People with damaged mitral valves, which allow blood to flow backward in the heart, live longer and healthier lives if they get immediate surgery to repair a severe defect rather than wait for symptoms to appear.
For decades, patients have delayed surgery with the goal of avoiding the operation’s dangers because the heart can often compensate and the risk of an operation was substantial. Today’s study published in the Journal of the American Medical Association shows the reasons for delaying are no longer true.
Getting the operation within three months boosts survival by 45 percent over a decade for those with valve regurgitation that hasn’t caused symptoms, the study found. The safety and success rates for surgical repair have risen dramatically in the past decade, said Rakesh Suri, a cardiovascular surgeon at the Mayo Clinic in Rochester, Minnesota.
“When the patient does develop severe regurgitation, at time zero of diagnosis, the clock begins ticking,” said Suri, the lead author of the study. “If we can relieve the strained heart muscle within a few months, we know it will last longer.”
The problem can be spotted initially during a routine physical exam, when a doctor detects a heart murmur. The condition at first may be mild and slowly progress.
More than 2 million people in the U.S. have mitral valve regurgitation, and the number with moderate to severe disease is expected to reach almost 5 million by 2030. While surgery can be performed to repair the damaged valve, companies including Medtronic Inc., Edwards Lifesciences Corp., Abbott Laboratories and St. Jude Medical Inc. make prosthetic devices.
The researchers analyzed data from 1,021 patients with severe regurgitation in the mitral valve, which lies between the left atrium and the left ventricle, the heart’s main pumping chamber. The patients didn’t yet have symptoms of the defect, such as shortness of breath, chest pain or irregular heartbeats.
After a decade, 86 percent of those treated within three months of diagnosis were still alive, compared with 69 percent of those who were initially monitored to see if the condition worsened. They were also markedly less likely to develop heart failure, which occurred in 7 percent of those getting immediate surgery and 23 percent of those who delayed.
There was no difference in the development of atrial fibrillation, an erratic heart rate that can lead to stroke.
“If a patient has severe leakage, it’s no longer something that should be managed in a silo,” Suri said in a telephone interview. “The warning bells should be sounded and these patients should be referred to heart valve centers.”
Timing may be critical. Of those who delayed surgery, 59 percent subsequently had an operation, a median of 1.7 years after the initial diagnosis.
While early surgery is reasonable for those with low risk and a high probability of success, the choice is less clear in those with medical conditions or other factors that could make the operation less successful, said Catherine Otto, a cardiologist at the University of Washington’s School of Medicine in Seattle.
“Although the majority of these patients will develop clear indications for valve surgery within two years, it may be reasonable to postpone the risks of having an intervention and having a prosthetic valve as long as possible,” she wrote in an editorial accompanying the study.