Half of eligible patients not getting mitral-valve surgery, single center reports

Thursday, August 27, 2009

by Shelley Wood

Ann Arbor, MI - Overblown fears about surgical risks or a lack of awareness of the risks of not operating may partly explain a lack of surgery referrals for mitral-valve repair, authors of a new study say [1]. Writing in the August 25, 2009 issue of the Journal of the American College of Cardiology, Dr David S Bach (University of Michigan, Ann Arbor) and colleagues report that just half of all patients with mitral regurgitation assessed at their hospital over a one-year period actually ended up getting surgery, and of those not operated on, three-quarters had at least one indication for surgery, according to American College of Cardiology/American Heart Association guidelines.

"The most common reason that people were not operated on was that physicians thought the risk associated with surgery was relatively high or that the mitral regurgitation did not pose a risk to the patient. And I think the pertinent findings are that our assessment, as cardiologists, of operative risk, is probably inflated compared with what the objectively calculated risks were. And our assessment of risk for unoperated mitral regurgitation was probably underestimated," Bach told heartwire. "The take-home message for cardiologists is that we need to be more careful about our assessment of operative risk."

Bach et al's study retrospectively identified 300 patients with moderate to severe mitral regurgitation screened by echocardiography over a one-year period. They identified 188 with functional mitral regurgitation, of whom just 30 underwent surgery, and 112 with "organic" mitral regurgitation, of whom 59 (53%) underwent surgery. According to the authors, a review of patients' charts indicated that the most common reasons for not referring patients for surgery was the existence of "stable" left ventricular size or function, an absence of symptoms, or major comorbidities.

But when the Society of Thoracic Surgery risk score was applied to patients who both had or had not had surgery, Bach et al found that predicted risk of perioperative mortality was similar between the two groups. Moreover, when ACC/AHA guidelines for surgery were applied to patient records, Bach et al found that a full 74% of the 53 patients deemed "inoperable" actually had one or more indications for surgery, according to the guidelines.

Importantly, Bach told heartwire, almost all patients who were referred for surgery did end up getting mitral-valve interventions, suggesting that it was not an unwillingness on the part of the surgeons that explained the disconnect between patient indications and subsequent interventions.

"I think there remains something of a bias in medicine and cardiology that surgery is risk, and surgery is a failure of our ability to manage the patient. . . . [Mitral-valve] diseases are not as benign as they were once thought to be, and the surgery is not as morbid as it was thought of in the past."

Bach believes cardiologists need to become better acquainted with the literature, discuss options more fully with their patients, and where possible, involve a surgeon in the consult. "I don't want to say that the cardiologist, if presented with a patient who has indications for surgery would say, no, I'm not willing to send that patient to surgery. I think what it is is a lack of familiarity with the guidelines or some hesitation about the risk/benefits of surgery."


  1. Bach DS, Awais M, Gurm HS, et al. Failure of guideline adherence for intervention in patients with severe mitral regurgitation. J Am Coll Cardiol 2009; 54:860-865.


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