Circulation. 2006;113:2238-2244
Published online before print May 1, 2006, doi: 10.1161/CIRCULATIONAHA.105.599175
Published online before print May 1, 2006, doi: 10.1161/CIRCULATIONAHA.105.599175
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
(Circulation. 2006;113:2238-2244.)
© 2006 American Heart Association, Inc.
Valvular Heart Disease |
Outcome of Watchful Waiting in Asymptomatic Severe Mitral Regurgitation
From the Department of Cardiology (R.R., F.R., U.K., H.G., M.K., D.K., G.M., H.B.) and the Core Unit for Medical Statistics and Informatics (M.S.), Medical University of Vienna, Vienna, Austria.
Correspondence to Raphael Rosenhek, MD, or Helmut Baumgartner, MD, Department of Cardiology, Medical University of Vienna, Waehringer Gürtel 18-20, A-1090 Vienna, Austria. E-mail raphael.rosenhek{at}meduniwien.ac.at or helmut.baumgartner@meduniwien.ac.at
Received November 2, 2005; revision received February 9, 2006; accepted February 17, 2006.
Background— The management of asymptomatic severe mitral regurgitation remains controversial. The aim of this study was to evaluate the outcome of a watchful waiting strategy in which patients are referred to surgery when symptoms occur or when asymptomatic patients develop left ventricular (LV) enlargement, LV dysfunction, pulmonary hypertension, or recurrent atrial fibrillation.
Methods and Results— A total of 132 consecutive asymptomatic patients (age 55±15 years, 49 female) with severe degenerative mitral regurgitation (flail leaflet or valve prolapse) were prospectively followed up for 62±26 months. Patients underwent serial clinical and echocardiographic examinations and were referred for surgery when the criteria mentioned above were fulfilled. Overall survival was not statistically different from expected survival either in the total group or in the subgroup of patients with flail leaflet. Eight deaths were observed. Thirty-eight patients developed criteria for surgery (symptoms, 24; LV criteria, 9; pulmonary hypertension or atrial fibrillation, 5). Survival free of any indication for surgery was 92±2% at 2 years, 78±4% at 4 years, 65±5% at 6 years, and 55±6% at 8 years. Patients with flail leaflet tended to develop criteria for surgery slightly but not significantly earlier. There was no operative mortality. Postoperative outcome was good with regard to survival, symptomatic status, and postoperative LV function.
Conclusions— Asymptomatic patients with severe degenerative mitral regurgitation can be safely followed up until either symptoms occur or currently recommended cutoff values for LV size, LV function, or pulmonary hypertension are reached. This management strategy is associated with good perioperative and postoperative outcome but requires careful follow-up.
CLINICAL PERSPECTIVE
Related Article:
-
Issue Highlights
Circulation 2006 113: 2165.[Extract] [Full Text]
This article has been cited by other articles:
 |
|
 |
|
  E. Picano, P. Pibarot, P. Lancellotti, J. L. Monin, and R. O. Bonow The emerging role of exercise testing and stress echocardiography in valvular heart disease. J. Am. Coll. Cardiol., December 8, 2009; 54(24): 2251 - 2260. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. Verma and T. G. Mesana Mitral-Valve Repair for Mitral-Valve Prolapse N. Engl. J. Med., December 3, 2009; 361(23): 2261 - 2269. [Full Text] [PDF]
|
|
|
|
 |
|
 P. Montant, F. Chenot, A. Robert, D. Vancraeynest, A. Pasquet, B. Gerber, P. Noirhomme, G. El Khoury, and J.-L. Vanoverschelde Long-term survival in asymptomatic patients with severe degenerative mitral regurgitation: A propensity score-based comparison between an early surgical strategy and a conservative treatment approach J. Thorac. Cardiovasc. Surg., December 1, 2009; 138(6): 1339 - 1348. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Tribouilloy, F. Grigioni, J. F. Avierinos, A. Barbieri, D. Rusinaru, C. Szymanski, M. Ferlito, L. Tafanelli, F. Bursi, F. Trojette, et al. Survival implication of left ventricular end-systolic diameter in mitral regurgitation due to flail leaflets a long-term follow-up multicenter study. J. Am. Coll. Cardiol., November 17, 2009; 54(21): 1961 - 1968. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. A. Pierard and J. Magne A new look to an old measurement. J. Am. Coll. Cardiol., November 17, 2009; 54(21): 1969 - 1970. [Full Text] [PDF]
|
|
|
|
 |
|
 N. A. Marsan, J. J.M. Westenberg, C. Ypenburg, V. Delgado, R. J. van Bommel, S. D. Roes, G. Nucifora, R. J. van der Geest, A. de Roos, J. C. Reiber, et al. Quantification of Functional Mitral Regurgitation by Real-Time 3D Echocardiography: Comparison With 3D Velocity-Encoded Cardiac Magnetic Resonance J. Am. Coll. Cardiol. Img., November 1, 2009; 2(11): 1245 - 1252. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Pizarro, O. O. Bazzino, P. F. Oberti, M. Falconi, F. Achilli, A. Arias, J. G. Krauss, and A. M. Cagide Prospective validation of the prognostic usefulness of brain natriuretic peptide in asymptomatic patients with chronic severe mitral regurgitation. J. Am. Coll. Cardiol., September 15, 2009; 54(12): 1099 - 1106. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. A. McCullough and G. S. Hanzel B-type natriuretic peptide and echocardiography in the surveillance of severe mitral regurgitation prior to valve surgery. J. Am. Coll. Cardiol., September 15, 2009; 54(12): 1107 - 1109. [Full Text] [PDF]
|
|
|
|
 |
|
 F. Chenot, P. Montant, D. Vancraeynest, A. Pasquet, B. Gerber, P. H. Noirhomme, G. E. Khoury, and J.-L. Vanoverschelde Long-term clinical outcome of mitral valve repair in asymptomatic severe mitral regurgitation Eur. J. Cardiothorac. Surg., September 1, 2009; 36(3): 539 - 545. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 Y.-K. Guo, Z.-G. Yang, G. Ning, L. Rao, L. Dong, Y. Pen, T.-M. Zhang, Y. Wu, X.-C. Zhang, and Q.-L. Wang Isolated Mitral Regurgitation: Quantitative Assessment with 64-Section Multidetector CT--Comparison with MR Imaging and Echocardiography Radiology, August 1, 2009; 252(2): 369 - 376. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
V. V. McLaughlin, S. L. Archer, D. B. Badesch, R. J. Barst, H. W. Farber, J. R. Lindner, M. A. Mathier, M. D. McGoon, M. H. Park, R. S. Rosenson, et al. ACCF/AHA 2009 Expert Consensus Document on Pulmonary Hypertension: A Report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association Developed in Collaboration With the American College of Chest Physicians; American Thoracic Society, Inc.; and the Pulmonary Hypertension Association J. Am. Coll. Cardiol., April 28, 2009; 53(17): 1573 - 1619. [Full Text] [PDF]
|
|
|
|
 |
|
 Writing Committee Members, V. V. McLaughlin, S. L. Archer, D. B. Badesch, R. J. Barst, H. W. Farber, J. R. Lindner, M. A. Mathier, M. D. McGoon, M. H. Park, et al. ACCF/AHA 2009 Expert Consensus Document on Pulmonary Hypertension: A Report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association: Developed in Collaboration With the American College of Chest Physicians, American Thoracic Society, Inc., and the Pulmonary Hypertension Association Circulation, April 28, 2009; 119(16): 2250 - 2294. [Full Text] [PDF]
|
|
|
|
|
|
D.-H. Kang, J. H. Kim, J. H. Rim, M.-J. Kim, S.-C. Yun, J.-M. Song, H. Song, K.-J. Choi, J.-K. Song, and J.-W. Lee Comparison of Early Surgery Versus Conventional Treatment in Asymptomatic Severe Mitral Regurgitation Circulation, February 17, 2009; 119(6): 797 - 804. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. Vahanian, B. Iung, L. Piérard, R. Dion, and J. Pepper CHAPTER 21 Valvular Heart Disease ESC Textbook of Cardiovascular Medicine, January 1, 2009; 2(1): med-9780199566990-chapter - med-9780199566990-chapter. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
W. H. Gaasch and T. E. Meyer Left Ventricular Response to Mitral Regurgitation: Implications for Management Circulation, November 25, 2008; 118(22): 2298 - 2303. [Full Text] [PDF]
|
|
|
|
|
|
D. Detaint, B. Iung, L. Lepage, D. Messika-Zeitoun, G. Baron, P. Tornos, C. Gohlke-Barwolf, and A. Vahanian Management of asymptomatic patients with severe non-ischaemic mitral regurgitation. Are practices consistent with guidelines? Eur. J. Cardiothorac. Surg., November 1, 2008; 34(5): 937 - 942. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
2006 WRITING COMMITTEE MEMBERS, R. O. Bonow, B. A. Carabello, K. Chatterjee, A. C. de Leon Jr, D. P. Faxon, M. D. Freed, W. H. Gaasch, B. W. Lytle, R. A. Nishimura, et al. 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines 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 (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons Circulation, October 7, 2008; 118(15): e523 - e661. [Full Text] [PDF]
|
|
|
|
|
|
C. J. Carlhall, T. C. Nguyen, A. Itoh, D. B. Ennis, W. Bothe, D. Liang, N. B. Ingels, and D. C. Miller Alterations in Transmural Myocardial Strain: An Early Marker of Left Ventricular Dysfunction in Mitral Regurgitation? Circulation, September 30, 2008; 118(14_suppl_1): S256 - S262. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. O. Bonow, B. A. Carabello, K. Chatterjee, A. C. de Leon Jr, D. P. Faxon, M. D. Freed, W. H. Gaasch, B. W. Lytle, R. A. Nishimura, P. T. O'Gara, et al. 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines 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 (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease) Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons J. Am. Coll. Cardiol., September 23, 2008; 52(13): e1 - e142. [Full Text] [PDF]
|
|
|
|
 |
|
 S. Buchner, K. Debl, F. Poschenrieder, S. Feuerbach, G. A.J. Riegger, A. Luchner, and B. Djavidani Cardiovascular Magnetic Resonance for Direct Assessment of Anatomic Regurgitant Orifice in Mitral Regurgitation Circ Cardiovasc Imaging, September 1, 2008; 1(2): 148 - 155. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. Grigioni, C. Tribouilloy, J. F. Avierinos, A. Barbieri, M. Ferlito, F. Trojette, L. Tafanelli, A. Branzi, C. Szymanski, G. Habib, et al. Outcomes in mitral regurgitation due to flail leaflets a multicenter European study. J. Am. Coll. Cardiol. Img., March 1, 2008; 1(2): 133 - 141. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. A. Grayburn Should we operate on asymptomatic patients with severe mitral regurgitation? J. Am. Coll. Cardiol. Img., March 1, 2008; 1(2): 142 - 144. [Full Text] [PDF]
|
|
|
|
 |
|
 A. J. Kerr, O. C. Raffel, G. A. Whalley, I. Zeng, and R. A. Stewart Elevated B-type natriuretic peptide despite normal left ventricular function on rest and exercise stress echocardiography in mitral regurgitation Eur. Heart J., February 1, 2008; 29(3): 363 - 370. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. I. Fann, N. B. Ingels Jr., and D. C. Miller Pathophysiology of Mitral Valve Disease Card. Surg. Adult, January 1, 2008; 3(2008): 973 - 1012. [Full Text]
|
|
|
|
|
|
T. Feldman and M. B. Leon Prospects for Percutaneous Valve Therapies Circulation, December 11, 2007; 116(24): 2866 - 2877. [Full Text] [PDF]
|
|
|
|
 |
|
 R. Lee and T. H. Marwick Assessment of subclinical left ventricular dysfunction in asymptomatic mitral regurgitation Eur J Echocardiogr, June 1, 2007; 8(3): 175 - 184. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. H. Jones The Year in Cardiovascular Surgery J. Am. Coll. Cardiol., May 8, 2007; 49(18): 1887 - 1898. [Full Text] [PDF]
|
|
|
|
|
|
R. O. Bonow, B. A. Carabello, K. Chatterjee, A. C. de Leon Jr, D. P. Faxon, M. D. Freed, W. H. Gaasch, B. W. Lytle, R. A. Nishimura, P. T. O'Gara, et al. ACC/AHA 2006 Guidelines 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 (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease) Developed in Collaboration With the Society of Cardiovascular Anesthesiologists Endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons J. Am. Coll. Cardiol., August 1, 2006; 48(3): e1 - e148. [Full Text] [PDF]
|
|
|
|
|
|
M. G. St. John Sutton and R. C. Gorman Surgery for Asymptomatic Severe Mitral Regurgitation in the Elderly: Early Surgery or Wait and Watch? Circulation, July 25, 2006; 114(4): 258 - 260. [Full Text] [PDF]
|
|
|
|
 |
|
 For Asymptomatic Severe MR, Watch and Wait? Journal Watch Cardiology, June 28, 2006; 2006(628): 3 - 3. [Full Text]
|
|
|
|
|
|
B. P. Griffin Timing of Surgical Intervention in Chronic Mitral Regurgitation: Is Vigilance Enough? Circulation, May 9, 2006; 113(18): 2169 - 2172. [Full Text] [PDF]
|
|