Mitral Valve Regurgitation from Flail Leaflets: Early Surgical Intervention May be Warranted

MedicalResearch.com Interview with: Rakesh M. Suri MD, D.Phil.
Mayo Clinic College of Medicine, Rochester, Minnesota

MedicalResearch.com: What might clinicians “take home” from this study?

Answers:

a. The contemporary outcomes of surgical correction of mitral regurgitation are excellent based upon results observed in this large multinational, multi-institutional study, Mitral valve surgery now has a low peri-operative risk of death or complications, and a very high likelihood of saving a patient’s own heart valve (>90% – repair); thereby avoiding the need for replacement with an artificial valve substitute.

b. All patients with severe degenerative mitral regurgitation are at risk for heart failure and/or death when surgical correction is delayed.  A safe period of “watchful waiting” in those with severe mitral regurgitation due to flail leaflets, even in the absence of traditional Class I triggers for surgery (symptoms or left ventricular dilation/dysfunction) does not exist.

c. Prompt mitral valve surgery within months following the diagnosis of severe degenerative mitral regurgitation, even in those without symptoms, is associated with important and sustained long term benefits including a 40% decrease in death and 60% less heart failure risk, sustained many years following surgical intervention

MedicalResearch.com:  Is a change in clinical practice warranted now?

Answer: We propose the following changes are warranted.

a. Patients with severe mitral regurgitation, even without symptoms or left ventricular dysfunction, should see a cardiologist with expertise in heart valve disease

b. An echocardiogram ascertaining the cause and severity of mitral regurgitation should be performed in those with suspected severe leakage, and repeated serially during longitudinal follow up in those with less-than-severe degrees of mitral regurgitation

c. Prompt referral to a cardiac care center and a referent mitral valve repair surgeon should occur once the diagnosis of severe degenerative mitral regurgitation is made

d. Surgeon and center-specific outcome data must be available to patients and cardiologists – including repair rate, peri-procedural risk, and availability of less invasive surgical options. These are important questions for patients to ask.

e. A thorough discussion of indications, risks, benefits, alternatives and patient preferences should occur between the patient, cardiologist and surgeon.

f. Mitral valve surgery should be performed without delay in asymptomatic patients with flail leaflets and severe mitral valve regurgitation by surgeons capable of offering a very high rate of valve repair (>95% in referent centers) with a very low risk of death or complications as determined by published benchmarks

g. Patients should be followed long term following surgical correction to optimize medical therapy (particularly in the presence of left ventricular dysfunction), confirming the stability of valve repair and freedom from heart failure.

Citation:

Association Between Early Surgical Intervention vs Watchful Waiting and Outcomes for Mitral Regurgitation Due to Flail Mitral Valve Leaflets

Rakesh M. Suri, MD, DPhil1; Jean-Louis Vanoverschelde, MD2; Francesco Grigioni, MD, PhD3; Hartzell V. Schaff, MD1; Christophe Tribouilloy, MD4; Jean-Francois Avierinos, MD5; Andrea Barbieri, MD6; Agnes Pasquet, MD2; Marianne Huebner, PhD1,7; Dan Rusinaru, MD4; Antonio Russo, MD3; Hector I. Michelena, MD1; Maurice Enriquez-Sarano, MD1