European Heart Journal Advance Access originally published online on March 9, 2007
European Heart Journal 2007 28(11):1358-1365; doi:10.1093/eurheartj/ehm001
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What are the characteristics of patients with severe, symptomatic, mitral regurgitation who are denied surgery?
1 Cardiology Department, Bichat Hospital, AP-HP, 46 rue Henri Huchard, 75018 Paris, France
2 Epidemiology, Biostatistic, and Clinical Research Department, Bichat Hospital, AP-HP, Paris, France
3 Cliniques Universitaires Saint-Luc, Brussels, Belgium
4 Cardiac Surgery Department, University Hospital, Cardiff, Wales, UK
Received 17 July 2006; revised 5 February 2007; accepted 9 February 2007; online publish-ahead-of-print 9 March 2007.
* Corresponding author. Tel: +33 1 40 25 67 6; fax: +33 1 40 25 67 32. E-mail address: bernard.iung{at}bch.aphp.fr
See page 1281 for the editorial comment on this article (doi:10.1093/eurheartj/ehm156)
Aim: To identify the proportion and characteristics of patients with severe symptomatic mitral regurgitation (MR) who are denied surgery.
Methods and results: In the Euro Heart Survey on valvular heart disease, 396 patients had severe symptomatic MR as assessed by Doppler-echocardiography (grade 
3/4) and New York Heart Association class II or greater. Patient characteristics were analysed according to the decision to operate or not. A decision not to operate was taken in 193 patients (49%). In multivariable analysis, decreased left ventricular ejection fraction (LVEF) [OR = 1.39 per 10% decrease, 95% CI (1.17–1.66), P = 0.0002], non-ischaemic aetiology [OR = 4.44, 95% CI (1.96–10.76), P = 0.0006], older age [OR = 1.40 per 10-year increase, 95% CI (1.15–1.72), P = 0.001], increased Charlson comorbidity index [OR = 1.38 per 1 point increase, 95% CI (1.12–1.72), P = 0.004], and grade 3 MR [OR = 2.23, 95% CI (1.28–3.29), P = 0.005] were associated with the decision not to operate. One-year survival was 96.0 ± 1.4% in patients with a positive decision for intervention vs. 89.5 ± 2.3% in those with a negative decision (P = 0.02).
Conclusion: Surgery was denied in 49% of patients with severe symptomatic MR. Impaired LVEF, older age, and comorbidity were the most striking characteristics of patients who were denied surgery. The weight of age and LVEF in the decision do not seem justified according to current knowledge.
Key Words: Mitral regurgitation • Mitral valve replacement • Mitral valve repair • Decision-making
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