Secondary mitral regurgitation in HF yields worse outcomes, yet valve repair rare
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Despite secondary mitral regurgitation in patients with HF being common and associated with mortality, surgical or transcatheter valve repair was seldom performed in this population, researchers reported.
Philipp E. Bartko, MD, PhD, of the department of internal medicine at Medical University of Vienna, and colleagues conducted an observational cohort study to determine the prevalence, long-term outcomes and treatment standards of secondary mitral regurgitation across the HF spectrum. They used data from the Viennese community health care provider network from 2010 to 2020, which included 13,223 patients with secondary mitral regurgitation across all HF subtypes.
The main outcome measures were the association between secondary mitral regurgitation and mortality in patients assigned by guideline diagnostic criteria to one of three HF subtypes: midrange, reduced and preserved ejection fraction.
Researchers reported severe secondary mitral regurgitation in 10% of patients, a condition that corresponded with increasing age (P < .001), occurred across the entire HF spectrum and was most frequent in patients with reduced EF (25%). Compared with the expected survival for people of the same age and sex in the same community, patients with severe secondary mitral regurgitation experienced higher-than-expected mortality (HR = 7.53; 95% CI, 6.83-8.3; P < .001).
Compared with patients with HF and no/mild secondary mitral regurgitation, those with moderate secondary mitral regurgitation had a 29% elevated risk for mortality (HR = 1.29; 95% CI, 1.2-1.38; P < .001) and those with severe secondary mitral regurgitation had an 82% elevated risk (HR = 1.82; 95% CI, 1.64-2.02; P < .001), Bartko and colleagues wrote.
Researchers observed that the association between severe secondary mitral regurgitation and excess mortality remained consistent after multivariate adjustment and across all three HF subgroups:
- HFmrEF: HR = 2.53; 95% CI, 2-3.19; P < .001;
- HFrEF: HR = 1.7; 1.43-2.03; P < .001; and
- HFpEF: HR = 1.52; 95% CI, 1.25-1.85; P < .001.
During the study period, despite available state-of-the-art health care, a high volume of HF and valve disease programs, a low barrier to health service access and a complete population health plan coverage, severe secondary mitral regurgitation was seldom treated with surgical valve repair (7%) or replacement (5%), while low-risk transcatheter repair (4%) was also rarely performed.
Reasons for these low numbers, the researchers wrote, include the excessive risks associated with surgical treatment, especially in older patients with HF, and the lack of controlled testing and solid data supporting transcatheter therapy in these HF subtypes.
“The extent of secondary mitral regurgitation is projected to increase with an aging population, indicating a growing demand for treatment,” the researchers wrote. “Echocardiographic screening and monitoring will be critical not only for diagnosis of heart failure but also for identifying high-risk patients with secondary mitral regurgitation. A close collaboration between general practicians, internal medicine specialists, and specialized heart valve and heart failure teams will be key to streamlining patient flow to tackle the growing demand for treatment and provide optimal patient care.”
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