Log in to MyACC
Risk of Surgical Mitral Valve Repair for Primary Mitral Regurgitation
Quick Takes
- Using data from the STS Adult Cardiac Surgery database for patients undergoing elective or urgent isolated MV repair for primary MR, there was a low overall operative mortality risk (expected mortality <1% in two thirds of patients, 90th percentile operative mortality 2.5%).
- There was a 6.4% rate of conversion to MV replacement, and conversion to valve replacement (CONV) was associated with a higher mortality risk (OR, 3.2%).
- Both mortality risk and risk of CONV were lower at higher-volume centers; an operative mortality of ≤1% was estimated at a volume of 25 cases annually.
Study Questions:
Is it possible to create a risk model for mortality, mortality and/or major morbidity (MM), and conversion to valve replacement (CONV) for patients with primary mitral regurgitation (MR) undergoing surgical mitral valve (MV) repair?
Methods:
A novel etiology- and procedure-specific algorithm was used with the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database to identify 53,462 consecutive patients between July 2014 and June 2020 with intention to treat primary MR using elective or urgent on-pump isolated MV repair (using STS criteria that also potentially included tricuspid valve repair, atrial fibrillation ablation, left atrial appendage obliteration, and/or atrial septal defect/patent foramen ovale closure). Risk models were fit for 30-day operative mortality, MM, and CONV.
Results:
Event rates for mortality (n = 619; 1.16%), MM (n = 4,746; 8.88%), and CONV (3,399; 6.36%) were low. During the 6-year study period, 526 of 881 (59.7%) hospitals and 1,947 of 2,404 (81.0%) surgeons experienced no mortality. However, mortality was higher in CONV patients versus repair (3.2% vs. 1.0%, odds ratio [OR], 3.18; 95% confidence interval [CI], 2.58-3.93; p < 0.001). The mortality risk model confirmed very low mortality risk for isolated MV repair for primary MR with mean mortality risk of 1.16%, median 0.55% (interquartile range, 0.30%-1.17%) with 90th and 95th percentiles 2.48% and 3.99%, respectively. The mortality risk was <0.5% in patients <65 years of age, with 97% of the total population across age groups having a risk of <3%. Only 2,118 of 8,568 (24.7%) patients aged ≥75 years had a >3% estimated risk of mortality. All event rates were lower with increasing program volumes. A total of 135 of 881 hospitals (15.3%) were responsible for 31,617 (59.1%) operations with a mortality of 0.73% and conversion rate of 3.69%; inflection point analysis for hospital volume revealed that an operative mortality of ≤1% was estimated at 25 cases annually.
Conclusions:
The authors conclude that this etiologic- and procedure-specific risk model establishes that the contemporary mortality risk of isolated MV repair for primary MR is <1% for the vast majority of patients.
Perspective:
Current international guidelines recommend MV repair as the first-line therapy for symptomatic patients with severe primary MR or for asymptomatic patients with reduced left ventricular (LV) systolic function, and consider MV repair to be reasonable for asymptomatic patients with normal LV size and systolic function and a >95% likelihood of successful repair and low operative risk. This study used data extracted from the STS Adult Cardiac Surgery Database over a 6-year interval between 2014 and 2020 to identify 53,462 consecutive patients with intention-to-treat primary MR using elective or urgent on-pump MV repair (potentially including tricuspid valve repair, atrial fibrillation ablation, left atrial appendage obliteration, and/or atrial septal defect/patent foramen ovale closure). It demonstrated a low overall mortality risk (expected mortality <1% in two thirds of patients, 90th percentile operative mortality 2.5%), a 93.6% rate of mitral valve repair (6.4% rate of CONV) with a higher mortality risk associated with CONV (OR, 3.2%), and both mortality risk and risk of CONV lower at higher-volume centers. Together with previous publications that have addressed the favorable long-term clinical outcomes of surgical MV repair for primary MR, this study helps reinforce its low risks; and, importantly, provides further evidence to support referral of patients with primary MR to high-volume reference centers.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Congenital Heart Disease and Pediatric Cardiology, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and VHD, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Interventions, CHD and Pediatrics and Quality Improvement, Interventions and Structural Heart Disease, Mitral Regurgitation
Keywords: Atrial Appendage, Atrial Fibrillation, Cardiac Surgical Procedures, Catheter Ablation, Foramen Ovale, Patent, Geriatrics, Heart Defects, Congenital, Heart Septal Defects, Atrial, Heart Valve Diseases, Mitral Valve Insufficiency, Morbidity, Risk, Secondary Prevention, Tricuspid Valve Insufficiency
< Back to Listings
