Mitral Valve Disease in the Elderly: Repair or Replace?

April 26, 2013

By Will Boggs, MD

NEW YORK (Reuters Health) Apr 26 - For elderly patients with mitral valve disease, surgery offers better survival than medical treatment, and repair seems better than replacement for most patients, a longitudinal analysis suggests.

"Mitral valve surgery in the elderly is safer than previously reported, and an approach of earlier identification and surgical referral appears justified regardless of age," Dr. Christina M. Vassileva from Southern Illinois University School of Medicine in Springfield told Reuters Health.

"In our investigation, we did not directly compare repair and replacement because such a comparison within this database would be flawed as we do not have the information on what informed the procedure choice," Dr. Vassileva said. "Nevertheless, those elderly patients who did receive mitral valve repair had near normal life expectancy after surgery. Therefore, every attempt should be made to perform mitral valve repair over replacement unless clinically contraindicated."

Dr. Vassileva and colleagues base these conclusions on the largest contemporary series on the operative mortality and long-term survival of Medicare fee-for-service beneficiaries undergoing primary isolated mitral valve repair or replacement between 1999 and 2009.

Their study, reported April 8th online in Circulation, included 47,279 patients, of whom 17,360 (36.7%) had mitral valve repair and 29,919 (63.3%) had valve replacement.

Comorbidities were common: 60.4% had heart failure, 17.5% had renal insufficiency, 17.6% had COPD, and 48.5% had atrial fibrillation.

Operative mortality was 3.9% with repair and 8.9% with replacement.

During a median follow-up of five years, survival estimates were better after repair (90.9% at one year, 77.1% at five years, and 53.6% at 10 years) than for patients undergoing replacement (82.6% at one year, 64.7% at five years, and 37.2% at 10 years).

When patients were stratified into age groups, survival estimates were higher for patients under 75 years old than for old patients, but the patterns were consistent: higher survival rates after repair than after replacement.

Female gender and the presence of comorbidities predicted lower likelihood of mitral valve repair, whereas younger age, elective admission status, and greater annual mitral procedure volume predicted higher likelihood of mitral valve repair.

These findings go counter to current guidelines that favor medical management of elderly asymptomatic or mildly symptomatic patients, the researchers note, but they say those guidelines were based on literature in which the risks of mitral valve surgery now seem overstated.

"It is important to emphasize that a surgical evaluation does not always translate into a decision to operate," Dr. Vassileva said. "The care of elderly patients is complex and decisions need to be carefully individualized. Consideration of anatomic valve characteristics, such as the presence of stenosis and valve calcifications all factor into the decision of whether mitral valve repair is appropriate."

"If indeed, the patient is a candidate for repair, outcomes are excellent," Dr. Vassileva said. "This is not to say that every valve should be repaired at all cost. The decision for valve repair should be made by the surgeon assuming they have adequate expertise to perform mitral repair. In addition, the presence or absence of concomitant coronary artery disease, and patient suitability for minimally invasive mitral valve operations also become relevant when counseling patients regarding the risk of surgery."

"While in my personal practice I am a strong proponent of repair, we cannot lose sight of the fact that when a patient has met an indication for a mitral valve intervention, the most important issue is that they are referred for mitral valve intervention," Dr. Vassileva concluded. "In our paper, we show that primary mitral valve replacement is also a safe procedure."

Dr. Rajni K. Rao and Dr. Elyse Foster from University of California, San Francisco address the question as to whether the guidelines should be revised to remove the statement urging a conservative approach in asymptomatic or mildly asymptomatic patients. "This study," they write, "along with other recent studies, suggests that when the valvular and clinical characteristics are propitious for repair, the same criteria should be applied across all age groups."

"When mitral valve replacement is likely, the outlook remains murky," they note. "The high operative risk may not be justified for an asymptomatic patient, unless it could be shown that early surgery could reduce later development of symptoms such as heart failure."

"We need additional options for treating common problems such as mitral regurgitation and more effective decision analysis for the elderly who are considering cardiac interventions," the editorial concludes. "We must consider quality and quantity of life as well as interventional risk as we assist patients in making the best choices for their golden years."


Circulation 2013.


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