Long Term Survival of Patients Undergoing Mitral Valve Repair and Replacement: A Longitudinal Analysis of Medicare Fee-for-Service Beneficiaries
What are the operative and long-term survival statistics among Medicare fee-for-service patients undergoing mitral valve (MV) replacement and MV repair?
The Medicare database was used to identify 47,279 fee-for-service beneficiaries ages ≥65 undergoing primary isolated MV repair or replacement from 2000 to 2009. Operative mortality and long- term survival were compared for repair and replacement.
Operative mortality was 3.9% for patients undergoing repair and 8.9% for patients undergoing replacement. Kaplan-Meier 1-, 5-, and 10-year survival estimates for patients undergoing repair were 90.9%, 77.1%, and 53.6%. Kaplan-Meier 1-, 5-, and 10-year survival estimates for patients undergoing replacement were 82.6%, 64.7%, and 37.2%. Important predictors of mitral repair included younger age (odds ratio [OR], 1.10; 95% confidence interval [CI], 1.05-1.14), elective admission status (OR, 1.34; 95% CI, 1.27-1.41), and annual mitral procedure volume >40 (OR, 1.57; 95% CI, 1.36-1.81). Female sex and the presence of comorbidities were associated with lower likelihood of repair.
The authors concluded that MV surgery in the Medicare population carries less risk than previously reported. In light of the favorable outcomes of elderly patients undergoing MV surgery, and especially MV repair, the authors concluded that an approach of earlier identification and surgical referral appears justified regardless of age.
This is an important study in that it reveals relatively low operative mortality for patients undergoing MV repair, and good 10-year outcomes associated with MV repair and replacement in the Medicare population. However, some caveats should be noted before broader conclusions are drawn. First, a variety of factors likely affect whether patients undergo MV repair versus replacement; some probably are justified (e.g., patients with an unrepairable valve might have different underlying disease/s than do patients with a repairable valve, and patients with a less favorable mid-term prognosis might preferentially undergo replacement rather than repair), and some might not be justified (e.g., replacement is preferentially performed at lower-volume centers). Second, there is inherent selection bias in studying the outcomes of patients who were referred for and underwent surgery, and it might not be appropriate to extrapolate favorable operative statistics to all older patients with MV disease. Finally, an argument for ‘early intervention’ among patients with mitral regurgitation still needs to be tempered with the age and general health of the patient, as well as the patient’s expectations in later years of life. Any conclusion that elderly patients are better off with ‘early’ intervention should come from a study that compared early intervention to usual clinical indications for surgery.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Cardiac Surgery and VHD, Interventions and Structural Heart Disease, Mitral Regurgitation
Keywords: Survivors, Fee-for-Service Plans, Mitral Valve Insufficiency, Cardiology, Comorbidity, Cardiovascular Diseases, Confidence Intervals, Heart Valve Prosthesis Implantation, Medicare, Cardiac Surgical Procedures, United States
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