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VALVULAR HEART DISEASE

Failure of Guideline Adherence for Intervention in Patients With Severe Mitral Regurgitation

Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan

Manuscript received January 6, 2009; revised manuscript received March 16, 2009, accepted March 16, 2009.

^_* Reprint requests and correspondence: Dr. David S. Bach, CVC Room 2147, SPC 5853, 1500 East Medical Center Drive, Ann Arbor, Michigan 48109-5853 (Email: dbach{at}umich.edu).

Objectives: This study sought to evaluate the incidence with which adult patients with significant mitral regurgitation (MR) do not undergo surgical intervention despite guideline recommendations, and the associated considerations resulting in no intervention.

Background: Despite the existence of accepted guidelines, many patients with severe symptomatic heart valve disease might not undergo intervention.

Methods: At a single large tertiary medical center, patients were retrospectively identified who had moderate-to-severe or severe MR on echocardiographic imaging during 2005. Clinical data were reviewed to determine indications for intervention and whether surgery was performed.

Results: During 2005, 300 patients were identified with significant MR, including 188 with functional MR and 112 with organic MR. Mitral surgery was performed in 30 of 188 patients with functional MR, mostly to treat heart failure or during another cardiac surgical procedure. Mitral surgery was performed in 59 (53%) of 112 patients with organic MR. Among unoperated patients with organic MR, common reasons included stable left ventricular size or function, absence of symptoms, and prohibitive comorbidities. Using American College of Cardiology/American Heart Association guidelines, 1 or more indication for intervention was present in 39 (74%) of 53 unoperated patients. Perioperative mortality risk was not higher for patients who did not undergo surgery (median 1.2%, interquartile range [IQR] 0.4% to 3.3%) than for those who did (median 1.1%, IQR 0.6% to 5.3%; p = 0.71). During follow-up, there were 12 cardiac and 2 unexplained deaths.

Conclusions: Among patients with severe organic MR, surgical intervention occurred in approximately one-half. However, accepted guideline indications for intervention were present in the majority of unoperated patients. Objectively assessed operative risk was not prohibitive in many unoperated patients.

Key Words: mitral regurgitation • mitral valve surgery • operative risk • guidelines • adherence/compliance

Abbreviations and Acronyms   ACC = American College of Cardiology   AHA = American Heart Association   EF = ejection fraction   IQR = interquartile range   LV = left ventricle/ventricular   MR = mitral regurgitation

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