Increasing Disadvantage of "Watchful Waiting" for Repairing Degenerative Mitral Valve Disease.
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.
Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
Farhang
F
Yazdchi
Department of Cardiothoracic Anesthesia, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
Colleen G
CG
Koch
Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
Tomislav
T
Mihaljevic
Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
Rory
R
Hachamovitch
Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio.
Ashley M
AM
Lowry
Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio.
Jiayan
J
He
Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
A Marc
AM
Gillinov
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.
Eugene H
EH
Blackstone
Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address: sabikj@ccf.org.
Joseph F
JF
Sabik
D005260:Female; D005500:Follow-Up Studies; D019918:Heart Valve Prosthesis Implantation; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D008297:Male; D008875:Middle Aged; D008944:Mitral Valve Insufficiency / Q000401:mortality / Q000601:surgery*; D009820:Ohio / Q000453:epidemiology; D012086:Reoperation / Q000639:trends; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D016896:Treatment Outcome; D057832:Watchful Waiting