Farhang Yazdchi1, Colleen G Koch2, Tomislav Mihaljevic1, Rory Hachamovitch3, Ashley M Lowry4, Jiayan He4, A Marc Gillinov1, Eugene H Blackstone5, Joseph F Sabik6. 1. Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. 2. Department of Cardiothoracic Anesthesia, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. 3. Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. 4. Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio. 5. Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio. 6. Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address: sabikj@ccf.org.
Abstract
BACKGROUND: Successful durable repair of severe degenerative mitral regurgitation with low operative mortality encourages intervention in asymptomatic patients rather than "watchful waiting." Our objectives were to assess trends in patient characteristics, timing of intervention, and evolving surgical techniques at a high-volume center, and determine effects of these changes on outcomes after mitral valve (MV) repair over a 25-year period. METHODS: From January 1, 1985, to January 1, 2011, 5,902 patients underwent isolated repair (with or without tricuspid repair for functional regurgitation) for degenerative MV disease at Cleveland Clinic. For illustration, the experience is presented in 3 eras: 1985 to 1997 (era 1, n = 1,184), 1997 to 2005 (era 2, n = 2,400), and 2005 to 2011 (era 3, n = 2,318). RESULTS: In era 3, more patients were asymptomatic on presentation (44% in New York Heart Association [NYHA] class I vs 25% in era 1), with less heart failure (11% vs 29%) and atrial fibrillation (9.9% vs 23%). Full sternotomy decreased from era 1 (n = 1,100/93%) to era 2 (n = 602/25%) (era 3, n = 717/31%), and robotic surgery emerged (n = 577/25%) in era 3. Median length of stay shortened (era 1 = 7 days, era 2 = 5.9 days, era 3 = 5.2 days, p < 0.0001), and in-hospital mortality remained low (era 1 = 5/0.42%, era 2 = 5/0.21%, era 3 = 1/0.043%); 0.73% overall required reoperation on the repaired valve before discharge, and 97% had 0 to 1+ regurgitation at discharge. CONCLUSIONS: Treatment trends over 25 years reveal that rather than watchful waiting, a more aggressive approach to degenerative MV disease, with earlier intervention for severe regurgitation in asymptomatic patients and less invasive operative techniques, is successful, safe, and effective.
BACKGROUND: Successful durable repair of severe degenerative mitral regurgitation with low operative mortality encourages intervention in asymptomatic patients rather than "watchful waiting." Our objectives were to assess trends in patient characteristics, timing of intervention, and evolving surgical techniques at a high-volume center, and determine effects of these changes on outcomes after mitral valve (MV) repair over a 25-year period. METHODS: From January 1, 1985, to January 1, 2011, 5,902 patients underwent isolated repair (with or without tricuspid repair for functional regurgitation) for degenerative MV disease at Cleveland Clinic. For illustration, the experience is presented in 3 eras: 1985 to 1997 (era 1, n = 1,184), 1997 to 2005 (era 2, n = 2,400), and 2005 to 2011 (era 3, n = 2,318). RESULTS: In era 3, more patients were asymptomatic on presentation (44% in New York Heart Association [NYHA] class I vs 25% in era 1), with less heart failure (11% vs 29%) and atrial fibrillation (9.9% vs 23%). Full sternotomy decreased from era 1 (n = 1,100/93%) to era 2 (n = 602/25%) (era 3, n = 717/31%), and robotic surgery emerged (n = 577/25%) in era 3. Median length of stay shortened (era 1 = 7 days, era 2 = 5.9 days, era 3 = 5.2 days, p < 0.0001), and in-hospital mortality remained low (era 1 = 5/0.42%, era 2 = 5/0.21%, era 3 = 1/0.043%); 0.73% overall required reoperation on the repaired valve before discharge, and 97% had 0 to 1+ regurgitation at discharge. CONCLUSIONS: Treatment trends over 25 years reveal that rather than watchful waiting, a more aggressive approach to degenerative MV disease, with earlier intervention for severe regurgitation in asymptomatic patients and less invasive operative techniques, is successful, safe, and effective.