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Ann Thorac Surg 2003;75:820-825
© 2003 The Society of Thoracic Surgeons
a Department of Cardiovascular-Thoracic Surgery, Rush Presbyterian-St. Lukes Medical Center, Chicago, IL, USA
b Louisiana State University Health Sciences Center, Marrero, LA, USA
Accepted for publication October 8, 2002.
* Address reprint requests to Dr Savage, Suite 1156, 1725 West Harrison St, Chicago, IL 60612, USA.
e-mail: chstcutter{at}aya.yale.edu
| Abstract |
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METHODS: We analyzed National Cardiac Database data to determine the operative approach for a diagnosis of mitral regurgitation.
RESULTS: A total of 21,741 isolated and combined mitral valve procedures were identified. The overall frequency of repair was 37.7% (8206). For procedures isolated to the mitral valve, the frequency of repair was 35.7% (3027/8486) whereas repair was more common with concomitant CABG (42.9% [3088/7193], p < 0.0001). The proportion of patients having repair decreased with age (41.2% [386/936] in 20 to 39 years, 36.1% [3513/9746] in > 70 years, p = 0.0016). Repair was more common in males (43.5% [4720/10860]) than females (32.0% [3472/10842], p < 0.0001). Repair was less common as NYHA Class increased (Class I, 47.8% [949/1984] vs Class IV, 33.2% [1803/5427]) and for emergent operative status (21.2% [156/736] vs 38.5% [8000/20773] for elective/urgent, both p < 0.0001). The number of prior operations did not affect the use of repair. Simple annuloplasty was performed in the majority of reported repairs (62.8% [3837/6115]), more so with associated CABG as compared to isolated repair (70.2% [2167/3088] vs 55.2% [1670/3027]; p < 0.0001).
CONCLUSIONS: Mitral repair was performed in over one-third of the patients reported in 1999 to 2000 and has increased since the National Cardiac Database inception. Repair usage differed based on sex, age, gravity of illness, and associated procedures. This provides a base line from which to expand the application of repair.
| Introduction |
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| Material and methods |
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| Results |
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| Comment |
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Realizing these constraints, the NCD demonstrates that valve repair has clearly penetrated into the national practice of cardiac surgery. In the fifth quintile of the 1990s decade fully 42.4% of purely regurgitant valves (no stenosis reported) were repaired. However, a review of all the repairs reveals that the majority of these were repaired by simple annuloplasty. This suggests that many valves that might have been repairable using complex repair techniques were instead replaced. The fact that repair usage was reduced in patients more than 70 years of age could be attributed to the fact that these patients are candidates for bioprostheses that, like valve repair, do not obligate the long-term use of anticoagulation. Reduced rates of valve repair in females could be attributed to the noted higher use of repair with associated CABG (Table 1) combined with a greater prevalence of ischemic disease in men. However, this is not borne out in the data presented. When CABG is broken out, the prevalence of repair is still higher in men. We have tried to break this out in Table 3 by excluding an associated diagnosis of mitral stenosis, yet the higher prevalence of repair in males persists. Perhaps the greatest limitation of this analysis is the absence of data reported to the NCD about etiology. The most favorable situation for valve repair is a degenerative, ischemic, or dilated etiology of the regurgitation, rheumatic valves are much less amenable to repair [1]. In order to overcome this limitation, CABG has been used as a crude surrogate for ischemic etiology and the presence of mitral stenosis a crude surrogate for rheumatic etiology in the above analysis.
Mitral valve repair can be performed with low operative mortality (3.4%) as reported by Muehrcke and Cosgrove [2] who combined data from nine published series. In addition, multiple studies have documented the long-term durability and low incidence of long-term complications of mitral valve repair [3, 4]. At 15 years, these results include 93.9% freedom from thromboembolism, 96.6% freedom from endocarditis, 95.6% freedom from anticoagulant-related hemorrhage, 87.3% freedom from reoperation (degenerative disease, 92.7%; rheumatic disease, 76.1%), and little or no mitral regurgitation in 91% of survivors [5]. In comparison with replacement, the long-term results of mitral valve repair are better. Enriquez-Sarano and coworkers [6] compared repair with replacement and noted an independent beneficial effect of valve repair on overall survival (hazard ratio, 0.39; p = 0.00001), operative mortality (odds ratio, 0.27; p = 0.026), late survival (hazard ratio, 0.44; p = 0.001), and postoperative ejection fraction (p = 0.001). Most surgeons agree that every patient with mitral valve regurgitation who requires surgery should be approached with the intent to repair rather than replace the valve. The ability to repair the valve has been incorporated into the indications for referral for surgery [7].
To put this data in perspective it is useful to have a "gold standard" to point to for comparison. Mohty and colleagues [8] from the Mayo Clinic compared 679 repairs and 238 replacements performed from 1980 to 1995. Realizing a referral bias (those patients who had potentially repairable valves might be preferentially referred), this experience suggests a standard for rates of utilization of repair. Of the 917 patients reviewed, the overall rate of repair (74%) for isolated mitral insufficiency (from 1980 to 1995) is almost twice that of the national rate of 42.4% (1999 to 2000, excluding mitral stenosis, Table 1) suggesting that nationally many more patients could benefit from mitral valve repair.
To approach this standard it may behoove the cardiac surgical community to adopt a more formal approach to educating surgeons in these techniques. Many of these techniques were described after practicing surgeons finished their training, and many recent trainees may not have been exposed to these techniques in their training. The residency review committee does not distinguish repair from replacement in the minimum case requirements for certification. Furthermore, if mitral valve surgery is a small component of a surgeons practice the opportunity to apply these techniques may be uncommon. Finally, although the benefits of repair are well described, many medical insurers do not differentiate between repair and replacement, and may not allow specific referral to a surgeon with expertise in mitral repair.
In summary, this analysis provides a snapshot of the current practice of mitral valve repair in the United States and discusses the limitations of data derived from the NCD. With this in mind, we suggest that mitral valve repair may be underutilized, consider some possible causes of this practice, and offer recommendations for increasing repair utilization.
| Acknowledgments |
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