Prompt Surgery May Be Best for Heart Valve Leak
Study findings challenge policy of 'watchful waiting' for people with mitral valve regurgitation
Tuesday, August 13, 2013
Doctors usually employ a strategy of "watchful waiting" when treating healthy people who have mitral valve regurgitation, which is backflow leakage through the valve that separates the two chambers on the left side of the heart.
"Traditionally, physicians are very reluctant to send patients for surgery, particularly for major operations like open heart surgery," said Dr. Robert Boova, chief of cardiovascular surgery at Jeanes Hospital in Philadelphia. "If they have minimal or no symptoms, physicians don't recommend surgery for them."
However, a 25-year Mayo Clinic study of more than 1,000 heart valve patients has determined that prompt repair of the heart valve can drastically improve survival rates. The findings are published Aug. 14 in the Journal of the American Medical Association.
Patients without symptoms who received early repair of their leaking heart valve had a 60 percent reduced risk of heart failure, and their five-year mortality rate improved by about half, the researchers found.
"We didn't expect the differences to be that striking," said Dr. Rakesh Suri of the Mayo Clinic College of Medicine in Rochester, Minn. "We were rather shocked to see they were."
The study followed 1,021 patients with mitral regurgitation who did not have symptoms of heart failure. Doctors placed 575 patients on "watchful waiting," while 446 underwent mitral valve surgery within three months of detection.
The 10-year survival rate of people who had surgery was 86 percent, compared to 69 percent for people who did not get immediate surgery. The risk of heart failure also was lower -- a 7 percent risk for those with early surgery versus 23 percent for those placed on observation.
The mitral valve leak is doing damage to the heart even if patients aren't showing typical symptoms such as fatigue or shortness of breath, Suri said. The leak forces the heart to pump harder to circulate blood throughout the body, setting the stage for heart disease and high blood pressure.
"There really is no safe period to watchfully wait," he said. "Once patients have severe leakage, it's like having chest pain when you're having a heart attack. We need to act now."
Dr. Mariell Jessup, president of the American Heart Association, said the Mayo study could prompt a change in the guidelines doctors use to determine when heart surgery is necessary.
"People will certainly have to look at this large study and the lessons learned from it and take it into consideration when they're updating the valvular guidelines," said Jessup, a cardiologist and professor of medicine at the University of Pennsylvania.
Suri said people who have a heart murmur should talk with their doctor about getting an echocardiogram, which can detect heart valve leakage.
If leakage is detected, the patient needs to seek out a cardiologist and a medical center with experience in repairing heart valves, he said.
"In the current era, it's 95 percent to 99 percent likely we'll be able to save that valve using their very own tissue," Suri said.
It is very important that patients seek out a top-notch heart center, Jessup said. Although heart valve surgery has improved dramatically over the years, it is still a complex procedure that must be performed by an expert.
"Just because the study says to go ahead and do it, don't have it done at a local hospital," Jessup said. "This is not routine surgery. It should be done in the hands of a surgeon who does this a lot."
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