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Management of asymptomatic patients with severe non-ischaemic mitral regurgitation. Are practices consistent with guidelines?

^a Cardiology Department, Bichat Hospital, AP-HP, Paris, France
^b Epidemiology, Biostatistic, and Clinical Research Department, Bichat Hospital, AP-HP, Paris, France
^c Cardiology Department, Vall d’Hebron Hospital, Barcelona, Spain
^d Cardiology Department, Heart Centre Bad Krozingen, Bad Krozingen, Germany

Received 20 March 2008; received in revised form 24 June 2008; accepted 3 July 2008.

^_* Corresponding author. Address: Cardiology Department, Bichat Hospital, 46 rue Henri Huchard, 75018 Paris, France. Tel.: +33 1 40 25 67 60; fax: +33 1 40 25 67 32. (Email: bernard.iung{at}bch.aphp.fr).

Objective: For asymptomatic patients with severe mitral regurgitation, guidelines recommend surgery in selected patients. However, little is known on how the current practice fits with guidelines. Methods: Of the 5001 patients prospectively included in the Euro Heart Survey on valvular heart disease, 877 had isolated mitral regurgitation and 546 had severe mitral regurgitation (grade 3/4 with Doppler echocardiography). Of them, 101 were asymptomatic and had non-ischaemic mitral regurgitation. The decision to refer the patients to surgery or not operate was analysed by comparing patient characteristics with American College of Cardiology/American Heart Association guidelines. Results: Coronary angiography was performed in 21 out of 33 patients (64%) who were considered for surgery. Catheterisation was performed in 27 patients (27%). A decision to operate was taken in 33 patients (33%). Decisions to refer to surgery or not were in accordance with guidelines in 63 patients (62%). Regarding discordant decisions, intervention was considered ‘over-used’ in 9 patients (9%) and ‘under-used’ in 29 patients (29%), of whom 24 had a class I or IIa indication for surgery. Of the 68 non-operated patients, 44 (65%) received at least one drug with haemodynamic effect. Conclusions: In asymptomatic patients with severe mitral regurgitation, preoperative coronary angiography seems under-used and cardiac catheterisation is frequently used. Regarding the decision to operate or not, a large number of patients were not referred to surgery even though they fulfilled recommendation for surgery. Thus, to avoid too late surgical referral, implementation of existing guidelines should be improved.

Key Words: Mitral regurgitation • Valvular surgery • Guidelines

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