EDITORIAL
EDITORIAL: ACQUIRED MITRAL VALVE
Physician heal thyself Donald D. Glower, MD
See related article on pages 50-8. Enriquez-Sarano and colleagues1 examined the outcomes of surgical mitral valve repair in 1512 patients with pure organic mitral regurgitation as a function of the guideline-based indication for operation. In the data presented, watchful waiting (class I or II complication triggers for mitral valve repair) was independently associated with a doubling or 40% increase in the risk of late heart failure or death relative to early surgery. The authors conclude that (1) the type of guideline-based indication for surgical correction of organic mitral regurgitation is associated with profound outcome consequences and that (2) surgical correction of severe mitral regurgitation based on a high probability of repair is associated with improved survival and low heart failure risk and should be the preferred strategy in valve centers offering very low operative risk and high repair rates. Historically, medical treatment decision-making has been primarily based on patient characteristics and NOT on characteristics of the treating physician. Enriquez-Sarano and colleagues1 present data suggesting that in the case of severe mitral regurgitation, patient outcomes can be improved by tailoring therapy on the basis of BOTH patient and physician characteristics. This concept is not new, with prior studies showing higher mitral repair rates and lower mortality for mitral surgery in higher-volume centers.2 Effectively, Enriquez-Sarano and colleagues1 argue for making early surgery (all severe mitral regurgitation that has a high likelihood of durable repair with low morbidity/mortality based on BOTH patient and surgeon characteristics) a class I indication for surgery. Presumably, the authors would retain current class I indications (symptoms, ventricular dysfunction, or dilation) and class IIa complication indications (pulmonary hypertension, atrial fibrillation, or flail leaflet) for mitral repair outside the setting of high likelihood of durable repair with low
From the Department of Surgery, Duke University Medical Center, Durham, NC. Disclosures: Author has nothing to disclose with regard to commercial support. Received for publication April 17, 2015; accepted for publication April 24, 2015. Address for reprints: Donald D. Glower, MD, Department of Surgery, Duke University Medical Center, Box 3851, Durham, NC 27710 (E-mail: Glowe001@ mc.duke.edu). J Thorac Cardiovasc Surg 2015;150:4-5 0022-5223/$36.00 Copyright Ó 2015 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2015.04.048
4
morbidity and mortality. The authors argue that this change in the guidelines would cause more patients to undergo early surgery and thus have better outcomes and survival. The authors correctly point out that current guidelines3 are based on class C evidence from clinical experience now 20 to 30 years old, whereas the data presented are from the last 10 to 15 years. Admittedly, surgical morbidity and mortality have improved in the last 20 years, and mitral repair techniques have changed with improving mitral repair rates. Unfortunately, we lack good data that mitral repair durability has improved in the last 15 years, because we only have good echocardiography follow-up of our repairs in selected series from the last 10 to 12 years. Although this very carefully analyzed large series from a single institution is not definitive, the findings are indeed concerning that current clinical practice and guidelines are in fact putting large numbers of patients at unnecessary risk of death and premature heart failure. If history continues to repeat itself, these data probably will be confirmed by other large centers and will eventually result in adjustment of the guidelines. The main argument against modifying current guidelines on the basis of these data (assuming that these data are indeed replicated at other institutions and in other studies) is that early surgery might cause patients who are not low risk or who do not have access to high repair rates to undergo unnecessary operations or receive replacement of repairable valves.3 Indeed, the current data are from a high-volume institution known for highquality mitral repair. On the other hand, national data from the Society of Thoracic Surgeons database from the last 10 to 15 years show that the current mitral valve repair rates in the general community are approximately 70% as opposed to approximately 90% at the Mayo Clinic.2 One difficulty with these arguments against early surgery is that even if some patients receive early mitral replacement instead of repair, the excess mortality at 10 years associated with mitral replacement versus repair may not be much different from the excess mortality at 10 years in those patients who received ‘‘watch and wait’’ surgery instead of early repair.
The Journal of Thoracic and Cardiovascular Surgery c July 2015
Editorial: Acquired Mitral Valve
Thus, those involved with setting the guidelines must choose whether the guidelines themselves should be tailored to treating physician characteristics (surgeon volume) versus having guidelines that consider patient characteristics and assume the same high standards for all physicians. Enriquez-Sarano and colleagues1 argue that the early surgery approach should be reserved for highervolume institutions and patients with a high likelihood of repair, as is indeed currently suggested in the current guidelines.3 As a practical matter, defining a high-volume center can be difficult, given that some relatively low-volume centers actually have good outcomes from mitral repair, and other large-volume centers have less than ideal mitral valve repair rates. Until the era of accurate public reporting of data, finding a truly high-volume, high-quality mitral valve repair center is not a certain matter. Nonetheless, these data of Enriquez-Sarano and colleagues1 suggest that making early surgery a class I indication for severe mitral
regurgitation with a high likelihood of repair based on BOTH patient and surgeon characteristics may be good for patients. Physicians should be honest enough to look at themselves and not just at the patients. Physician, heal thyself. References 1. Enriquez-Sarano M, Suri RM, Clavel MA, Mantovani F, Michelena HI, Pislaru S, et al. Is there an outcome penalty linked to guideline-based indications for valvular surgery? Early and long-term analysis of patients with organic mitral regurgitation. J Thorac Cardiovasc Surg. 2015; 150:50-8. 2. Gammie JS, O’Brien SM, Griffith BP, Ferguson TB, Peterson ED. Influence of hospital procedural volume on care process and mortality for patients undergoing elective surgery for mitral regurgitation. Circulation. 2007; 115:881-7. 3. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP III, Guyton RA, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Thorac Cardiovasc Surg. 2014;148:e1-132.
The Journal of Thoracic and Cardiovascular Surgery c Volume 150, Number 1
5
EDITORIAL
Glower
EDITORIAL: ACQUIRED MITRAL VALVE
Physician heal thyself Donald D. Glower, MD
See related article on pages 50-8. Enriquez-Sarano and colleagues1 examined the outcomes of surgical mitral valve repair in 1512 patients with pure organic mitral regurgitation as a function of the guideline-based indication for operation. In the data presented, watchful waiting (class I or II complication triggers for mitral valve repair) was independently associated with a doubling or 40% increase in the risk of late heart failure or death relative to early surgery. The authors conclude that (1) the type of guideline-based indication for surgical correction of organic mitral regurgitation is associated with profound outcome consequences and that (2) surgical correction of severe mitral regurgitation based on a high probability of repair is associated with improved survival and low heart failure risk and should be the preferred strategy in valve centers offering very low operative risk and high repair rates. Historically, medical treatment decision-making has been primarily based on patient characteristics and NOT on characteristics of the treating physician. Enriquez-Sarano and colleagues1 present data suggesting that in the case of severe mitral regurgitation, patient outcomes can be improved by tailoring therapy on the basis of BOTH patient and physician characteristics. This concept is not new, with prior studies showing higher mitral repair rates and lower mortality for mitral surgery in higher-volume centers.2 Effectively, Enriquez-Sarano and colleagues1 argue for making early surgery (all severe mitral regurgitation that has a high likelihood of durable repair with low morbidity/mortality based on BOTH patient and surgeon characteristics) a class I indication for surgery. Presumably, the authors would retain current class I indications (symptoms, ventricular dysfunction, or dilation) and class IIa complication indications (pulmonary hypertension, atrial fibrillation, or flail leaflet) for mitral repair outside the setting of high likelihood of durable repair with low
From the Department of Surgery, Duke University Medical Center, Durham, NC. Disclosures: Author has nothing to disclose with regard to commercial support. Received for publication April 17, 2015; accepted for publication April 24, 2015. Address for reprints: Donald D. Glower, MD, Department of Surgery, Duke University Medical Center, Box 3851, Durham, NC 27710 (E-mail: Glowe001@ mc.duke.edu). J Thorac Cardiovasc Surg 2015;150:4-5 0022-5223/$36.00 Copyright Ó 2015 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2015.04.048
4
morbidity and mortality. The authors argue that this change in the guidelines would cause more patients to undergo early surgery and thus have better outcomes and survival. The authors correctly point out that current guidelines3 are based on class C evidence from clinical experience now 20 to 30 years old, whereas the data presented are from the last 10 to 15 years. Admittedly, surgical morbidity and mortality have improved in the last 20 years, and mitral repair techniques have changed with improving mitral repair rates. Unfortunately, we lack good data that mitral repair durability has improved in the last 15 years, because we only have good echocardiography follow-up of our repairs in selected series from the last 10 to 12 years. Although this very carefully analyzed large series from a single institution is not definitive, the findings are indeed concerning that current clinical practice and guidelines are in fact putting large numbers of patients at unnecessary risk of death and premature heart failure. If history continues to repeat itself, these data probably will be confirmed by other large centers and will eventually result in adjustment of the guidelines. The main argument against modifying current guidelines on the basis of these data (assuming that these data are indeed replicated at other institutions and in other studies) is that early surgery might cause patients who are not low risk or who do not have access to high repair rates to undergo unnecessary operations or receive replacement of repairable valves.3 Indeed, the current data are from a high-volume institution known for highquality mitral repair. On the other hand, national data from the Society of Thoracic Surgeons database from the last 10 to 15 years show that the current mitral valve repair rates in the general community are approximately 70% as opposed to approximately 90% at the Mayo Clinic.2 One difficulty with these arguments against early surgery is that even if some patients receive early mitral replacement instead of repair, the excess mortality at 10 years associated with mitral replacement versus repair may not be much different from the excess mortality at 10 years in those patients who received ‘‘watch and wait’’ surgery instead of early repair.
The Journal of Thoracic and Cardiovascular Surgery c July 2015
Editorial: Acquired Mitral Valve
Thus, those involved with setting the guidelines must choose whether the guidelines themselves should be tailored to treating physician characteristics (surgeon volume) versus having guidelines that consider patient characteristics and assume the same high standards for all physicians. Enriquez-Sarano and colleagues1 argue that the early surgery approach should be reserved for highervolume institutions and patients with a high likelihood of repair, as is indeed currently suggested in the current guidelines.3 As a practical matter, defining a high-volume center can be difficult, given that some relatively low-volume centers actually have good outcomes from mitral repair, and other large-volume centers have less than ideal mitral valve repair rates. Until the era of accurate public reporting of data, finding a truly high-volume, high-quality mitral valve repair center is not a certain matter. Nonetheless, these data of Enriquez-Sarano and colleagues1 suggest that making early surgery a class I indication for severe mitral
regurgitation with a high likelihood of repair based on BOTH patient and surgeon characteristics may be good for patients. Physicians should be honest enough to look at themselves and not just at the patients. Physician, heal thyself. References 1. Enriquez-Sarano M, Suri RM, Clavel MA, Mantovani F, Michelena HI, Pislaru S, et al. Is there an outcome penalty linked to guideline-based indications for valvular surgery? Early and long-term analysis of patients with organic mitral regurgitation. J Thorac Cardiovasc Surg. 2015; 150:50-8. 2. Gammie JS, O’Brien SM, Griffith BP, Ferguson TB, Peterson ED. Influence of hospital procedural volume on care process and mortality for patients undergoing elective surgery for mitral regurgitation. Circulation. 2007; 115:881-7. 3. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP III, Guyton RA, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Thorac Cardiovasc Surg. 2014;148:e1-132.
The Journal of Thoracic and Cardiovascular Surgery c Volume 150, Number 1
5
EDITORIAL
Glower
