Survival loss linked to guideline-based indications for degenerative mitral regurgitation surgery.
(2024) European heart journal. Cardiovascular Imaging — Vol. 25, n° 12, p. 1703-1711 (2024)
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Vanoverschelde, Jean-Louis 
- Abstract
- (en) AIMS: Operating on patients with severe degenerative mitral regurgitation (DMR) is based on ACC/AHA or ESC/EACTS guidelines. Doubts persist on best surgical indications and their potential association with postoperative survival loss. We sought to investigate whether guideline-based indications lead to late postoperative survival loss in DMR patients. METHODS AND RESULTS: We analysed outcome of 2833 patients from the Mitral Regurgitation International Database registry undergoing surgical correction of DMR. Patients were stratified by surgical indications: Class I trigger (symptoms, left ventricular end-systolic diameter ≥ 40 mm, or left ventricular ejection fraction < 60%, n = 1677), isolated Class IIa trigger [atrial fibrillation (AF), pulmonary hypertension (PH), or left atrial diameter ≥ 55 mm, n = 568], or no trigger (n = 588). Postoperative survival was compared after matching for clinical differences. Restricted mean survival time (RMST) was analysed. During a median 8.5-year follow-up, 603 deaths occurred. Long-term postoperative survival was lower with Class I trigger than in Class IIa trigger and no trigger (71.4 ± 1.9, 84.3 ± 2.3, and 88.9 ± 1.9% at 10 years, P < 0.001). Having at least one Class I criterion led to excess mortality (P < 0.001), while several Class I criteria conferred additional death risk [hazard ratio (HR): 1.53, 95% confidence interval (CI): 1.42-1.66]. Isolated Class IIa triggers conferred an excess mortality risk vs. those without (HR: 1.46, 95% CI: 1.00-2.13, P = 0.05). Among these patients, isolated PH led to decreased postoperative survival vs. those without (83.7 ± 2.8% vs. 89.3 ± 1.6%, P = 0.011), with the same pattern observed for AF (81.8 ± 5.0% vs. 88.3 ± 1.5%, P = 0.023). According to RMST analysis, compare to those operated on without triggers, operating on Class I trigger patients led to 9.4-month survival loss (P < 0.001) and operating on isolated Class IIa trigger patients displayed 4.9-month survival loss (P = 0.001) after 10 years. CONCLUSION: Waiting for the onset of Class I or isolated Class IIa triggers before operating on DMR patients is associated with postoperative survival loss. These data encourage an early surgical strategy.
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Vancraeynest, D., Pouleur, A.-C., de Meester, C., Pasquet, A., Gerber, B., Michelena, H., Benfari, G., Essayagh, B., Tribouilloy, C., Rusinaru, D., Grigioni, F., Barbieri, A., Bursi, F., Avierinos, J.-F., Guerra, F., Biagini, E., Yeo, K. K., Ewe, S. H., Lee, A. P.-W., et al. (2024). Survival loss linked to guideline-based indications for degenerative mitral regurgitation surgery. European heart journal. Cardiovascular Imaging, 25(12), 1703-1711. https://doi.org/10.1093/ehjci/jeae176 (Original work published 2024)