In valvular heart disease, when is valve surgery most appropriate?

From the Guidelines

Valve surgery is most appropriate in patients with severe valvular heart disease who are symptomatic or have left ventricular dysfunction, as indicated by a left ventricular ejection fraction (LVEF) ≤60% or left ventricular end-systolic diameter (LVESD) ≥40 mm. This recommendation is based on the most recent and highest quality study, which suggests that mitral valve repair is reasonable in asymptomatic patients with chronic severe primary mitral regurgitation (MR) and preserved left ventricular (LV) function (LVEF >60% and LVESD <40 mm) when there is a high likelihood of a successful and durable repair 1.

Key Considerations

• The presence of severe MR can lead to progressively more severe MR, causing LV dilatation and increased stress on the mitral apparatus, resulting in further damage to the valve apparatus and poorer prognosis 1.
• Longitudinal follow-up demonstrating a progressive decrease in EF toward 60% or a progressive increase in LVESD approaching 40 mm is an indication for intervention 1.
• Mitral valve repair is preferred over replacement when feasible, especially for posterior leaflet pathology, which typically has excellent repair outcomes with lower operative mortality and better long-term survival compared to valve replacement 1.

Indications for Surgery

• Symptomatic patients with LVEF >30% 1
• Asymptomatic patients with LV dysfunction (LVESD ≥45 mm and/or LVEF ≤60%) 1
• Asymptomatic patients with preserved LV function and new onset of atrial fibrillation or pulmonary hypertension (systolic pulmonary pressure at rest >50 mmHg) 1
• Asymptomatic patients with preserved LV function, high likelihood of durable repair, low surgical risk, and flail leaflet and LVESD ≥40 mm 1

Conclusion Not Applicable

Instead, the key points to consider are:

• Early surgical intervention can prevent irreversible left ventricular dysfunction in patients with severe MR and early signs of left ventricular dilation.
• Mitral valve repair is the preferred technique when the results are expected to be durable.
• The management of asymptomatic patients is controversial, but surgery can be proposed in selected asymptomatic patients with severe MR, in particular when repair is likely.

From the Research

Valve Surgery in Valvular Heart Disease

Valve surgery is a common treatment option for valvular heart disease, and the timing of surgery is crucial for optimal outcomes. The decision to perform valve surgery depends on various factors, including the severity of the disease, symptoms, and left ventricular function.

Indications for Valve Surgery

• Symptomatic patients with severe mitral regurgitation are clear indications for surgical correction 2.
• Asymptomatic patients with severe mitral regurgitation and left ventricular dysfunction or dilation also warrant surgery 2.
• The presence of other clinical sequelae, such as atrial arrhythmias and pulmonary hypertension, can also influence the decision to operate 2.
• Early surgery in asymptomatic patients with severe organic mitral regurgitation may restore life expectancy, especially if valve repair is performed 3.

Timing of Valve Surgery

• The optimal timing of valve surgery in asymptomatic patients with severe mitral regurgitation is still debated 2, 3.
• Some studies suggest that early surgery in asymptomatic patients can improve outcomes and reduce the risk of late death and heart failure 3, 4.
• A study found that surgery intervention should be encouraged before the onset of left ventricular ejection fraction (LVEF) less than 65% or left atrial volume index 53 mL/m2 or more 5.
• Another study found that prompt surgical correction of severe mitral regurgitation within 3 months following diagnosis in asymptomatic patients can convey a 40% decrease in the risk of late death and a 60% diminution in heart failure incidence 4.

Predictors of Outcomes

• Preoperative LVEF and left atrial volume index are predictors of early postoperative left ventricular dysfunction, which can lead to poor long-term survival after mitral valve repair in asymptomatic degenerative mitral regurgitation patients with preserved left ventricular function 5.
• Greater ventricular dimensions can predict mitral regurgitation improvement after isolated aortic valve replacement, which is associated with significantly better long-term survival 6.