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Valve Surgery: Sooner Is Better

Heart Operation Aids Survival Even for Symptom-Free Patients, Study Says

By January W. Payne
Washington Post Staff Writer
Tuesday, March 15, 2005; Page HE01

People with severe mitral valve regurgitation -- often diagnosed after doctors hear a heart murmur during routine exams -- should consider surgery even if they don't have symptoms, finds a study in the March 3 New England Journal of Medicine.

This advice, if translated into medical practice, could result in more aggressive diagnostic screening and tens of thousands of preventive heart surgeries a year.

Mitral Valve Regurgitation
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The study results, said James Gammie, a cardiac surgeon at the University of Maryland Medical Center, show that for those with severe regurgitation, which mostly affects adults over 55, "it's almost inevitable that within five years you're going to have heart surgery or be dead. . . . A lot of [patients] were just followed, and a lot of those people died. That's the big story. Those people need surgery."

Moderate-to-severe mitral valve regurgitation affects 2 million to 2.7 million Americans, said the study's lead author, Maurice Enriquez-Sarano, a cardiologist and director of the Valvular Heart Diseases Center at the Mayo Clinic in Rochester, Minn. That number is expected to rise to 3.8 million to 4.8 million by 2030 as the population ages. The prospective study is the first to analyze and compare patient outcomes for those treated surgically and nonsurgically.

Mitral valve regurgitation is a progressive condition in which the mitral valve, which separates the upper and lower left chambers of the heart, doesn't close properly, causing some blood to leak back into the upper chamber. People with a defective valve may experience fatigue, exhaustion, lightheadedness, heart palpitations, cough and shortness of breath -- or may go for years without any symptoms.

"It is very difficult to make a decision on what to do for these [asymptomatic] patients," Enriquez-Sarano said. The general practice has been to adopt a wait-and-see approach because it was not known how the risks of the condition at this stage stacked up against the risks of surgery.

The study's results show that "mitral [valve] regurgitation is a serious problem and should be taken seriously. The predictor of outcome is how much leakage there is," rather than whether there are currently symptoms, said Enriquez-Sarano.

The research, conducted by the Mayo Clinic from 1991 to 2000 and funded by the American Heart Association and the National Institutes of Health, followed 456 patients, slightly more than half of whom had surgery. The study grouped patients by severity of mitral valve leakage, classifying them as mild, moderate or severe, according to the volume of blood backwashing into the upper chamber. Sixty-three percent of participants were men; their average age was 63.

Findings showed that patients with the most severe regurgitation who did not receive surgery to repair or replace their leaky valves had a five-year survival rate of 58 percent -- 20 percentage points lower than would ordinarily be predicted for people that age. Similar patients who had surgery had survival rates of 78 percent -- equal to that of the general population.

Through surgery, doctors are "taking the disease out of your body. There are so few diseases where you can do that, [and the others] usually don't restore life expectancy," Enriquez-Sarano said.

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