title: Negative impact of atrial fibrillation and pulmonary hypertension after mitral valve surgery in asymptomatic patients with severe mitral regurgitation: a 20-year follow-up.
abstract: OBJECTIVE
  The timing for mitral valve (MV) surgery in asymptomatic patients with severe mitral regurgitation (MR) and preserved left ventricular (LV) function remains controversial. We aimed at analysing the long-term outcome of asymptomatic patients with atrial fibrillation (AF) and/or pulmonary hypertension (PHT) after successful MV repair.
  
  
  METHODS
  From January 1992 to December 2012, 382 patients with severe degenerative MR, with no or mild symptoms, preserved LV function (ejection fraction > 60%) and LV systolic dimensions <45 mm were submitted to surgery and followed up for up to 22 years (3209 patient-years). Patients with associated surgeries, other than tricuspid repair, were excluded. Patients with AF and/or PHT (Group A; n = 106, 24.4%) were compared with patients without these comorbidities (Group B; n = 276, 63.6%). Propensity-score matching (for preoperative variables) was performed obtaining 102 patients in each arm. Survival and event-free survival [major cardiac and cerebrovascular events (MACCEs); freedom from mitral reoperation and recurrent moderate and severe MR] were analysed.
  
  
  RESULTS
  MV repair was performed in 98.2% of cases and tricuspid annuloplasty in 6.9%. Overall 30-day mortality was 0.8%, not different between groups, and absent in patients with isolated posterior leaflet prolapse (n = 211). Patients with AF/PHT had worse late survival by comparison with Group B patients (67.0 ± 7.4 vs 86.5 ± 3.9% at 15 years, P < 0.001), survival free from MACCE (52.7 ± 8.7 vs 74.5 ± 5.0%, P < 0.001), from recurrent moderate and severe MR (65.1 ± 10.3 vs 87.0 ± 3.8%, P = 0.002) and from mitral reoperation during the follow-up (87.3 ± 6.3 vs 94.2 ± 2.7%, P = 0.04). These differences were confirmed in the propensity score-matched population. Patients from Group A also displayed a lesser degree of reverse remodelling. There was a significant reduction in the systolic pulmonary artery pressure (SPAP) after surgery, more pronounced in Group A patients; nonetheless, the mean SPAP at late follow-up was higher in these patients (45 vs 30 mmHg).
  
  
  CONCLUSIONS
  MV repair can be achieved in the great majority of patients with degenerative regurgitation, with low mortality (<1%). Asymptomatic or mildly symptomatic patients with severe MR, preserved LV function and AF/PHT had poorer long-term survival and event-free survival even after a successful surgery. The durability of MV repair was also compromised in these patients, which indicates that they should have been operated earlier.
authors.affiliation: Centre of Cardiothoracic Surgery, University Hospital and Faculty of Medicine, Coimbra, Portugal.
authors.forename: Gonçalo F
authors.initials: GF
authors.lastname: Coutinho
authors.affiliation: Centre of Cardiothoracic Surgery, University Hospital and Faculty of Medicine, Coimbra, Portugal.
authors.forename: Ana Luís
authors.initials: AL
authors.lastname: Garcia
authors.affiliation: Centre of Cardiothoracic Surgery, University Hospital and Faculty of Medicine, Coimbra, Portugal.
authors.forename: Pedro M
authors.initials: PM
authors.lastname: Correia
authors.affiliation: Centre of Cardiothoracic Surgery, University Hospital and Faculty of Medicine, Coimbra, Portugal.
authors.forename: Carlos
authors.initials: C
authors.lastname: Branco
authors.affiliation: Centre of Cardiothoracic Surgery, University Hospital and Faculty of Medicine, Coimbra, Portugal antunes.cct.chuc@sapo.pt.
authors.forename: Manuel J
authors.initials: MJ
authors.lastname: Antunes
mesh_terms: D000368:Aged; D000704:Analysis of Variance; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000453:epidemiology* / Q000601:surgery; D015331:Cohort Studies; D015897:Comorbidity; D018572:Disease-Free Survival; D015150:Echocardiography, Doppler; D004562:Electrocardiography / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D006976:Hypertension, Pulmonary / Q000175:diagnosis / Q000453:epidemiology* / Q000601:surgery; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D008944:Mitral Valve Insufficiency / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000601:surgery*; D008991:Monitoring, Physiologic / Q000379:methods; D015999:Multivariate Analysis; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome
keywords: Asymptomatic patients; Atrial fibrillation; Degenerative mitral regurgitation; Long-term outcomes; Pulmonary hypertension