Survival loss linked to guideline-based indications for degenerative mitral regurgitation surgery
Authors: Vancraeynest David , Pouleur Anne-Catherine , de Meester Christophe , Pasquet Agnès , Gerber Bernhard , Michelena Hector , Benfari Giovanni , Essayagh Benjamin , Tribouilloy Christophe , Rusinaru Dan , Grigioni Francesco , Barbieri Andrea , Bursi Francesca , Avierinos Jean-François , Guerra Federico , Biagini Elena , Yeo Khung Keong , Ewe See Hooi , Lee Alex Pui-Wai , Vanoverschelde Jean-Louis J , Enriquez-Sarano Maurice ,   MIDA (Mitral Regurgitation International Database) investigators, Benfari Giovanni , Essayagh Benjamin , Antoine Clemence , Malouf Joseph F , Michelena Hector , Nkomo Vuyisile T , Enriquez-Sarano Maurice L , Guerra Federico , Barbarossa Alessandro , Russo Antonio Dello , Wong Randolph , Wan Song , Chow Josie , Fan Yiting , Lee Alex P W , Ewe See Hooi , Yeo Khung Keong , Keh Yann Shan , Hamid Nadira , Pin Ding Zee , Trojette Faouzi , Touati Gilles , Remadi Jean Paul , Poulain Henri J , Tribouilloy Christophe , Ditaranto Raffaello , Caponetti Giuseppe , Savini Carlo , Pacini Davide , Biagini Elena , Chello Massimo , Nusca Annunziata , Melfi Rosetta , Ussia Gian Paolo , Grigioni Francesco , de Meester Christophe , El Khoury Gebrine , Gerber Bernhard L , Pasquet Agnès , Vancraeynest David , Vanoverschelde Jean-Louis , Collart Frédéric , Théron Alexis , Avierinos Jean Francois , Barbieri Andrea , Bursi Francesca , Mantovani Francesca , Modena Maria Grazia , Boriani Giuseppe , Benfari Giovanni , Rossi Andrea , Onorati Francesco , Ribichini Flavio L 
Published: July 2024

Abstract

Aims
Operating on patients with severe degenerative mitral regurgitation (DMR) is based on ACC/AHA or ESC/EACTS guidelines. Doubts persist on best surgical indications and their potential association with postoperative survival loss. We sought to investigate whether guideline-based indications lead to late postoperative survival loss in DMR patients.

Methods and results
We analysed outcome of 2833 patients from the Mitral Regurgitation International Database registry undergoing surgical correction of DMR. Patients were stratified by surgical indications: Class I trigger (symptoms, left ventricular end-systolic diameter ≥ 40 mm, or left ventricular ejection fraction &lt; 60%, n = 1677), isolated Class IIa trigger [atrial fibrillation (AF), pulmonary hypertension (PH), or left atrial diameter ≥ 55 mm, n = 568], or no trigger (n = 588). Postoperative survival was compared after matching for clinical differences. Restricted mean survival time (RMST) was analysed. During a median 8.5-year follow-up, 603 deaths occurred. Long-term postoperative survival was lower with Class I trigger than in Class IIa trigger and no trigger (71.4 ± 1.9, 84.3 ± 2.3, and 88.9 ± 1.9% at 10 years, P &lt; 0.001). Having at least one Class I criterion led to excess mortality (P &lt; 0.001), while several Class I criteria conferred additional death risk [hazard ratio (HR): 1.53, 95% confidence interval (CI): 1.42–1.66]. Isolated Class IIa triggers conferred an excess mortality risk vs. those without (HR: 1.46, 95% CI: 1.00–2.13, P = 0.05). Among these patients, isolated PH led to decreased postoperative survival vs. those without (83.7 ± 2.8% vs. 89.3 ± 1.6%, P = 0.011), with the same pattern observed for AF (81.8 ± 5.0% vs. 88.3 ± 1.5%, P = 0.023). According to RMST analysis, compare to those operated on without triggers, operating on Class I trigger patients led to 9.4-month survival loss (P &lt; 0.001) and operating on isolated Class IIa trigger patients displayed 4.9-month survival loss (P = 0.001) after 10 years.

Conclusion
Waiting for the onset of Class I or isolated Class IIa triggers before operating on DMR patients is associated with postoperative survival loss. These data encourage an early surgical strategy.