European Heart Journal Advance Access originally published online on May 10, 2007
European Heart Journal 2007 28(11):1281-1282; doi:10.1093/eurheartj/ehm156
Surgical referral in symptomatic mitral regurgitation: greater compliance with guidelines is needed
Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Room H3411, Ottawa, Ontario, Canada K1Y 4W7
* Corresponding author. Tel: +1 613 761 4189; fax: +1 613 761 4170. E-mail address: kchan{at}ottawaheart.ca
This editorial refers to ‘What are the characteristics of patients with severe, symptomatic, mitral regurgitation who are denied surgery?’
by M. Mirabel et al., on page 1358
Significant valvular heart disease is a common public health problem with an overall prevalence of 2.5% which increases to 13% of the population aged 75 years and older.1 It will become an increasingly important problem as the baby-boomer population ages in the western world in the coming decades, because the burden of all forms of valve disease increases with age. Mitral regurgitation (MR) is the most common form of valve disease, and patients with severe MR can remain asymptomatic for many years.1 Once symptoms develop, these patients should undergo valve surgery.2 The study by Mirabel et al.3 provides important information as to why some symptomatic patients with severe MR are not referred for surgery. Their findings are based on the prospective Euro Heart Survey of patients with valvular heart disease conducted in 92 European centres in 2001. They examined the clinical characteristics and outcomes of patients with symptomatic severe MR (3+ and 4+) who were not referred for surgery and these patients accounted for about half of the 396 patients with severe symptomatic MR. Of those who underwent surgery, 41% had mitral valve repair. Many of the characteristics of patients not referred for surgery are expected and consistent with clinical practice. These patients were older and had lower ejection fraction (EF) and more co-morbidities. It is easy to understand the reluctance to perform mitral valve surgery in the elderly as they have limited life expectancy and higher operative mortality when compared with the younger age group. However, age by itself should not be a contraindication of surgery, because elderly patients derive similar benefits in terms of amelioration of symptoms and improved survival compared with younger patients.4 The increasing use of valve repair instead of replacement and refinement in surgical techniques have reduced the operative mortality across all age groups including the elderly.5,6
Over half of the patients (58%), denied surgery in the study by Mirabel et al., had mild to moderate left ventricular dysfunction (EF = 30–60%). The presence of left ventricular dysfunction (with the exception of severe dysfunction, that is EF < 30%) in the setting of severe MR is an indication for surgery even in the absence of symptoms.2 This is an important point since the most common reason for not proceeding with surgery in this study was a positive response to treatment. Also of note is the observation that among patients who were denied surgery, 20% had 4+ MR and 70% had NHYA class III or IV symptoms. These patients met previous and current criteria for mitral valve surgery.2,7,8 Waiting for a recurrence of symptoms or development of more severe symptoms is not justified and will lead to worse short- and long-term mortalities.9
The under-referral for surgery in patients with severe MR may not be limited to Europe. A recent Canadian study assessed the clinical decision on valve surgery in severe MR using a self-administered questionnaire which was mailed directly to cardiologists.10 There was only an overall 66% compliance rate with current guidelines. Even in symptomatic patients with severe MR and left ventricular dysfunction (EF = 50–60%), over 40% of the respondents would not refer these patients for surgery, despite this being a class I indication according to the recent ACC/AHA Practice Guidelines.2 The study did not clearly define the reasons for this poor compliance.
Although it would appear that there was pervasive and unjustified denial of surgery to the elderly and patients with left ventricular dysfunction, the findings of Mirabel et al. must be interpreted with caution because of the inherent limitations of surveys. Determining the exact reason for not referring to surgery is difficult in a survey if specific questions are not incorporated in the survey and if the reasons are multi-factorial. The results are pertinent largely to hospitalized patients, as most patients in the study (83%) were hospitalized. Heart failure on admission was present in 39%, angina in 32%, and atrial fibrillation in 34% of the 396 patients. These patients are not representative of the vast majority of patients with severe MR who are being followed in outpatient clinics. It is possible that patients who were denied surgery had symptoms which were not entirely attributable to MR. Compared with patients who were referred for surgery, patients who were denied surgery had less severe MR with 80% having 3+ MR and smaller left ventricular diastolic dimension and lower systolic pulmonary artery pressure. There was also a higher prevalence of concomitant coronary artery disease and prior myocardial infarction, which may be responsible for the reported symptoms such as dyspnoea.
So, what lessons have we learned from the study by Mirabel et al.? Their results underscore that symptomatic patients with severe MR, particularly the elderly and the patients with left ventricular dysfunction, are under-referred for surgery. Despite the publication and wide dissemination of guidelines for the management of patients with valvular heart disease, there remains suboptimal compliance with guidelines in clinical practice in the real world. This may be partly due to our own biases based on clinical experience and perhaps a reluctance or discomfort with adopting new practices.10 With improvements in surgical techniques leading to better outcome and the increasing prevalence of valvular heart disease in our aging population, the issue of appropriate and timely treatment of MR becomes ever more important. There must be a concerted effort on the part of cardiology societies and leaders in the field of valvular heart disease to increase the dissemination of guidelines and improve the application of guidelines through better education and promotion. We are quite proficient in the development of guidelines, but clearly more research is needed to provide a better understanding on how to implement them more effectively.
Conflict of interest: none declared.
Footnotes
The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.
doi:10.1093/eurheartj/ehm001 
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Related articles in EHJ:
- What are the characteristics of patients with severe, symptomatic, mitral regurgitation who are denied surgery?
- Mariana Mirabel, Bernard Iung, Gabriel Baron, David Messika-Zeitoun, Delphine Détaint, Jean-Louis Vanoverschelde, Eric G. Butchart, Philippe Ravaud, and Alec Vahanian
EHJ 2007 28: 1358-1365.[Abstract] [FREE Full Text]
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