Abstract 3679: Impact of Early Surgery on Survival of Patients With Severe Mitral Regurgitation
Background: Optimal timing of surgery in degenerative mitral regurgitation (MR) remains a controversial topic. The impact of current ACC/AHA guideline recommendations regarding optimal timing of surgery on outcomes is untested and contemporary data is lacking.
Methods: We identified a cohort of 481 patients with severe, degenerative MR (1995–2007) from the Duke Cardiovascular Disease Database who met at least one ACC/AHA guideline indication for surgery. Exclusion criteria were rheumatic disease, congenital mitral valve (MV) disease, hypertrophic cardiomyopathy, >1 vessel coronary disease, endocarditis, other severe valve disease, h/o valve repair/replacement. For summary purposes patients were grouped as follows:
early surgery (≤2 months of meeting indications),
late surgery (≥2 months), and
medical management (no surgery).
For early and late surgery patients a Cox regression model was constructed for time to death after 2 months with a time dependent covariate term for late surgery. The model was adjusted for age, h/o CHF, EF, left ventricular (LV) dimensions, MV repair, and Charlson Comorbity Index.
Results: We observed 168 patients having early surgery with 153 surviving 2 months, 94 having late surgery, and 219 medically managed. The median length of follow-up was 4.3 years. Over all, 127/168 early surgery group and 84/94 late surgery group patients underwent MV repair. There were 35 deaths (22%), with 2 occurring before 2 months, in the early surgery group and 20 (21%) in the late group. In the multivariable model, those undergoing early surgery had a lower hazard for death compared to those who underwent late surgery. [HR 0.54 (95% CI 0.30, 0.97), p=0.039]. MV repair was independently associated with survival [HR 0.45 (95% CI 0.25, 0.83), p=0.01]
Conclusions: In patients with severe MR, our model indicated improved survival for those receiving surgery within 2 months of meeting guideline indications. These data support the current ACC/AHA guidelines for referral to surgery in patients with severe MR who have symptoms, a declining EF or enlarging LV dimensions rather than delaying surgery. A large randomized trial is needed to definitively answer the question of optimal timing of surgery in patients with severe degenerative MR.