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.
Survival loss linked to guideline-based indications for degenerative mitral regurgitation surgery / 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.; Vanoverschelde, J. -L. J.; Enriquez-Sarano, M.; Essayagh, B.; Antoine, C.; Malouf, J. F.; Michelena, H.; Nkomo, V. T.; Enriquez-Sarano, M. L.; Barbarossa, A.; Russo, A. D.; Wong, R.; Wan, S.; Chow, J.; Fan, Y.; Lee, A. P. W.; Ewe, S. H.; Yeo, K. K.; Keh, Y. S.; Hamid, N.; Pin, D. Z.; Trojette, F.; Touati, G.; Remadi, J. P.; Poulain, H. J.; Tribouilloy, C.; Ditaranto, R.; Caponetti, G.; Savini, C.; Pacini, D.; Chello, M.; Nusca, A.; Melfi, R.; Ussia, G. P.; De Meester, C.; El Khoury, G.; Gerber, B. L.; Vancraeynest, D.; Vanoverschelde, J. -L.; Collart, F.; Theron, A.; Avierinos, J. F.; Bursi, F.; Mantovani, F.; Modena, M. G.; Boriani, G.; Rossi, A.; Onorati, F.; Ribichini, F. L.. - In: EUROPEAN HEART JOURNAL. CARDIOVASCULAR IMAGING. - ISSN 2047-2404. - 25:12(2024), pp. 1703-1711. [10.1093/ehjci/jeae176]
Survival loss linked to guideline-based indications for degenerative mitral regurgitation surgery
Onorati F.;Ribichini F. L.
2024-01-01
Abstract
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.| File | Dimensione | Formato | |
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