Outcome and undertreatment of mitral regurgitation: a community cohort study

Volha Dziadzko, Marie Annick Clavel, Mikhail Dziadzko, Jose R. Medina-Inojosa, Hector I Michelena, Joseph Maalouf, Vuyisile T Nkomo, Prabin Thapa, Maurice E Sarano

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Abstract

Background: Mitral regurgitation is the most common valve disease worldwide but whether the community-wide prevalence, poor patient outcomes, and low rates of surgical treatment justify costly development of new therapeutic interventions remains uncertain. Therefore, we did an observational cohort study to assess the clinical characteristics, outcomes, and degree of undertreatment of mitral regurgitation in a community setting. Methods: We used data from Mayo Clinic electronic health records and the Rochester Epidemiology Project to identify all cases of moderate or severe isolated single-valvular mitral regurgitation (with no other severe left-sided valvular disease or previous mitral surgery) diagnosed during a 10-year period in the community setting in Olmsted County (MN, USA). We assessed clinical characteristics, mortality, heart failure incidence, and results of cardiac surgery post-diagnosis. Findings: Between Jan 1, 2000, and Dec 31, 2010, 1294 community residents (median age at diagnosis 77 years [IQR 66–84]) were diagnosed with moderate or severe mitral regurgitation by Doppler echocardiography (prevalence 0·46% [95% CI 0·42–0·49] overall; 0·59% [0·54–0·64] in adults). Left-ventricular ejection fraction below 50% was frequent (recorded in 538 [42%] patients), and these patients had a slightly lower regurgitant volume than those with an ejection fraction of 50% or higher (mean 39 mL [SD 16] vs 45 mL [21], p<0·0001). Post-diagnosis mortality was mainly cardiovascular in nature (in 420 [51%] of 824 patients for whom the cause of death was available) and higher than expected for residents of the county for age or sex (risk ratio [RR] 2·23 [95% CI 2·06–2·41], p<0·0001). This excess mortality affected all subsets of patients, whether they had a left-ventricular ejection fraction lower than 50% (RR 3·17 [95% CI 2·84–3·53], p<0·0001) or of 50% or higher (1·71 [1·53 −1·91], p<0·0001) and with primary mitral regurgitation (RR 1·73 [95% CI 1·53–1·96], p<0·0001) or secondary mitral regurgitation (2·72 [2·48–3·01], p<0·0001). Even patients with a low comorbidity burden combined with favourable characteristics such as left-ventricular ejection fraction of 50% or higher (RR 1·28 [95% CI 1·10–1·50], p<0·0017) or primary mitral regurgitation (1·29 [1·09–1·52], p=0·0030) incurred excess mortality. Heart failure was frequent (mean 64% [SE 1] at 5 years postdiagnosis), even in patients with left-ventricular ejection fraction of 50% or higher (49% [2] at 5 years postdiagnosis) or in those with primary mitral regurgitation (48% [2]). Mitral surgery was ultimately done in only 198 (15%) of 1294 patients, of which the predominant type of surgery was valve repair (in 149 [75%] patients). Mitral surgery was done in 28 (5%) of 538 patients with left-ventricular ejection fraction below 50% and in 170 (22%) of 756 patients with ejection fraction of 50% or higher, and in 34 (5%) of 723 with secondary mitral regurgitation versus 164 (29%) of 571 with primary regurgitation. All other types of cardiac surgery combined were performed in only 3% more patients (237 [18%] patients) than the number who underwent mitral surgery. Interpretation: In the community, isolated mitral regurgitation is common and is associated with excess mortality and frequent heart failure postdiagnosis in all patient subsets, even in those with normal left-ventricular ejection fraction and low comorbidity. Despite these poor outcomes, only a minority of affected patients undergo mitral (or any type of cardiac) surgery even in a community with all means of diagnosis and treatment readily available and accessible. This suggests that in a wider population there might be a substantial unmet need for treatment for this disorder. Funding: Mayo Clinic Foundation.

Original languageEnglish (US)
Pages (from-to)960-969
Number of pages10
JournalThe Lancet
Volume391
Issue number10124
DOIs
StatePublished - Mar 10 2018

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Mitral Valve Insufficiency
Cohort Studies
Stroke Volume
Odds Ratio
Mortality
Thoracic Surgery
Heart Failure
Comorbidity
Doppler Echocardiography
Electronic Health Records
Sex Ratio
Therapeutics
Observational Studies
Cause of Death

ASJC Scopus subject areas

  • Medicine(all)

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Outcome and undertreatment of mitral regurgitation : a community cohort study. / Dziadzko, Volha; Clavel, Marie Annick; Dziadzko, Mikhail; Medina-Inojosa, Jose R.; Michelena, Hector I; Maalouf, Joseph; Nkomo, Vuyisile T; Thapa, Prabin; Sarano, Maurice E.

In: The Lancet, Vol. 391, No. 10124, 10.03.2018, p. 960-969.

Research output: Contribution to journalArticle

Dziadzko, V, Clavel, MA, Dziadzko, M, Medina-Inojosa, JR, Michelena, HI, Maalouf, J, Nkomo, VT, Thapa, P & Sarano, ME 2018, 'Outcome and undertreatment of mitral regurgitation: a community cohort study', The Lancet, vol. 391, no. 10124, pp. 960-969. https://doi.org/10.1016/S0140-6736(18)30473-2
Dziadzko V, Clavel MA, Dziadzko M, Medina-Inojosa JR, Michelena HI, Maalouf J et al. Outcome and undertreatment of mitral regurgitation: a community cohort study. The Lancet. 2018 Mar 10;391(10124):960-969. https://doi.org/10.1016/S0140-6736(18)30473-2
Dziadzko, Volha ; Clavel, Marie Annick ; Dziadzko, Mikhail ; Medina-Inojosa, Jose R. ; Michelena, Hector I ; Maalouf, Joseph ; Nkomo, Vuyisile T ; Thapa, Prabin ; Sarano, Maurice E. / Outcome and undertreatment of mitral regurgitation : a community cohort study. In: The Lancet. 2018 ; Vol. 391, No. 10124. pp. 960-969.
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abstract = "Background: Mitral regurgitation is the most common valve disease worldwide but whether the community-wide prevalence, poor patient outcomes, and low rates of surgical treatment justify costly development of new therapeutic interventions remains uncertain. Therefore, we did an observational cohort study to assess the clinical characteristics, outcomes, and degree of undertreatment of mitral regurgitation in a community setting. Methods: We used data from Mayo Clinic electronic health records and the Rochester Epidemiology Project to identify all cases of moderate or severe isolated single-valvular mitral regurgitation (with no other severe left-sided valvular disease or previous mitral surgery) diagnosed during a 10-year period in the community setting in Olmsted County (MN, USA). We assessed clinical characteristics, mortality, heart failure incidence, and results of cardiac surgery post-diagnosis. Findings: Between Jan 1, 2000, and Dec 31, 2010, 1294 community residents (median age at diagnosis 77 years [IQR 66–84]) were diagnosed with moderate or severe mitral regurgitation by Doppler echocardiography (prevalence 0·46{\%} [95{\%} CI 0·42–0·49] overall; 0·59{\%} [0·54–0·64] in adults). Left-ventricular ejection fraction below 50{\%} was frequent (recorded in 538 [42{\%}] patients), and these patients had a slightly lower regurgitant volume than those with an ejection fraction of 50{\%} or higher (mean 39 mL [SD 16] vs 45 mL [21], p<0·0001). Post-diagnosis mortality was mainly cardiovascular in nature (in 420 [51{\%}] of 824 patients for whom the cause of death was available) and higher than expected for residents of the county for age or sex (risk ratio [RR] 2·23 [95{\%} CI 2·06–2·41], p<0·0001). This excess mortality affected all subsets of patients, whether they had a left-ventricular ejection fraction lower than 50{\%} (RR 3·17 [95{\%} CI 2·84–3·53], p<0·0001) or of 50{\%} or higher (1·71 [1·53 −1·91], p<0·0001) and with primary mitral regurgitation (RR 1·73 [95{\%} CI 1·53–1·96], p<0·0001) or secondary mitral regurgitation (2·72 [2·48–3·01], p<0·0001). Even patients with a low comorbidity burden combined with favourable characteristics such as left-ventricular ejection fraction of 50{\%} or higher (RR 1·28 [95{\%} CI 1·10–1·50], p<0·0017) or primary mitral regurgitation (1·29 [1·09–1·52], p=0·0030) incurred excess mortality. Heart failure was frequent (mean 64{\%} [SE 1] at 5 years postdiagnosis), even in patients with left-ventricular ejection fraction of 50{\%} or higher (49{\%} [2] at 5 years postdiagnosis) or in those with primary mitral regurgitation (48{\%} [2]). Mitral surgery was ultimately done in only 198 (15{\%}) of 1294 patients, of which the predominant type of surgery was valve repair (in 149 [75{\%}] patients). Mitral surgery was done in 28 (5{\%}) of 538 patients with left-ventricular ejection fraction below 50{\%} and in 170 (22{\%}) of 756 patients with ejection fraction of 50{\%} or higher, and in 34 (5{\%}) of 723 with secondary mitral regurgitation versus 164 (29{\%}) of 571 with primary regurgitation. All other types of cardiac surgery combined were performed in only 3{\%} more patients (237 [18{\%}] patients) than the number who underwent mitral surgery. Interpretation: In the community, isolated mitral regurgitation is common and is associated with excess mortality and frequent heart failure postdiagnosis in all patient subsets, even in those with normal left-ventricular ejection fraction and low comorbidity. Despite these poor outcomes, only a minority of affected patients undergo mitral (or any type of cardiac) surgery even in a community with all means of diagnosis and treatment readily available and accessible. This suggests that in a wider population there might be a substantial unmet need for treatment for this disorder. Funding: Mayo Clinic Foundation.",
author = "Volha Dziadzko and Clavel, {Marie Annick} and Mikhail Dziadzko and Medina-Inojosa, {Jose R.} and Michelena, {Hector I} and Joseph Maalouf and Nkomo, {Vuyisile T} and Prabin Thapa and Sarano, {Maurice E}",
year = "2018",
month = "3",
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TY - JOUR

T1 - Outcome and undertreatment of mitral regurgitation

T2 - a community cohort study

AU - Dziadzko, Volha

AU - Clavel, Marie Annick

AU - Dziadzko, Mikhail

AU - Medina-Inojosa, Jose R.

AU - Michelena, Hector I

AU - Maalouf, Joseph

AU - Nkomo, Vuyisile T

AU - Thapa, Prabin

AU - Sarano, Maurice E

PY - 2018/3/10

Y1 - 2018/3/10

N2 - Background: Mitral regurgitation is the most common valve disease worldwide but whether the community-wide prevalence, poor patient outcomes, and low rates of surgical treatment justify costly development of new therapeutic interventions remains uncertain. Therefore, we did an observational cohort study to assess the clinical characteristics, outcomes, and degree of undertreatment of mitral regurgitation in a community setting. Methods: We used data from Mayo Clinic electronic health records and the Rochester Epidemiology Project to identify all cases of moderate or severe isolated single-valvular mitral regurgitation (with no other severe left-sided valvular disease or previous mitral surgery) diagnosed during a 10-year period in the community setting in Olmsted County (MN, USA). We assessed clinical characteristics, mortality, heart failure incidence, and results of cardiac surgery post-diagnosis. Findings: Between Jan 1, 2000, and Dec 31, 2010, 1294 community residents (median age at diagnosis 77 years [IQR 66–84]) were diagnosed with moderate or severe mitral regurgitation by Doppler echocardiography (prevalence 0·46% [95% CI 0·42–0·49] overall; 0·59% [0·54–0·64] in adults). Left-ventricular ejection fraction below 50% was frequent (recorded in 538 [42%] patients), and these patients had a slightly lower regurgitant volume than those with an ejection fraction of 50% or higher (mean 39 mL [SD 16] vs 45 mL [21], p<0·0001). Post-diagnosis mortality was mainly cardiovascular in nature (in 420 [51%] of 824 patients for whom the cause of death was available) and higher than expected for residents of the county for age or sex (risk ratio [RR] 2·23 [95% CI 2·06–2·41], p<0·0001). This excess mortality affected all subsets of patients, whether they had a left-ventricular ejection fraction lower than 50% (RR 3·17 [95% CI 2·84–3·53], p<0·0001) or of 50% or higher (1·71 [1·53 −1·91], p<0·0001) and with primary mitral regurgitation (RR 1·73 [95% CI 1·53–1·96], p<0·0001) or secondary mitral regurgitation (2·72 [2·48–3·01], p<0·0001). Even patients with a low comorbidity burden combined with favourable characteristics such as left-ventricular ejection fraction of 50% or higher (RR 1·28 [95% CI 1·10–1·50], p<0·0017) or primary mitral regurgitation (1·29 [1·09–1·52], p=0·0030) incurred excess mortality. Heart failure was frequent (mean 64% [SE 1] at 5 years postdiagnosis), even in patients with left-ventricular ejection fraction of 50% or higher (49% [2] at 5 years postdiagnosis) or in those with primary mitral regurgitation (48% [2]). Mitral surgery was ultimately done in only 198 (15%) of 1294 patients, of which the predominant type of surgery was valve repair (in 149 [75%] patients). Mitral surgery was done in 28 (5%) of 538 patients with left-ventricular ejection fraction below 50% and in 170 (22%) of 756 patients with ejection fraction of 50% or higher, and in 34 (5%) of 723 with secondary mitral regurgitation versus 164 (29%) of 571 with primary regurgitation. All other types of cardiac surgery combined were performed in only 3% more patients (237 [18%] patients) than the number who underwent mitral surgery. Interpretation: In the community, isolated mitral regurgitation is common and is associated with excess mortality and frequent heart failure postdiagnosis in all patient subsets, even in those with normal left-ventricular ejection fraction and low comorbidity. Despite these poor outcomes, only a minority of affected patients undergo mitral (or any type of cardiac) surgery even in a community with all means of diagnosis and treatment readily available and accessible. This suggests that in a wider population there might be a substantial unmet need for treatment for this disorder. Funding: Mayo Clinic Foundation.

AB - Background: Mitral regurgitation is the most common valve disease worldwide but whether the community-wide prevalence, poor patient outcomes, and low rates of surgical treatment justify costly development of new therapeutic interventions remains uncertain. Therefore, we did an observational cohort study to assess the clinical characteristics, outcomes, and degree of undertreatment of mitral regurgitation in a community setting. Methods: We used data from Mayo Clinic electronic health records and the Rochester Epidemiology Project to identify all cases of moderate or severe isolated single-valvular mitral regurgitation (with no other severe left-sided valvular disease or previous mitral surgery) diagnosed during a 10-year period in the community setting in Olmsted County (MN, USA). We assessed clinical characteristics, mortality, heart failure incidence, and results of cardiac surgery post-diagnosis. Findings: Between Jan 1, 2000, and Dec 31, 2010, 1294 community residents (median age at diagnosis 77 years [IQR 66–84]) were diagnosed with moderate or severe mitral regurgitation by Doppler echocardiography (prevalence 0·46% [95% CI 0·42–0·49] overall; 0·59% [0·54–0·64] in adults). Left-ventricular ejection fraction below 50% was frequent (recorded in 538 [42%] patients), and these patients had a slightly lower regurgitant volume than those with an ejection fraction of 50% or higher (mean 39 mL [SD 16] vs 45 mL [21], p<0·0001). Post-diagnosis mortality was mainly cardiovascular in nature (in 420 [51%] of 824 patients for whom the cause of death was available) and higher than expected for residents of the county for age or sex (risk ratio [RR] 2·23 [95% CI 2·06–2·41], p<0·0001). This excess mortality affected all subsets of patients, whether they had a left-ventricular ejection fraction lower than 50% (RR 3·17 [95% CI 2·84–3·53], p<0·0001) or of 50% or higher (1·71 [1·53 −1·91], p<0·0001) and with primary mitral regurgitation (RR 1·73 [95% CI 1·53–1·96], p<0·0001) or secondary mitral regurgitation (2·72 [2·48–3·01], p<0·0001). Even patients with a low comorbidity burden combined with favourable characteristics such as left-ventricular ejection fraction of 50% or higher (RR 1·28 [95% CI 1·10–1·50], p<0·0017) or primary mitral regurgitation (1·29 [1·09–1·52], p=0·0030) incurred excess mortality. Heart failure was frequent (mean 64% [SE 1] at 5 years postdiagnosis), even in patients with left-ventricular ejection fraction of 50% or higher (49% [2] at 5 years postdiagnosis) or in those with primary mitral regurgitation (48% [2]). Mitral surgery was ultimately done in only 198 (15%) of 1294 patients, of which the predominant type of surgery was valve repair (in 149 [75%] patients). Mitral surgery was done in 28 (5%) of 538 patients with left-ventricular ejection fraction below 50% and in 170 (22%) of 756 patients with ejection fraction of 50% or higher, and in 34 (5%) of 723 with secondary mitral regurgitation versus 164 (29%) of 571 with primary regurgitation. All other types of cardiac surgery combined were performed in only 3% more patients (237 [18%] patients) than the number who underwent mitral surgery. Interpretation: In the community, isolated mitral regurgitation is common and is associated with excess mortality and frequent heart failure postdiagnosis in all patient subsets, even in those with normal left-ventricular ejection fraction and low comorbidity. Despite these poor outcomes, only a minority of affected patients undergo mitral (or any type of cardiac) surgery even in a community with all means of diagnosis and treatment readily available and accessible. This suggests that in a wider population there might be a substantial unmet need for treatment for this disorder. Funding: Mayo Clinic Foundation.

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