Is there an outcome penalty linked to guideline-based indications for valvular surgery? Early and long-term analysis of patients with organic mitral regurgitation

Maurice E Sarano, Rakesh M. Suri, Marie Annick Clavel, Francesca Mantovani, Hector I Michelena, Sorin Pislaru, Douglas W. Mahoney, Hartzell V Schaff

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Abstract

OBJECTIVE: The timing of surgical correction of mitral regurgitation remains controversial. A major source of dispute regards the potential short- and long-term postoperative outcome penalty associated with the type of guideline-based indication for surgery.

METHODS: Between 1990 and 2000, 1512 patients (aged 64 ± 14 years, mitral prolapse in 89%, valve repair in 88%) underwent surgical correction of pure organic mitral regurgitation. Patients were stratified according to surgical indication into class I triggers (ClassI-T: heart failure symptoms, ejection fraction <60%, end-systolic diameter ≥40 mm, n = 794), class II triggers based on clinical complications (ClassII-CompT: atrial fibrillation or pulmonary hypertension, n = 195), or early class II triggers based on a combination of severe mitral regurgitation and high probability of valve repair (ClassII-EarlyT: n = 523).

RESULTS: Operative mortality was highest with ClassI-T (1.1% vs 0% and 0%, P = .016). Long-term survival was lower with ClassI-T (15-year 42% ± 2%; adjusted hazard ratio [HR], 1.89; 95% confidence interval [CI], 1.53-2.34; P < .0001) and ClassII-CompT (15-year 53% ± 4%, adjusted HR, 1.39; 95% CI, 1.04-1.84; P = .027) versus ClassII-EarlyT (15-year 70% ± 3%, P < .0001). Postoperative excess mortality with ClassI-T and ClassII-CompT was confirmed by age stratification, inverse probability weighting, and expected survival adjustment. Excess postoperative heart failure was high with ClassI-T (adjusted HR, 2.49; 95% CI, 1.82-3.47; P < .0001) and ClassII-CompT (adjusted HR, 1.98; 95% CI, 1.30-3.00; P = .002).

CONCLUSIONS: The type of guideline-based indication for surgical correction of organic mitral regurgitation is associated with profound outcome consequences on long-term postoperative mortality and heart failure, despite low operative risk and high repair rates. Conversely, surgical correction of severe mitral regurgitation based on high probability of repair (ClassII-EarlyT) is associated with improved survival and low heart failure risk and should be the preferred strategy in valve centers offering low operative risk and high repair rates.

Original languageEnglish (US)
Pages (from-to)50-58
Number of pages9
JournalJournal of Thoracic and Cardiovascular Surgery
Volume150
Issue number1
DOIs
StatePublished - Jul 1 2015

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Mitral Valve Insufficiency
Guidelines
Heart Failure
Confidence Intervals
Mortality
Social Adjustment
Dissent and Disputes
Survival
Prolapse
Pulmonary Hypertension
Atrial Fibrillation

Keywords

  • guidelines
  • heart failure
  • mitral regurgitation
  • surgery
  • survival
  • valve repair

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Is there an outcome penalty linked to guideline-based indications for valvular surgery? Early and long-term analysis of patients with organic mitral regurgitation. / Sarano, Maurice E; Suri, Rakesh M.; Clavel, Marie Annick; Mantovani, Francesca; Michelena, Hector I; Pislaru, Sorin; Mahoney, Douglas W.; Schaff, Hartzell V.

In: Journal of Thoracic and Cardiovascular Surgery, Vol. 150, No. 1, 01.07.2015, p. 50-58.

Research output: Contribution to journalArticle

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abstract = "OBJECTIVE: The timing of surgical correction of mitral regurgitation remains controversial. A major source of dispute regards the potential short- and long-term postoperative outcome penalty associated with the type of guideline-based indication for surgery.METHODS: Between 1990 and 2000, 1512 patients (aged 64 ± 14 years, mitral prolapse in 89{\%}, valve repair in 88{\%}) underwent surgical correction of pure organic mitral regurgitation. Patients were stratified according to surgical indication into class I triggers (ClassI-T: heart failure symptoms, ejection fraction <60{\%}, end-systolic diameter ≥40 mm, n = 794), class II triggers based on clinical complications (ClassII-CompT: atrial fibrillation or pulmonary hypertension, n = 195), or early class II triggers based on a combination of severe mitral regurgitation and high probability of valve repair (ClassII-EarlyT: n = 523).RESULTS: Operative mortality was highest with ClassI-T (1.1{\%} vs 0{\%} and 0{\%}, P = .016). Long-term survival was lower with ClassI-T (15-year 42{\%} ± 2{\%}; adjusted hazard ratio [HR], 1.89; 95{\%} confidence interval [CI], 1.53-2.34; P < .0001) and ClassII-CompT (15-year 53{\%} ± 4{\%}, adjusted HR, 1.39; 95{\%} CI, 1.04-1.84; P = .027) versus ClassII-EarlyT (15-year 70{\%} ± 3{\%}, P < .0001). Postoperative excess mortality with ClassI-T and ClassII-CompT was confirmed by age stratification, inverse probability weighting, and expected survival adjustment. Excess postoperative heart failure was high with ClassI-T (adjusted HR, 2.49; 95{\%} CI, 1.82-3.47; P < .0001) and ClassII-CompT (adjusted HR, 1.98; 95{\%} CI, 1.30-3.00; P = .002).CONCLUSIONS: The type of guideline-based indication for surgical correction of organic mitral regurgitation is associated with profound outcome consequences on long-term postoperative mortality and heart failure, despite low operative risk and high repair rates. Conversely, surgical correction of severe mitral regurgitation based on high probability of repair (ClassII-EarlyT) is associated with improved survival and low heart failure risk and should be the preferred strategy in valve centers offering low operative risk and high repair rates.",
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AU - Sarano, Maurice E

AU - Suri, Rakesh M.

AU - Clavel, Marie Annick

AU - Mantovani, Francesca

AU - Michelena, Hector I

AU - Pislaru, Sorin

AU - Mahoney, Douglas W.

AU - Schaff, Hartzell V

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N2 - OBJECTIVE: The timing of surgical correction of mitral regurgitation remains controversial. A major source of dispute regards the potential short- and long-term postoperative outcome penalty associated with the type of guideline-based indication for surgery.METHODS: Between 1990 and 2000, 1512 patients (aged 64 ± 14 years, mitral prolapse in 89%, valve repair in 88%) underwent surgical correction of pure organic mitral regurgitation. Patients were stratified according to surgical indication into class I triggers (ClassI-T: heart failure symptoms, ejection fraction <60%, end-systolic diameter ≥40 mm, n = 794), class II triggers based on clinical complications (ClassII-CompT: atrial fibrillation or pulmonary hypertension, n = 195), or early class II triggers based on a combination of severe mitral regurgitation and high probability of valve repair (ClassII-EarlyT: n = 523).RESULTS: Operative mortality was highest with ClassI-T (1.1% vs 0% and 0%, P = .016). Long-term survival was lower with ClassI-T (15-year 42% ± 2%; adjusted hazard ratio [HR], 1.89; 95% confidence interval [CI], 1.53-2.34; P < .0001) and ClassII-CompT (15-year 53% ± 4%, adjusted HR, 1.39; 95% CI, 1.04-1.84; P = .027) versus ClassII-EarlyT (15-year 70% ± 3%, P < .0001). Postoperative excess mortality with ClassI-T and ClassII-CompT was confirmed by age stratification, inverse probability weighting, and expected survival adjustment. Excess postoperative heart failure was high with ClassI-T (adjusted HR, 2.49; 95% CI, 1.82-3.47; P < .0001) and ClassII-CompT (adjusted HR, 1.98; 95% CI, 1.30-3.00; P = .002).CONCLUSIONS: The type of guideline-based indication for surgical correction of organic mitral regurgitation is associated with profound outcome consequences on long-term postoperative mortality and heart failure, despite low operative risk and high repair rates. Conversely, surgical correction of severe mitral regurgitation based on high probability of repair (ClassII-EarlyT) is associated with improved survival and low heart failure risk and should be the preferred strategy in valve centers offering low operative risk and high repair rates.

AB - OBJECTIVE: The timing of surgical correction of mitral regurgitation remains controversial. A major source of dispute regards the potential short- and long-term postoperative outcome penalty associated with the type of guideline-based indication for surgery.METHODS: Between 1990 and 2000, 1512 patients (aged 64 ± 14 years, mitral prolapse in 89%, valve repair in 88%) underwent surgical correction of pure organic mitral regurgitation. Patients were stratified according to surgical indication into class I triggers (ClassI-T: heart failure symptoms, ejection fraction <60%, end-systolic diameter ≥40 mm, n = 794), class II triggers based on clinical complications (ClassII-CompT: atrial fibrillation or pulmonary hypertension, n = 195), or early class II triggers based on a combination of severe mitral regurgitation and high probability of valve repair (ClassII-EarlyT: n = 523).RESULTS: Operative mortality was highest with ClassI-T (1.1% vs 0% and 0%, P = .016). Long-term survival was lower with ClassI-T (15-year 42% ± 2%; adjusted hazard ratio [HR], 1.89; 95% confidence interval [CI], 1.53-2.34; P < .0001) and ClassII-CompT (15-year 53% ± 4%, adjusted HR, 1.39; 95% CI, 1.04-1.84; P = .027) versus ClassII-EarlyT (15-year 70% ± 3%, P < .0001). Postoperative excess mortality with ClassI-T and ClassII-CompT was confirmed by age stratification, inverse probability weighting, and expected survival adjustment. Excess postoperative heart failure was high with ClassI-T (adjusted HR, 2.49; 95% CI, 1.82-3.47; P < .0001) and ClassII-CompT (adjusted HR, 1.98; 95% CI, 1.30-3.00; P = .002).CONCLUSIONS: The type of guideline-based indication for surgical correction of organic mitral regurgitation is associated with profound outcome consequences on long-term postoperative mortality and heart failure, despite low operative risk and high repair rates. Conversely, surgical correction of severe mitral regurgitation based on high probability of repair (ClassII-EarlyT) is associated with improved survival and low heart failure risk and should be the preferred strategy in valve centers offering low operative risk and high repair rates.

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KW - heart failure

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KW - survival

KW - valve repair

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