Early mitral surgery associated with long-term survival, low HF risk

A registry study in patients with flail mitral valve regurgitation showed that early valve repair surgery is associated with greater long-term survival and a lower risk for HF compared with initial medical management.

There has been debate whether early surgical intervention or medical nonsurgical observation is a better strategy in patients with severe mitral valve regurgitation but no symptoms of HF or left ventricular dysfunction.

“The present data substantiate the opportunity to improve long-term patient survival and diminish late [HF] risk in those with mitral regurgitation due to flail mitral leaflets through early referral for surgical correction where appropriate expertise exists,” Rakesh M. Suri, MD, DPhil, of the Mayo Clinic College of Medicine, Rochester, Minn., and colleagues wrote.

Suri and colleagues analyzed patients in the Mitral Regurgitation International Database from 1980 to 2004 who were diagnosed with flail mitral valve regurgitation as detected by transthoracic echocardiography, but had no symptoms of HF or LV dysfunction (n=1,021).

They compared those who had early surgery (n=446), defined as within 3 months of diagnosis, with those who had medical management for the first 3 months after diagnosis (n=575). The primary outcome was all-cause mortality. Secondary outcomes included HF and new-onset atrial fibrillation. Mean follow-up time was 10.3 years.

There was no difference between the groups in early mortality and new-onset HF after 3 months. However, after 10 years, early surgery patients had higher survival rates compared with medical management patients (86% vs. 69%; adjusted HR=0.55; 95% CI, 0.41-0.72). Early surgery was associated with a 5-year reduction in mortality of 52.6% (P<.001).

Early surgery was also associated with lower HF risk after 10 years (7% vs. 23%; adjusted HR=0.29; 95% CI, 0.19-0.43).

The researchers did not observe a reduction in late-onset AF (HR=0.85, 95% CI, 0.64-1.13).

Similar results were confirmed in unmatched and matched populations, using various statistical methods.

Among those who did not have early surgery, 59% underwent mitral valve surgery eventually, a median 1.65 years after diagnosis of a flail leaflet.

In an accompanying editorial, Catherine M. Otto, MD, of the University of Washington School of Medicine, Seattle, wrote: “The findings indicate that it may be more beneficial to offer early surgery for patients with severe mitral regurgitation due to a flail mitral valve leaflet, rather than waiting for symptom onset or classic indications for intervention.”

However, Otto wrote, it may be prudent to wait on surgery for patients for whom surgical risk is high or the likelihood of valve repair is low. She also said it is best for patients with severe valve dysfunction to be referred to a heart valve center to be treated with a team approach.

For more information:

Otto CM. JAMA. 2013;310:587-588.

Suri RM. JAMA. 2013;310:609-616.

Disclosure: See the full study for a list of the researchers’ relevant financial disclosures. Otto reports no relevant financial disclosures.