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Comparison of Early Surgery versus Conventional Treatment in Asymptomatic Severe Mitral Regurgitation
Kanh D, Kim JH, Rim JH, et al.
Reviewer: Mohammed Minhaj, MD
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’ 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.
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