Abstract 14202: Adverse Prognostic Impact of Classical Clinical Triggers for Surgical Correction of Organic Mitral Regurgitation: A Very Long-term Outcome Study
Background: Clinical guidelines for management of patients with mitral regurgitation (MR) define triggers for surgery as class I_mandatory (heart failure symptoms, ejection fraction<60% or left ventricular end-systolic diameter ≥40mm) or class II_reasonable (atrial fibrillation or pulmonary hypertension). Early surgery without these triggers is controversial. The implications of clinical triggers on outcome of organic MR surgery have not been defined in contemporary surgical era.
Methods: Long-term outcome of 1512 consecutive patients operated 1990-2000 for isolated organic MR was analyzed according to clinical triggers for surgery. Median follow-up was 11.3 years and MR etiology was degenerative in 86%.
Results: The clinical trigger for surgery was class I in 794 and class II (without class I) in 195, while early surgery was performed in 523. Early-surgery patients were younger (60±14 vs. 66±11 for class II and 66±13 for class I, p<0.01), more often male (74% vs. 67% for class II and 61% for class I, p<0.01) and underwent more valve repair (91% vs. 88% for class II and 86% for class I, p=0.02). Operative mortality was low and slightly different between groups (0% vs. 0% for class II and 1.1% for class I, p=0.02). Fifteen-year survival was higher after early surgery (70±3% vs. 53±4% for class II and 42±2% for class I, p<0.01). Adjusting for age, sex, STS score, valve repair, diabetes, creatinine, coronary disease and bypass, mortality risk-ratio was 1.38[1.02-1.82], p=0.03 for class II and 1.86[1.51-2.30], p<0.001 for class I vs. early-surgery. Early-surgery was also associated with lowest 15-year heart failure risk (15±3% vs.27±4% for class II and 35±2% for class I, p<0.001). After comprehensive adjustment heart failure risk-ratio was 2.0[1.3-3.0], p<0.001 for class II and 2.5[1.8-3.5], p<0.001 for class I compared to early surgery.
Conclusion: In patients with organic MR, early surgery can be performed safely with high mitral valve repair rate. Late survival and freedom from heart failure are greatest following early-surgery in comparison to either class I or class II triggers. These data support the performance of early mitral valve surgery for severe organic MR without overt clinical triggers in centers providing low operative risk and high repair rates.
- © 2013 by American Heart Association, Inc.