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June 22, 2017
Degenerative Disease Surgical indications

Surgical Indications

In patients with degenerative mitral valve disease, the very low operative mortality (less than 0.5%) and excellent long-term results of mitral valve reconstruction have considerably modified the indications of surgery during the last decade.

Several factors such as clinical symptoms, atrial fibrillation, severity of mitral regurgitation, left ventricular ejection fraction, left ventricular end-systolic diameter, pulmonary hypertension, and the overall surgical risk profile (age, co-morbid factors) should be taken into consideration for the decision-making with regard to the indication of surgery.

All symptomatic patients with moderate or severe mitral regurgitation should be referred for surgical intervention. It is preferable to operate on patients early in their symptomatic course, as long-term survival following mitral valve reconstruction is less favorable in patients with New York Heart Association Class III or IV symptoms or left ventricular ejection fraction <60%. It is important to stress that in patients with degenerative mitral valve disease with New York Heart Association Class I or II and ejection fraction >60%, the life-expectancy following mitral valve reconstruction is similar to that of an age and gender matched general population. As Carpentier stated "following valvular reconstruction most patients with degenerative valve disease are cured for the rest of their lives".

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From Tribouilloy CM, Enriquez-Sarano M, Schaff HV, et al. Impact of preoperative symptoms on survival after surgical correction of organic mitral regurgitation: rationale for optimizing surgical indications. Circulation 1999;99(3):400-405 - Reproduced with the permission of the publisher
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From Tribouilloy CM, Enriquez-Sarano M, Schaff HV, et al. Impact of preoperative symptoms on survival after surgical correction of organic mitral regurgitation: rationale for optimizing surgical indications. Circulation 1999;99(3):400-405 - Reproduced with the permission of the publisher

Patients with mild to moderate degrees of mitral regurgitation in the presence of symptoms will often be found to have increased mitral regurgitation or inadequate increase in ejection fraction on stress echocardiography and should also be considered for surgical treatment.

Asymptomatic patients with left ventricular dilatation (left ventricular end-systolic diameter >45 mm), decreased ejection fraction (<60%), atrial fibrillation or pulmonary hypertension (pulmonary artery systolic pressure > 50 mm Hg at rest or > 60 mm Hg with exercise) should also be referred for elective mitral valve surgery. When following patients with asymptomatic moderate to severe mitral regurgitation, one should pay particular attention to serial ejection fraction, as a drop to <60% confers poorer long term survival even with successful mitral valve reconstruction.

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From Enriquez-Sarano M, Tajik AJ, Schaff HV, et al. Echocardiographic prediction of survival after surgical correction of organic mitral regurgitation. Circulation 1994;90:830-837 - Reproduced with the permission of the publisher
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From Enriquez-Sarano M, Tajik AJ, Schaff HV, et al. Echocardiographic prediction of survival after surgical correction of organic mitral regurgitation. Circulation 1994;90:830-837 - Reproduced with the permission of the publisher

The decision to refer or accept an asymptomatic patient for mitral valve surgery should also take into consideration one important factor which is the likelihood of valve reconstruction which depends mainly on 1) the etiology of mitral regurgitation (Barlow's disease vs. fibroelastic deficiency) and 2) surgeons skill and experience in valve reconstruction. For example, patients with Barlow's disease and bileaflet prolapse which often require a complex operative procedure should be referred to centers where reconstructive surgery can be performed with a great certainty.




REFERENCES

Enriquez-Sarano M, Tajik AJ, Schaff HV, et al. Echocardiographic prediction of left ventricular function after correction of mitral regurgitation: results and clinical implications. J Am Coll Cardiol 1994;24(6):1536-1543

Enriquez-Sarano M, Tajik AJ, Schaff HV, et al. Echocardiographic prediction of survival after surgical correction of organic mitral regurgitation. Circulation 1994;90:830-837

Ling LH, Enriquez-Sarano M, Seward JB, et al. Clinical outcome of mitral regurgitation due to flail leaflet. N Engl J Med 1996;335(19):1417-23

Enriquez-Sarano M, Rossi A, Seward JB, et al. Determinants of pulmonary hypertension in left ventricular dysfunction. J Am Coll Cardiol 1997;29(1):153-9

Tribouilloy CM, Enriquez-Sarano M, Schaff HV, et al. Impact of preoperative symptoms on survival after surgical correction of organic mitral regurgitation: rationale for optimizing surgical indications. Circulation 1999;99(3):400-405

Borer JS, Bonow RO. Contemporary approach to aortic and mitral regurgitation. Circulation 2003;108(20):2432-2438

Enriquez-Sarano M, Avierinos JF, Messika-Zeitoun D, et al. Quantitative determinants of the outcome of asymptomatic mitral regurgitation. N Engl J Med 2005;352(9):875-83

Bonow RO, Carabello BA, Chatterjee K, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008;118(15):e523-661


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