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

Authors: Enriquez-Sarano, Maurice; Suri, Rakesh M.; Clavel, Marie-Annick; Mantovani, Francesca; Michelena, Hector I.; Pislaru, Sorin V.; Mahoney, Douglas W.; Schaff, Hartzell V.
Abstract: Objective: The timing of surgical correction of mitral regurgitation remains controversial. A major source of dispute regards the potential short- and longterm 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 ¼ 794), class II triggers based on clinical complications (ClassII-CompT: atrial fibrillation or pulmonary hypertension, n ¼ 195), or early class II triggers based on a combination of severe mitral regurgitation and high probability of valve repair (ClassII-EarlyT: n ¼ 523). Results: Operative mortality was highest with ClassI-T (1.1% vs 0% and 0%, P ¼ .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 ¼ .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 ¼ .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. (J Thorac Cardiovasc Surg 2015;150:50-8)
Document Type: Article de recherche
Issue Date: 1 July 2015
Open Access Date: Restricted access
Document version: VoR
This document was published in: Journal of thoracic and cardiovascular surgery, Vol. 150 (1), 50-58 (2015)
Alternative version: 2015.04.009
Collection:Articles publiés dans des revues avec comité de lecture

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