Early surgical intervention for mitral regurgitation associated with greater long-term survival

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1. Early mitral valve surgery increased 10-year long-term survival rates, decreased the risk of long-term heart failure, and did not change the rate of late-onset atrial fibrillation. 

2. There was no difference in 3-month early mortality or early onset heart failure between surgery or medical management of mitral regurgitation. 

Evidence Rating Level: 2 (Good)           

Study Rundown: Management of mitral regurgitation is controversial because of the lack of data on long-term outcomes. This study compared the effectiveness of medical management versus early surgical intervention on survival, heart failure, and atrial fibrillation for mitral regurgitation caused by flail mitral valves without symptoms of heart failure or left ventricular dysfunction. At three months, there was no difference between medical versus surgical management on early mortality or heart failure. Early surgery was associated with higher rates of post-operative atrial fibrillation. Surgical intervention significantly increased long-term 10-year survival rates, and lowered rates of long-term heart failure. Early surgery was also associated with a 5-year reduction in mortality. There was no long-term difference in new-onset atrial fibrillation between medical or surgical interventions. The results of this study may inform future practice guidelines in managing asymptomatic mitral regurgitation with surgical options. Strengths of the study include utilizing data from a large multicenter international registry, and substantiating long-term results by several statistical analysis methods. The study was limited by the ability to generalize results to mitral valve regurgitation from other causes or with other co-morbid heart conditions.

Click to read the study published today in JAMA

Click to read the editorial published today in JAMA

Relevant Reading: Comparison of early surgery versus conventional treatment in asymptomatic severe mitral regurgitation

In-Depth [retrospective cohort study]: This study used the Mitral Regurgitation International Database (MIDA) to identify 1021 patients with flail mitral valve regurgitation who did not have heart failure symptoms or left ventricular dysfunction as diagnosed by transthoracic echocardiography between 1980 – 2004. Initially, 575 patients were medically managed and 446 underwent mitral valve surgery. Treatment strategies showed no difference in surgery versus medical management in early mortality (1.1% vs 0.5%, P = 0.28) or new onset heart failure (0.9% vs 0.9%, P = .28), but did show a higher rate of new-onset atrial fibrillation (6.2% vs 1.2%, P < 0.001) in surgical management within the first 3 months. At 10 years, long-term survival was higher (86% vs 69%, P < 0.001), and long-term heart failure risk was lower (7% vs 23%, P<0.001) with surgery versus medical management. There was no difference observed in long-term rates of atrial fibrillation. In addition, early surgery reduced 5-year mortality by 52.6% (P<0.001), even in patients with class II triggers (59.3%, P=0.002).

By Gayatri Boddupalli and Brittany Hasty

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