June 11th, 2012

The Changing Face of Mitral Valve Surgery

It’s not easy to decide whether to refer an elderly patient with severe, symptomatic mitral regurgitation (MR) for surgery. Mitral valve repair and replacement remain the definitive treatments for symptomatic MR, but they come with particularly high risks in the elderly.

Given the lack of U.S. national surveillance data on this topic, my colleagues and I decided to study trends in the performance of mitral valve surgery, as well as postsurgery hospital readmission (30 days) and mortality (30 days and 1 year), for all Medicare fee-for-service beneficiaries from 1999 through 2008. Our results, published in May, included several key findings:

1. Mitral valve surgery patients are getting older: The overall rate of surgery remained relatively constant from 1999 through 2008, but the percentage of surgery patients who were age 85 or older increased from 8.8% to 12.7%.

2. Risk-adjusted mortality declined dramatically, both at 30 days (from 8.1% to 4.2%) and at 1 year (from 15.3% to 9.2%).

3. Risk-adjusted hospital readmission declined modestly (from 23.0% to 21.0%).

4. Improvements were generally seen across age, sex, and race subgroups, but mortality rates remained higher for women than for men − and for nonwhites than for whites − throughout the 10-year period.

Our study was not designed to explore the reasons for improvement. Possible contributors are the increasing rates of mitral valve repair, lower postoperative complications, and changes in referral patterns (e.g., being referred for surgery earlier).

Will these findings change your practice? What are your considerations as you decide whether to refer elderly patients for mitral valve surgery?

One Response to “The Changing Face of Mitral Valve Surgery”

  1. James Pate, MD says:

    So much of the confusion about mitral surgery relates to the apples and orange problem. Those of us who operated upon advanced Rheumatic valves are always aware of the different disease states, pathological anatomy, physiology, etc. between Rheumatic, Ruptured chordae or papillary muscle, myxomatous degeneration of a prolapsed valve, or problems with conduction and ventricular anatomy. It would be nice if everyone reporting “series” restricted themselves to ONE diagnosis and ONE patho-physiologic state. Maybe we could learn a lot more from well described data than from big series (necessary to worship at the alter of statistical analysis).