Advance Publication by-J-STAGE

Circulation Journal
Official Journal of the Japanese Circulation Society
REVIEW
http://www. j-circ.or.jp

Triggers for Surgical Referral in Degenerative  

Mitral Valve Regurgitation
Shinobu Itagaki, MD; David H. Adams, MD; Anelechi C. Anyanwu, MD

Degenerative mitral valve disease is the most common etiology of mitral regurgitation in developed countries. De-
generative mitral valve disease should be distinguished from other valvular disease because most of the lesions
caused by degenerative changes are amenable to valve repair as opposed to replacement, and successful durable
repair with optimal timing can maintain the patient’s normal life expectancy. Despite dramatic surgical progress in
degenerative mitral valve repair over the past few decades and detailing of surgical indications in established prac-
tice guidelines, prevailing data suggest a significant number of patients are still not referred for surgery in a timely
fashion or are even denied for surgery for inappropriate reasons. This article reviews the current surgical triggers
which all practicing cardiovascular specialists should be familiar with and which should prompt immediate surgical
referral.

Key Words: Degenerative mitral valve disease; Mitral regurgitation; Surgical indications

M
itral regurgitation (MR) is the most common valvu-
lar heart disease and affects 2.5% of the general
population in the United States.1 The etiology of
MR is variable and generally classified as degenerative, isch-
emic, rheumatic, infective, or congenital. In developed coun-
tries, because of the reduced prevalence of the rheumatic etiol-
ogy, degenerative mitral valve disease is the most common
etiology of MR.1
In degenerative mitral valve disease, infiltrative or dysplas-
tic tissue changes cause elongation or rupture of the mitral
valve chordae, resulting in leaflet prolapse and usually associ-
ated annular dilatation.2,3 Degenerative changes are also often
seen in the mitral valve leaflets.
Degenerative mitral valve disease is unique compared with
other valvular heart disease4 in several regards. It often affects
otherwise relatively healthy individuals; the natural history is
insidious; repair not replacement is the surgical treatment of
choice; the surgical techniques are still evolving and can be
technically demanding in selected complex cases; and, most
importantly, the restoration of life expectancy can be expected
if appropriately treated.5 These unique characteristics of de-
generative mitral valve disease, in turn, pose specific problems,
such as inconsistent referral practices among cardiologists,
widely varied surgical expertise and practice, variable rate of
valve replacement among institutions, and controversy over the
indications for surgery, particularly in asymptomatic patients.
The aim of this article is to review the current basis for
management of degenerative mitral valve disease, to help bet-
ter understand the optimal management strategy for these pa-
tients.
Definition of Severe MR
The determination of MR severity is the critical first step in
managing patients with degenerative mitral disease because
severity denotes prognosis and dictates the management.6 Echo-
cardiography is the essential tool for evaluation of MR. The
diagnosis of severe MR should be based on an integrative ap-
proach, such as recommended by the American Society of
Echocardiography (ASE)7 to allow consistent estimation of
MR severity.
Although 3-dimensional echocardiography, an emerging mo-
dality, shows promise with cumulative experience and evi-
dence,8,9 2-dimensional (2D) and Doppler transthoracic and/or
transesophageal echocardiography remain the gold standard
diagnostic tool for MR. There are several parameters in 2D
and Doppler echocardiography to evaluate MR severity. Table 1
summarizes the ASE approach to defining the severity of MR.
Each parameter has its own advantage and limitation and no
single parameter can make a definite diagnosis of severe MR
by itself. All parameters need to be interpreted as a group for
better diagnostic accuracy. Echocardiography is also impor-
tant in the evaluation of the mechanism of MR, which com-
prises the pathophysiologic triad of etiology, lesion, and dys-
function.10 Combined with history and physical examination,
echocardiography can accurately determine the MR mechanism.
A detailed description of the MR mechanism should be avail-
able, especially when the patient with degenerative MR is re-
ferred for surgery, because the feasibility of repair is highly
dependent on the mechanism. Essentially, all degenerative mi-
tral valves are repairable, and although this is feasible in refer-

Received July 26, 2012; revised manuscript received October 9, 2012; accepted October 11, 2012; released online October 31, 2012
Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY, USA
Grant sponsor: None.
Mailing address:  Anelechi C. Anyanwu, MD, MSc, FRCS, Associate Professor, Department of Cardiothoracic Surgery, The Mount Sinai
School of Medicine, 1190 Fifth Avenue, New York, NY 10029, USA.   E-mail: anelechi.anyanwu@mountsinai.org
ISSN-1346-9843   doi: 10.1253/circj.CJ-12-0972
All rights are reserved to the Japanese Circulation Society. For permissions, please e-mail: cj@j-circ.or.jp
 Advance Publication by-J-STAGE
Table 1.  Grading of Mitral Regurgitation Severity
Mild
Specific signs • Small central jet <4 cm2 or <20% of
LA area
• Vena contracta width <0.3 cm
• No or minimal flow convergence
Supportive signs • Systolic dominant flow in pulmonary
veins
• A-wave dominant mitral inflow
• Soft density continuous-wave Doppler
MR signal
• Normal LV size
Quantitative
parameters
   RVol, m/beat <30
   RF, % <30
   ERO, mm2 <20
ERO, effective regurgitant orifice are; LA, left atrium; LV, left ventricle; MR, mitral regurgitation; RF, regurgitant fraction; RVol, regurgitant
volume.
ence mitral centers,11 this can only be achieved on a popula-
tion level by matching the mechanism of MR to the appropriate
surgical expertise necessary to deal with the identified mecha-
nism.12 The baseline left ventricular (LV) function and size
should also be documented by echocardiography and changes
from these baseline values may subsequently be used to guide
the necessity and timing of surgery.
Overview of the 2006 ACC/AHA Guidelines
Other than echocardiographic surveillance, no specific man-
agement is recommended for less than severe degrees of MR.
However, once a diagnosis of severe MR is confirmed, surgi-
cal intervention should be a considered treatment option. In
the current American College of Cardiology/American Heart
Association (ACC/AHA) guidelines13 (Figure), there are 5
surgical indications specified, with severe MR as a prerequi-
site: (1) symptoms; (2) LV dysfunction; (3) LV enlargement;
(4) new onset atrial fibrillation (AF); and (5) pulmonary hy-
pertension (PHT). Each condition by itself is considered as an
agreed-on indication for surgery as either a Class I (recom-
mended) or Class IIa (reasonable). The rationale and validity
for each indication will be reviewed subsequently.
The first question in evaluating the indication for surgery is
whether the patient is symptomatic or asymptomatic. The pres-
ence of symptoms related to MR is considered as a Class I
indication for surgery. If the patient is asymptomatic, then the
next question is whether the patient has LV dysfunction or
dilatation, which are currently defined as ejection fraction
(LVEF) ≤60% and/or LV end-systolic diameter (ESD) ≥40 mm,
either of which are considered as Class I indications. If the
patient is asymptomatic with a normal left ventricle, then the
presence of PHT, which is defined as pulmonary artery sys-
tolic pressure (PASP) ≥50 mmHg at rest or ≥60 mmHg after
exercise, or new onset AF are Class IIa indications. Besides
these 5 surgical indications, there is another controversial
surgical indication, which is the mere presence of severe MR.
This is the only surgical indication in which there is disagree-
ment between the 2006 ACC/AHA guidelines (Class IIa:
ITAGAKI S et al.
Moderate
Mild to Moderate to Severe
moderate severe
Signs of MR >mild, but no criteria for • Vena contracta width ≥0.7 cm with
severe MR large central MR jet (area >40% of
LA) or with a wall-impinging jet of any
size
• Large flow convergence
• Systolic reversal in pulmonary veins
• Prominent flail leaflet or ruptured
papillary muscle
Signs of MR >mild, but no criteria for • Dense triangular continuous-wave
severe MR Doppler MR jet
• E-wave dominant mitral inflow (E
>1.2 m/s)
• Enlarged LV and LA size
30–44 45–59 ≥60
30–39 40–49 ≥50
20–29 30–39 ≥40
reasonable) and the 2007 European Society of Cardiology
(ESC) guidelines (Class IIb: may be considered). This is also
the only indication in which both guidelines specify a clear
cutoff of a successful repair rate >90%. For other indications,
although the guidelines stipulate a preference for repair, a de-
sired repair rate is not stated. Other factors such as risk strati-
fication, local logistics, and informed patient’s preference
should also be involved in the decision-making, but, notably,
the ACC/AHA guidelines stipulate the importance of “surgi-
cal centers experienced in performing MV repair” and strongly
encourage cardiologists to refer the asymptomatic patient to
these centers if none of the previously cited 5 indications are
present.
The ESC recently released revised guidelines and made
some significant changes.14 The detail of these changes will be
mentioned in the section on each conventional indication.
It should be emphasized that the ACC/AHA guidelines de-
fine not only the surgical indications but also the recommend-
ed surveillance before surgery. The guidelines recommend pe-
riodic surveillance, which is a combination of history, physical
examination, and echocardiography. The interval is annual for
moderate MR and becomes more frequent for moderate to
severe MR, which is every 6–12 months with the instruction
for the patient to promptly report symptoms. Although severe
MR is the only recommended trigger for surgery, this close
follow-up is also the guideline-recommended standard once
MR with moderate or more severity is diagnosed.
Interpretation of Landmark Studies
The surgical indications in the guidelines are predominantly
based on retrospective studies, either natural history study or
surgical series, published during the period when the surgical
techniques and expertise were still rapidly evolving and the
guidelines too were evolving. Also, existing data demonstrate
that, in real-world clinical practice, even in developed coun-
tries, the management of patients with degenerative mitral
disease is far from ideal. In fact, the data still show relatively
frequent valve replacement15,16 with high variability of repair
 Advance Publication by-J-STAGE
Surgical Triggers for Degenerative MR

Figure.    American College of Cardiology/American Heart Association (ACC/AHA) management algorithm for severe mitral regur-
gitation. *The likelihood of successful mitral valve repair is greater than 90%. MR, mitral regurgitation; AF, atrial fibrillation; Echo,
echocardiography; EF, ejection fraction; ESD, end-systolic dimension; HT, hypertension.

rate and outcomes between institutes.17 The data also suggest
suboptimal adherence to guidelines for surgical referral among
cardiologists and referring physicians.18–20 Therefore, when
interpreting the studies from which the guideline indications
for surgery were derived, one has to be cognizant of several
factors:
•  W ho was enrolled and excluded? (ie, etiology: degenera-
tive vs. other, and the prevalence of the 5 guideline surgi-
cal indications at the study enrollment)
•  How were patients followed during the period of “medi-
cal” management? (ie, the level of adherence to guide-
line-recommended follow-up)
•  Were patients promptly referred? (indicated by preva-
lence of patients without severe symptoms and relatively
preserved LV function)
•  Who operated in the surgical arm? (ie, the level of surgi-
cal expertise with repair rate and durability)
•  Source of studies (the majority of analysis on which
guidelines are based emanate from relatively few institu-
tions).
All these factors have a significant effect on the “natural” course
of the study cohort and, without close scrutiny, the result can
be potentially misleading.21
Symptoms: Class I Indication
In the current ACC/AHA guidelines, symptoms (defined as
New York Heart Association (NYHA) Class II, III, or IV) are
a Class I indication. The NYHA functional class is subjective,
but is widely used in clinical practice and research as an indi-
cator of symptoms. The guidelines cite a study,22 published in
1999 to support the validity of symptoms as a surgical indica-
tor. In that surgical study, patients with severe nonischemic
(degenerative 79%, rheumatic 8%, endocarditis 8%, and oth-
ers 4%) MR who underwent mitral surgery (repair in 72%)
were enrolled from 1984 to 1991. The enrolled patients were
divided into 2 groups based on their NYHA functional class
at surgery: Class I/II or Class III/IV. The Class I/II group had
 Advance Publication by-J-STAGE
excellent survival comparable to the expected survival, where-
as the Class III/IV group had worse survival than expected.
The presence of preoperative NYHA Class III/IV remained an
independent predictor of postoperative excess mortality in the
overall population after multivariate adjustment for confound-
ing factors such as age, LVEF and other comorbidities and
continued to be so in a subgroup analysis of patients who un-
derwent repair. These findings were subsequently validated by
several other studies.
LV Dysfunction: Class I Indication
LVEF is currently the most conventional and widely used pa-
rameter to describe LV function but, in the setting of severe
MR, LVEF does not necessarily reflect the actual LV function,
which is myocardial contractile capacity. This is because LVEF
is pre- and afterload-dependent and severe MR creates a fa-
vorable loading condition to help show apparently high LVEF
by increasing preload with regurgitant volume and reducing
afterload with backward ejection to the left atrium. In the set-
ting of severe MR, therefore, the interpretation of LVEF is not
straightforward and normal LVEF does not mean preserved
myocardial contractile capacity or forward (through aortic valve)
stroke volume, which are what matters. Another important
limitation on LVEF is that, although the ASE recommends
quantitative assessment of LVEF,23 it is still frequently visu-
ally estimated, making it not very clear whether the cutoff of
60% has an accurate basis.24 Nonetheless, LV dysfunction,
defined as LVEF with a cutoff ≤60%, is currently a Class I
indication.
The main criticism of the use of LVEF <60% as an indica-
tion for surgery is that once the LVEF is less than 60%, irre-
versible myocardial damage may have ensued and life expec-
tancy is compromised on a population level, independent of
successful mitral surgery. Patients with LVEF <60% have a
worse long-term survival after mitral valve surgery, compared
with those with normal ventricular function.25,26 Additionally,
the LVEF does not normalize in many patients, despite suc-
cessful mitral valve repair, up to 5 years post surgery.27
LV Enlargement: Class I Indication
LV enlargement, which is defined as LVESD ≥40 mm, is con-
sidered as a Class I indication. By 2006, the year in which the
current ACC/AHA guidelines were issued, there were only
studies with either a small cohort or mixed etiology available
to support the validity of LVESD as a surgical indication.25,28–30
This was reflected in the discordance of cutoff value for LVESD
between the US and European guidelines, ESC using 45 mm as
the cutoff in its 2007 guidelines.31
As in the case of LV dysfunction, the use of LV dilatation
as an indication for surgery has been recently challenged be-
cause there are data that suggest that once the LV is dilated,
irreversible myocardial damage has taken place and life ex-
pectancy will be compromised regardless of subsequent mitral
valve repair.32 The observational study by Tribouilloy et al
showed an independent, strong association between LVESD
≥40 mm and worse outcomes under medical management and
even after surgery after multivariate adjustment of other po-
tential prognostic factors (age, sex, symptoms, LVEF and AF).32
The result was the same in a subgroup analysis of patients free
of baseline Class I indication (symptoms or low LVEF). Many
now argue for intervention on severe MR prior to the onset of
LV dysfunction or dilatation.
Taking into account the result of that study, the 2012 re-
ITAGAKI S et al.
cently released ESC guidelines include the range of 40–45 mm
as a Class IIa indication, even in the absence of symptoms or
LV dysfunction, which was not considered a surgical trigger
in the previous 2007 guidelines. The Class I cutoff of 45 mm
remains.
Pulmonary Hypertension: Class IIa Indication
PHT, defined as PASP >50 mmHg at rest or >60 mmHg at
exercise, is a Class IIa indication by itself. Even in the absence
of symptoms and LV dysfunction, surgery is reasonable in the
presence of PHT. To support the validity of PHT as a surgical
indication, the guidelines cite a study published in 1990,33 which
dealt with 48 patients with MR and showed the association of
preoperative pulmonary pressure and postoperative LV func-
tion after MV replacement, so the validity and specific cutoff
of 50 mmHg has been more dependent on experts’ consensus
than on direct data. A recent 2011 study further investigated
PHT as a surgical indication.34 This observational study dem-
onstrated that by the time the patient developed PHT, currently
defined as PASP >50 mmHg, it was most likely the patient
already had other surgical indications as well. This raises the
question of the validity of the current cutoff of 50 mmHg.
Exercise PHT, defined as PASP >60 mmHg at exercise, is
also a Class IIa indication in the North American guidelines.
In Europe, exercise-induced PHT was not included in the 2007
guidelines, but is specified as a Class IIb indication in the lat-
est 2012 guidelines. Although there are no robust data avail-
able showing the direct association of exercise PHT and ad-
verse outcomes in patients with degenerative MR, one study35
investigated the incidence of exercise PHT in asymptomatic
patients with degenerative MR (severe in 60%, moderate in
40%) and its effect on the subsequent occurrence of symp-
toms. The prevalence of exercise PHT was detected in almost
half of the patients (46%) and strongly associated with the
subsequent development of symptoms. A cutoff of 56 mmHg
gave the best predictive power, concluding that the currently
recommended cutoff of >60 mmHg was reasonable. Although
that study focused on exercise PHT, it also gave an important
insight to resting PHT. In the study’s cohort, the prevalence of
resting PHT was only 15%. The true prevalence of resting PHT
could be even lower, considering the study only enrolled the
patients with measurable pulmonary artery pressures by Dop-
pler echocardiography. The study showed that although the
resting PHT was also associated with subsequent symptoms,
the best predictive cutoff was 36 mmHg, much lower than the
current cutoff of 50 mmHg. This finding suggests that less than
severe PHT could already be an early sign of decompensation,
and that the PASP rarely reaches as high as 50 mmHg without
the development of symptoms, LV dysfunction, or AF. Al-
though it is true that PHT is a common sequela of severe MR,
a lower cutoff for PHT definition may be reasonable for its use
as a surgical indicator. In fact, another study36 also showed the
association of PHT with a lower cutoff and subsequent occur-
rence of symptoms and LV dysfunction in a similar patient
cohort, supporting this proposal.
Atrial Fibrillation: Class IIa Indication
AF is the only objective indication for surgery that is based on
the presence or absence of a categorical factor. Other surgical
indications are based on an arbitrary cutoff of continuous pa-
rameters (LVEF, LVESD, and PASP) or the subjective pres-
ence of symptoms. AF has been shown to be a serious compli-
cation of MR and is associated with cardiac morbidity and
 Advance Publication by-J-STAGE
Surgical Triggers for Degenerative MR

Table 2.  Pros and Cons of Prophylactic Surgery and Watchful Waiting

Prophylactic surgery
Requirement • Highly predictable (>90%), durable repair (<5% resid-
ual mitral regurgitation) with very low operative
mortality (<1%)
 ros (especially if the
P • Potential long-term solution with prevention of cardiac
requirement is met) events secondary to severe mitral regurgitation
• Possible better preservation of life expectancy
 ons (especially if the
C • Small risk of operative mortality and morbidity
requirement is not met) • Risk of unwanted replacement with subsequent
higher risk of prosthesis related events
• Risk of recurrent mitral regurgitation and persistence
of same risk of cardiac events associated with mitral
regurgitation
Watchful waiting
• Regular and thorough echocardiographic and clinical
surveillance and prompt surgical referral once indi-
cated
• ≈50% will avoid surgery in the midterm (5–10 years)
• Risk of overlooking surgical indications and subse-
quent higher cardiac event rate
• Once surgical indication is met, long-term survival
may already be irreversibly compromised

mortality, especially related to thromboembolic events during
medical follow-up.37 Although sinus rhythm may be restored
using combined mitral valve repair and the maze procedure
with a variable success rate,38,39 the presence of preoperative
AF is independently associated with worse survival after mi-
tral valve repair.40 Preoperative AF and persistent or recurrent
AF after surgery are all closely related to left atrial (LA) size.
LA size is also related to new onset of AF after surgery in
patients with no prior history of AF at surgery. The new onset
of AF after surgery is also associated with adverse outcomes.41
This close relation of AF incidence and LA size and the more
profound effect of AF on the surgical outcome in the era of
mitral repair provides the rationale for investigating LA size
as a potential indication for surgical intervention. In fact, LA
size was for the first time incorporated into the guidelines in
Europe as a parameter for surgical indication.
Left Atrial Size
The LA size is known to be related to cardiac morbidity and
mortality.42 In recent years, there have been studies showing
the association between LA size and the outcomes in patients
with degenerative MR.43–46 Although LA volume as opposed
to diameter has been shown to be more powerful prognostic
indicator,44–46 LA diameter is more widely used in routine clin-
ical practice and research. In a study43 that enrolled patients
with degenerative MR in sinus rhythm at baseline, LA enlarge-
ment with LA diameter of 55 mm as the cutoff was associated
with increased mortality under medical management but not
after surgery, independent of Class I indication (symptoms,
LVEF, and LVESD). Although patients were in sinus rhythm
at enrollment, presumably subsequent AF incidence was fre-
quent in the LA enlargement group, partly accounting for the
adverse outcomes in this group. The effect of PASP was not
adjusted either and the correlation of PASP and LA size was
not given, so it is unclear whether LA size remained a signifi-
cant predictor of outcomes after adjustment for PASP. None-
theless, the study showed the possibility of LA size as a poten-
tial surgical indication, especially when measurable PASP is
not available. As mentioned, LA size is now another trigger
for surgical indication in the 2012 European guidelines: a vol-
ume index ≥60 ml/m2 is considered as a Class IIb indication
even in sinus rhythm. Although still Class IIb, LA size seems
to be a reasonable parameter to quantify and predict the risk
of subsequent AF before it actually occurs.
Other Potential Surgical Indicators
Besides LA size, newer surgical indicators have been proposed
with cumulative evidence, such as B-type natriuretic pep-
tide,47–49 exercise tolerance,50 and LV contraction reserve.51
Percutaneous Mitral Clip Procedure
The percutaneous mitral clip procedure52–54 is under investiga-
tion and currently not the treatment of choice for degenerative
(primary) MR. In the latest 2012 ESC guidelines, this proce-
dure may be considered (Class IIb) only for patients with symp-
tomatic, severe secondary MR despite optimal medical thera-
py who are judged inoperable or at high risk for surgery.
Prophylactic Surgery vs. Watchful Waiting
The appropriateness and timing of surgery for severe MR in
patients who do not have any of the 5 guideline-defined surgi-
cal indications (symptoms, LV dysfunction, LV dilatation, AF,
and PHT) remain controversial. The current ACC/AHA guide-
lines are in favor of prophylactic surgery for asymptomatic
severe MR (Class IIa indication), whereas the European guide-
lines remain in favor of watchful waiting (with asymptomatic
severe MR as a Class IIb indication for surgery). It is notable
that despite their different positions both guidelines clearly men-
tion the need for experienced centers with a successful repair
rate of at least 90% if prophylactic surgery is considered.
Both guidelines cite 2 landmark studies for this discussion.6,55
In the first study published in 2005,6 198 asymptomatic pa-
tients with severe degenerative MR were enrolled. They were
free of symptoms, but not necessarily of other currently agreed-
on indications, because LVEF >50% was included, 10% had
AF, and PASP was 42±13 mmHg at enrollment. The subse-
quent follow-up was done by the patients’ personal physicians
and the strategy was not clearly mentioned. Of 198, 163 (82%)
had surgery during the follow-up of 5 years (unclear if pro-
phylactic or indication-driven) and 35 (18%) were managed
solely medically. Overall 5-year survival of the 198 patients
was good at 85%, comparable to 86% of expected survival
from the general population, but the 5-year survival of the 35
solely medically managed patients was worse at 53%, com-
pared with the expected 78%.
In the second study published in 2006,55 132 asymptomatic
patients with severe degenerative MR were enrolled. The pa-
tients were free of symptoms and also other indications, re-
flecting the younger cohort than in the previous study. The
subsequent follow-up was predefined by a valve clinic, with
periodic close follow-up and referral to surgery if any 1 of the
5 surgical indications appeared. Of the 132 patients, 38 (29%)
had surgery during follow-up of 8 years (all indication-driven)
and 94 (71%) were managed solely medically. Overall, the
 Advance Publication by-J-STAGE
8-year survival of the 132 surgical patients was excellent at
91%, comparable to the expected survival from the general
population. Among the 94 solely medically managed patients,
there were 6 deaths (3 cardiac, 3 non-cardiac). Of the 3 car-
diac cases, 2 were patients who met the surgical indication but
refused surgery. Thus, the result of solely medically managed
patients seemed excellent under a watchful waiting strategy.
Although these studies provided important information on
the present discussion of management of patients free of surgi-
cal indications, the direct comparison of prophylactic surgery
and watchful waiting were not allowed because the strategy of
prophylactic surgery was not adopted in either study.
In 2009, another study,36 which was unique in that it ad-
opted a prophylactic surgery strategy and compared it with
watchful waiting strategy, was published. This study enrolled
447 patients with severe degenerative MR free of any surgical
indication. Unlike the previous 2 studies, the patients were as-
signed to 2 different strategies, seemingly based on physician
and patient preferences: early prophylactic surgery (n=161) and
watchful waiting (n=286). In the prophylactic surgery group,
7-year survival from cardiac death was 100%, although deaths
excluded as non-cardiac included strokes and infection, which
may be related to the surgery. In the watchful waiting group,
of the 286, 53 (19%) had surgery during the follow-up (all
indication-driven) and 233 (81%) were managed solely medi-
cally during the follow-up of 7 years. Of note, of 79 patients
who met the surgical indication, 28 presented with admission
to the hospital for chronic heart failure, raising the question of
the intensity of the follow-up routine. Nonetheless, the overall
7-year freedom rate from cardiac death in the 286 patients in
the watchful waiting group was excellent at 95% (the expected
survival was not given). Among the 233 solely medically man-
aged patients, there were 11 cardiac deaths, of which 6 were
patients who met the surgical indication but refused surgery.
Even though the authors focus on the superiority of early sur-
gery, these results do also represent a good result for watchful
waiting. Also, the prophylactic surgery group had an unusual
absence of midterm cardiac death, raising the question as to
whether these results would be replicated in other cohorts.
Prophylactic surgery is certainly a reasonable option, pro-
vided valve repair is highly predictable and durable. We would
argue that the repair rate should be near 100%, higher than rec-
ommended in the guidelines, if prophylactic surgery is per-
formed, because this patient group is otherwise relatively healthy
and young and also valve replacement places them at risk of
prosthesis-related complications. Medical follow-up may also
have reasonable outcomes with vigilant watchful waiting,56
but with this strategy there must be awareness that life expec-
tancy for some patients can be compromised if they develop
guideline indications. The pros and cons of each strategy are
summarized in Table 2.
The decision-making process should be an integrated ap-
proach, involving the risk stratification of the patients (age,
comorbidities, and capability of adhering to guideline-recom-
mended follow-up) and the patient’s preference after being given
all relevant information regarding the natural history, surgical
expertise at the center, and benefits/risks of surgery.
Conclusions
The 2006 ACC/AHA guidelines specify 5 surgical indications:
symptoms, LV dysfunction, LV enlargement, PHT, and new
onset AF. The validity of severe MR in and of itself as a surgi-
cal indication is still controversial and other potential indica-
tors are under investigation. These discussions are only mean-
ITAGAKI S et al.
ingful when medical surveillance before surgery is vigilant and
other currently agreed-on surgical indications are well under-
stood and work as an actual trigger for surgery. The real-world
current clinical practice, however, remains suboptimal for many
patients, so all practicing cardiovascular specialists should be
familiar with the current guidelines for management.
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