 |
|
|
 |
 |
|
 |
|
|
|
|
|
|
|
|
|
|
|
|
|
 |
|
||||||||||||
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
|
 |
 |
 |
 |
 |
 |
|
|||||||
NEWS
Kevin Johns receives the John Hinckley Lifetime Outstanding Service Award
Pro/Con
Mitral Regurgitation Can Be Reliably Assessed In The Operating Room Under General Anesthesia
Literature Reviews
Acute Kidney Injury After Cardiac Surgery Focus on Modifiable Risk Factors
Intensive versus Conventional Glucose Control in Critically Ill Patients
Glycemic variability: A strong independent predictor of mortality in critically ill patients
Foundation Update
SCA Foundation to host reception honoring Michael Roizen on Sunday, April 19
The Society of Cardiovascular Anesthesiologists (SCA) publishes the SCA Bulletin bimonthly. The information presented in the SCA Bulletin has been obtained by the editors. Validity of opinions presented, drug dosages, accuracy and completeness of content are not guaranteed by SCA.
Comparison of Early Surgery versus Conventional Treatment in Asymptomatic Severe Mitral Regurgitation
Kanh D, Kim JH, Rim JH, et al.
Circulation February 17, 2009; 119:797-804
Reviewer: Mohammed Minhaj, MD
University of Chicago, Chicago, IL
Abstract Excerpt
Optimal timing for surgical intervention in asymptomatic patients with severe mitral regurgitation (MR) remains unclear. The purpose of this study was to compare long-term effects of patients with asymptomatic severe MR who underwent early surgical intervention with those who did not. From 1996 - 2005, 447 consecutive patients with asymptomatic, severe MR were enrolled in the study and evaluated prospectively. Management was determined by the treating physician and 161 patients had early surgical intervention, with the remaining 286 patients undergoing conventional treatment. There were no significant differences in the two groups with respect to age, gender, euroSCORE, or ejection fraction. Follow-up was for a median of about 2000 days and end-points studied included: operative mortality, cardiac death, repeat mitral valve surgery, and development of congestive heart failure requiring hospitalization.
In the early surgery group, there were 2 repeat surgeries and no cardiac deaths or operative mortality compared with 12 cardiac deaths, 1 surgery, and 22 admissions for congestive heart failure in the conventional treatment group. Both the 7 year estimated cardiac mortality and the 7 year event free survival rates in the early operated group were significantly lower than the conventional treatment group.
Factors predicting eventual development of surgical indications or congestive heart failure in the conventional treatment group included baseline pulmonary hypertension, age, and effective regurgitant orifice area.
The authors concluded that the strategy of early surgical intervention in patients with severe, asymptomatic MR was associated with improved long-term survival.
Reviewer’s Comments
As the mortality associated with mitral valve surgery has certainly declined over the past few decades, there has been increased interest in optimal timing for surgery in patients who suffer from isolated mitral valve regurgitation. While the natural progression of asymptomatic MR varies amongst patients, it appears that with increasing age both a reduction in left ventricular compliance and degeneration of already diseased leaflets results in increased complications, including the development of congestive heart failure and pulmonary hypertension.
The authors’ results certainly suggest that early intervention is associated with improved outcomes especially with respect to cardiac mortality. When comparing the early surgical intervention group with the conventional treatment group, over a ¼ of the patients ended up eventually meeting criteria for surgical intervention and their complication risk was higher than in the early surgical intervention group. Given the increased risk of cardiac surgery in older patients, one could postulate that this would be an argument for earlier intervention. One of the limitations in this study was that the average of patients was around 50 at the time of enrollment and the good surgical outcome could have partially been attributed to the age of the patients at the time of surgical intervention. The results may not be broadly applicable to older patients presenting with asymptomatic MR and further work in this area would be beneficial. Another limitation was that treatment was left up to the physician, that is patients were not randomized to either treatment group.
It should be recognized that the American College of Cardiology/American Heart Association guidelines do suggest that early mitral valve repair at experienced surgical centers should be recommended in patients with asymptomatic MR. While the results of this paper seem to be consistent with the idea that early surgical intervention in patients with asymptomatic MR is safe and may improve outcomes, prospective randomized studies (especially in older patients) will hopefully elucidate the optimal age and time when patients should be referred for surgery.