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Published on: May 19, 2020
Survival loss linked to guideline-based indications for degenerative mitral regurgitation surgery
David Vancraeynest1, Anne-Catherine Pouleur1, Christophe de Meester1
1Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, and IREC/CARD UCLouvain, Av Hippocrate 10/2806, B-1200 Brussels, Belgium.
Insights
Waiting for guideline-based surgical triggers in degenerative mitral regurgitation (DMR) patients is linked to reduced survival. Early surgery is recommended to improve outcomes for DMR patients.
Area of Science:
- Cardiovascular Surgery
- Cardiac Surgery
- Mitral Valve Disease
Background:
- Current guidelines for operating on severe degenerative mitral regurgitation (DMR) are based on ACC/AHA or ESC/EACTS recommendations.
- Uncertainty exists regarding optimal surgical timing and its impact on long-term survival after DMR surgery.
Purpose of the Study:
- To investigate whether adherence to guideline-based surgical indications for DMR is associated with late postoperative survival loss.
- To evaluate the impact of different surgical trigger classes on patient outcomes.
Main Methods:
- Analysis of 2833 patients undergoing DMR surgical correction from the Mitral Regurgitation International Database registry.
- Stratification of patients based on surgical indications: Class I, isolated Class IIa, or no trigger.
- Comparison of postoperative survival using restricted mean survival time (RMST) analysis and hazard ratios after matching for clinical differences.
Main Results:
- Long-term survival was significantly lower in patients operated on for Class I triggers compared to Class IIa or no triggers (71.4% vs. 84.3% and 88.9% at 10 years, respectively).
- Class I triggers were associated with excess mortality (P < 0.001), with multiple Class I criteria increasing death risk (HR: 1.53).
- Isolated Class IIa triggers also conferred an excess mortality risk (HR: 1.46, P = 0.05), with isolated pulmonary hypertension or atrial fibrillation specifically linked to decreased survival.
Conclusions:
- Delaying surgery for degenerative mitral regurgitation until Class I or isolated Class IIa triggers manifest is associated with significant postoperative survival loss.
- These findings support an early surgical intervention strategy for patients with severe DMR to improve long-term survival.
Aims:
Operating on patients with severe degenerative mitral regurgitation (DMR) is based on ACC/AHA or ESC/EACTS guidelines. Doubts persist on best surgical indications and their potential association with postoperative survival loss. We sought to investigate whether guideline-based indications lead to late postoperative survival loss in DMR patients.
Methods And Results:
We analysed outcome of 2833 patients from the Mitral Regurgitation International Database registry undergoing surgical correction of DMR. Patients were stratified by surgical indications: Class I trigger (symptoms, left ventricular end-systolic diameter ≥ 40 mm, or left ventricular ejection fraction < 60%, n = 1677), isolated Class IIa trigger [atrial fibrillation (AF), pulmonary hypertension (PH), or left atrial diameter ≥ 55 mm, n = 568], or no trigger (n = 588). Postoperative survival was compared after matching for clinical differences. Restricted mean survival time (RMST) was analysed. During a median 8.5-year follow-up, 603 deaths occurred. Long-term postoperative survival was lower with Class I trigger than in Class IIa trigger and no trigger (71.4 ± 1.9, 84.3 ± 2.3, and 88.9 ± 1.9% at 10 years, P < 0.001). Having at least one Class I criterion led to excess mortality (P < 0.001), while several Class I criteria conferred additional death risk [hazard ratio (HR): 1.53, 95% confidence interval (CI): 1.42-1.66]. Isolated Class IIa triggers conferred an excess mortality risk vs. those without (HR: 1.46, 95% CI: 1.00-2.13, P = 0.05). Among these patients, isolated PH led to decreased postoperative survival vs. those without (83.7 ± 2.8% vs. 89.3 ± 1.6%, P = 0.011), with the same pattern observed for AF (81.8 ± 5.0% vs. 88.3 ± 1.5%, P = 0.023). According to RMST analysis, compare to those operated on without triggers, operating on Class I trigger patients led to 9.4-month survival loss (P < 0.001) and operating on isolated Class IIa trigger patients displayed 4.9-month survival loss (P = 0.001) after 10 years.
Conclusion:
Waiting for the onset of Class I or isolated Class IIa triggers before operating on DMR patients is associated with postoperative survival loss. These data encourage an early surgical strategy.
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