaths in 278 subjects. On multivariable analysis, the number of secondary outcome determinants was independently associated with increased postoperative mortality (hazard ratio [HR], 1.6; 95% confidence interval [CI], 1.1-2.2; p = 0.01; HR, 1.8; 95% CI, 1.2-2.6; p = 0.002; and HR, 2.6; 95% CI, 1.7-3.8; p < 0.001; for 1, 2, or 3-4 factors, respectively). A model incorporating the number of secondary outcome determinants had a higher C-index to identify risk of mortality than models using other markers alone.
Conclusions:
The authors conclude that the presence and number of secondary outcome determinants in patients with DMR undergoing mitral valve surgery improves the ability to estimate mortality risk over traditional variables alone.
Perspective:
This study demonstrates the additive value of marked left atrial dilatation, pulmonary hypertension, atrial fibrillation, and at least moderate tricuspid regurgitation in assessing the mortality risk of patients with DMR undergoing mitral valve surgery over established Class I surgical indications alone. These results suggest that adverse sequelae from DMR may lead to irreversible cardiac changes that increase mortality and could support earlier interventions in some patients. In patients with borderline Class I indications for mitral valve replacement, the presence of these secondary outcome determinants could suggest a potential benefit from earlier surgery. It is also possible that intervention prior to a patient developing these secondary outcome determinants could lower future mortality, although future studies are needed to fully assess this hypothesis. These findings should inform future guidelines evaluating the utility and timing of mitral valve surgery in patients with DMR.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Valvular Heart Disease, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Pulmonary Hypertension, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Hypertension, Mitral Regurgitation
Keywords: Atrial Fibrillation, Cardiac Surgical Procedures, Cardiology Interventions, Dilatation, Heart Valve Diseases, Mitral Valve Insufficiency, Mitral Valve Prolapse, Hypertension, Pulmonary, Survival, Tricuspid Valve Insufficiency
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