Early Surgery Is Recommended for Mitral Regurgitation
2010; Lippincott Williams & Wilkins; Volume: 121; Issue: 6 Linguagem: Inglês
10.1161/circulationaha.109.868083
ISSN1524-4539
AutoresMaurice Enriquez‐Sarano, Thoralf M. Sundt,
Tópico(s)Cardiac Structural Anomalies and Repair
ResumoHomeCirculationVol. 121, No. 6Early Surgery Is Recommended for Mitral Regurgitation Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessArticle CommentaryPDF/EPUBEarly Surgery Is Recommended for Mitral Regurgitation Maurice Enriquez-Sarano, MD and Thoralf M. SundtIII, MD Maurice Enriquez-SaranoMaurice Enriquez-Sarano From the Divisions of Cardiovascular Diseases and Internal Medicine (M.E.-S.) and Cardiac Surgery (T.M.S.), Mayo Clinic, Rochester, Minn. and Thoralf M. SundtIIIThoralf M. SundtIII From the Divisions of Cardiovascular Diseases and Internal Medicine (M.E.-S.) and Cardiac Surgery (T.M.S.), Mayo Clinic, Rochester, Minn. Originally published16 Feb 2010https://doi.org/10.1161/CIRCULATIONAHA.109.868083Circulation. 2010;121:804–812Mitral regurgitation (MR), the systolic flow reversal from the left ventricle to the left atrium, is currently the most frequent valvular heart disease.1 Because MR affects predominantly patients ≥65 years of age,1 with age at surgery most often in the sixth decade,2 the observed prevalence will increase with the aging of the population. Thus, the number of US citizens affected by moderate or severe MR will almost double between 2000 and 2030, reaching almost 5 million by then.1 MR mechanism is classified as organic (intrinsic valve lesions) or functional (structurally normal mitral valve with MR caused by ventricular dysfunction).3 Indications of mitral surgery, the only current approved treatment of MR, are disputed because large clinical trials in MR have not been reported and outcome studies provide the best evidence available but require careful interpretation. The benefit of surgery is uncertain in functional MR and is not addressed here.4 However, we illustrate here that overwhelmingly coherent cumulative evidence obtained worldwide shows that early surgery should be the preferred management approach for organic MR. This approach differs from standard guidelines, and it is essential that its principles, rationales, and conduct be fully considered.Response by Gillam and Schwartz see p 804Principles Guiding Early Surgery in Organic MRGuidelines for the management of valve diseases mention class I versus class II indications as having agreed-on versus conflicting evidence/opinions.5 This classification is problematic for MR treatment because class I indications, based mostly on symptoms and overt left ventricular (LV) dysfunction, lead to the performance of rescue surgery (surgery for patients at considerable risk if unoperated) but do not result in optimal long-term outcomes for patients with organic MR.6,7 The concept of uniform surgical recommendations that supposedly apply equally to all centers is also problematic; recent studies have shown that the quality of surgical outcomes in MR is heterogeneous.8 Thus, the standard guideline framework of treatment indications, generalizable for medical therapies such as statins or aspirin, is not applicable to surgical treatment of valve diseases, particularly MR.Data-driven principles that should guide surgical indications in organic MR are as follows. First, rescue surgery for defined symptoms or overt LV dysfunction is necessary9 but not desirable, and early surgery in patients without such characteristics provides the best long-term outcomes.6 Second, advanced repair centers with highly skilled teams (surgeon, cardiologists, echocardiographers, anesthesiologists, nursing team) and proven results are optimal for conducting early surgery.8,10 With this framework in mind, all decisions should be individualized to parameters characterizing the MR but also to comprehensive patient descriptors, particularly age, comorbidity, and personal aspirations.Rationales for Early SurgeryRationale 1: In Patients With Organic MR, Surgery Is Almost UnavoidableThe advent of reliable Doppler echocardiographic diagnosis of mitral valve disease allowed the clinical outcome of patients with MR to be defined. In studies of patients in their 50s at diagnosis, rates of surgical indications were reported to be between ≈7% and 10% per year.11,12 Larger studies of patients in their 60s at diagnosis of severe organic MR measured rates of death or cardiac surgery ranging from 10%,13 to 18%9 to 22%14 and 30%15 per year. With an average of ≈20% per year, 10 years after diagnosis, 90% of patients either are dead or have undergone surgery. Thus, only a small fraction of patients may remain alive and not operated on long term after diagnosis of severe organic MR. Hence, the question in both young or older patients is not "if" but "when" surgery should be performed: under duress from the disease or preemptively to minimize risk and normalize life expectancy.Rationale 2: Class I Indications of Mitral Surgery Are Associated With Dire Outcome ConsequencesClass I indications for isolated organic MR are for symptomatic patients or those with an ejection fraction (EF) ≤60% or LV end-systolic dimension ≥40 mm.5 Although it is satisfying to relieve symptoms by surgery, this approach implies considerable risk6 with markedly higher operative and late postoperative mortality, resulting overall in an 80% increase in mortality after surgery compared with those with no or minimal symptoms.6 The observation, confirmed in various centers,16,17 that excess mortality (versus expected survival) is observed after surgery in patients who had preoperative symptoms despite the symptomatic relief provided by the surgery contrasts with the restoration of life expectancy in patients with no or minimal symptoms preoperatively (Figure 1).6,16 Similarly, patients who undergo surgery because their EF has declined to <60% do not incur excess operative mortality, but late mortality is increased by 180% with EF <50% and by 80% with EF of 50% to 59% (Figure 1).7 The association of reduced preoperative EF with excess postoperative mortality has also been confirmed independently,18–20 and its association with postoperative LV dysfunction persists in the era of valve repair.21 Thus, MR surgery with either of these class I indications rescues patients from risks imposed by symptoms and low EF under medical management but is followed by considerable residual excess mortality. New data on long-term survival according to LV end-systolic dimension suggest similar excess postoperative mortality associated with end-systolic LV diameter ≥40 mm.22 Thus, rescue surgery for any class I indication is associated with excess postoperative mortality and cannot be the preferred surgical indication in organic MR. Download figureDownload PowerPointFigure 1. Excess postoperative mortality after mitral surgery affecting patients operated on for symptoms or low EF. A and B, Observed postoperative survival (solid line) compared to expected survival (dashed line) for the specific subgroup of patients with no or minimal (class II) symptoms (A) or severe (class III or IV) symptoms (B) (both reprinted from Tribouilloy C, Enriquez-Sarano M, Schaff H, Orszulak T, Bailey K, Tajik A, Frye R. Impact of preoperative symptoms on survival after surgical correction of organic mitral regurgitation: rationale for optimizing surgical indications. Circulation. 1999;99:400–405 with permission of the publisher. Copyright © 1999, the American Heart Association). After surgery for severe symptoms, survival remains lower than the expected survival (74% of expected at 10 years), whereas after surgery, in class I or II, survival is identical to that expected (104% of expected at 10 years). Thus, excess mortality persists after surgery in patients operated on with severe symptoms, whereas life expectancy is restored in patients with no or minimal symptoms. C, Echocardiographic prediction of survival after surgical correction of organic MR showing postoperative survival according to preoperative EF (reprinted from Enriquez-Sarano M, Tajik A, Schaff H, Orszulak T, Bailey K, Frye R. Echocardiographic prediction of survival after surgical correction of organic mitral regurgitation. Circulation. 1994;90:830–837 with permission of the publisher. Copyright © 1994, the American Heart Association). The patients with EF ≥60% display the best survival, whereas patients with EF <50% and even those with EF 50% to 59% display markedly reduced postoperative survival. Thus, mitral surgery for patients with EF <60% results in excess postoperative mortality.Rationale 3: Restorative Surgery Is Possible in Most Patients With Organic MR in Western CountriesRestorative surgery is based on indications associated with postoperative restoration of life expectancy and morbidity risk.6,15 Patients with no or minimal symptoms before surgery display postoperative survival identical to that of the general population, even with operative mortality of 0.5% to 1% accounted for.6,15,16 Similarly, long-term postoperative survival of patients with EF ≥60% rejoins that of the general population.7 Thus, early surgery (no or minimal symptoms and EF ≥60%) suppresses the mortality of MR and restores it to that of persons of similar age and sex who never had MR and never had cardiac surgery. This statement is true in a setting in which most surgeries are valve repairs14 because valve replacement in general is associated with much higher postoperative mortality than after repair.23 Repair is highly feasible regardless of age24 because most organic MR in the Western world is degenerative with mitral valve prolapse (type 2 of Carpentier). Valve repair is now associated with minimal operative mortality (close to 0%) in the context of early surgery.11 Valve repair also provides survival superior to valve replacement2,25,26 regardless of the type of prolapse (anterior versus posterior prolapse),27 preserves the normal valvular-ventricular interaction and results in better LV function,23 is associated with less postoperative heart failure,23 and after the initial ≈1.5% stroke risk of the first 30 days, restores the risk of stroke to that of the general population.28 These major benefits were confirmed by a meta-analysis based on worldwide data.26Progress in the technique of valve repair, with decreased use of chordal shortening and increased valvular resuspension by use of artificial chords or chordal transfer, with consistent use of annuloplasty rings and increased use of intraoperative transesophageal echocardiographic to evaluate the adequacy of repair, has resulted in higher feasibility of repair and reduction of reoperation needs.27,29 It is undeniable that the clinical practice of valve repair is globally insufficient and heterogeneous, with high-volume centers providing higher repair rates and lower operative mortality than low-volume centers.8 Some centers report notable rates of residual or recurrent MR,30 but in large mitral repair centers, recurrence of MR20 and mitral reoperation rates are low,2,20,29 between 5% and 10% at 10 years (lower than bioprostheses and equal to mechanical valves),2 and rerepairs can be performed with good outcomes.31 Furthermore, in large repair centers, repair rates ≥90% are achieved in most organic MR, particularly degenerative MR.2,24,32 Whether minimally invasive mitral surgery, thoracoscopic or robotic, affects risk, discomfort, and durability of valve repair is uncertain.33,34 However, this issue is not relevant to the need for early surgical repair for organic MR. Thus, advanced repair centers offer services, high repair rates, high quality of repair, and low operative risk, which allow restorative early mitral surgery.Rationale 4: Organic MR Is a Condition With Serious Outcome ConsequencesOutcomes of Organic MR as a WholeUnder medical management, patients with MR resulting from flail mitral leaflets display excess mortality compared with the general population,9 representing the ultimate definition of a severe condition (Figure 2). In addition, in patients with no specific risk factors besides the organic MR, we observed a sudden death rate of 0.8% per year,35 which, although not considerable, is approximately double the spontaneous risk in the general population. This observation was contested by a prospective study conducted in Austria, which noted low mortality.12 However, in that small study, patients were young (by 5 to 10 years compared with other MR series)9,14,15,27,36,37 and displayed smaller end-diastolic LV diameter than other organic MR studies (by 5 to 6 mm for valve prolapse2,27 and by 4 mm/m2 for flail leaflets9), consistent with moderate rather than uniformly severe MR.9,13,15 Other evidence suggests that severe organic MR is indeed associated with excess mortality. In a geographically defined community, in which referral biases were minimized, asymptomatic patients with mitral prolapse incurred excess mortality directly related to the severity of MR.36 In addition, in a large prospective study of quantified organic MR, patients with large effective regurgitant orifice (ERO; ≥40 mm2), affirming MR severity, had excess mortality15 compared with the general population and with patients with a lesser degree of MR (Figure 2). A recent analysis integrating all modern "natural history" studies shows that patients with moderate to severe MR incur ≈3% per year mortality compared with 6% for severe MR.3 Additionally, all studies show high rates of cardiac events (cardiac death, heart failure, atrial fibrillation), which in severe MR approximate 10% per year.15,36,38,39 Thus, comprehensive examination of the literature shows that severe MR is associated with excess mortality and high morbidity. Consequently, it is essential that we define the patients at high risk who may benefit most from early surgery. Download figureDownload PowerPointFigure 2. Reduced survival under medical management associated with severe MR. The 3 panels are from 3 different studies of various mitral valve diseases. A, Patients diagnosed with MR caused by flail leaflets incur under medical management excess mortality, with observed survival (dotted line) lower than expected survival (solid line) (reprinted from Ling H, Enriquez-Sarano M, Seward J, Tajik A, Schaff H, Bailey K, Frye R. Clinical outcome of mitral regurgitation due to flail leaflets. N Eng J Med. 1996;335:1417–1423 with permission of the publisher. Copyright © 1999, Massachusetts Medical Society. All rights reserved). B, Results from the only available study36 of mitral valve disease in the community (ie, without the biases of referral series). The study focused on asymptomatic patients with mitral valve prolapse (MVP) and various degrees of MR and observed that moderate or severe MR and EF ≤50% were risk factors for mortality. The lower solid thin curve represents patients with either of these factors, including moderate or severe MR in 86% of cases, and shows that patients with either of these characteristics incur excess mortality compared with patients with less severe or no MR (dotted line shows those with minor risk factors; solid thick line, without minor risk factors) and denoted by P(Dif) as the P value between these curves and compared with expected survival, by P(exp) as the P value. Thus, patients with asymptomatic MVP and moderate or severe MR incur excess mortality (reprinted from Avierinos JF, Gersh BJ, Melton LJ III, Bailey KR, Shub C, Nishimura RA, Tajik AJ, Enriquez-Sarano M. Natural history of asymptomatic mitral valve prolapse in the community. Circulation. 2002;106:1355–1361 with permission of the publisher. Copyright © 2002, the American Heart Association). C, Results from a prospective study of the effect of quantitative assessment of MR on outcome. In that study, the ERO was predictive of mortality independently of age and, when ≥40 mm2 (solid thin line), was associated with excess mortality compared with expected mortality and survival of patients with less severe MR (reprinted from Enriquez-Sarano M, Avierinos JF, Messika-Zeitoun D, Detaint D, Capps M, Nkomo V, Scott C, Schaff HV, Tajik AJ. Quantitative determinants of the outcome of asymptomatic mitral regurgitation. N Engl J Med. 2005;352:875–883 with permission of the publisher. Copyright © 2005, Massachusetts Medical Society. All rights reserved).Traditional MarkersTraditional markers (symptoms, LV characteristics) are poor markers of outcome. Studies conducted in the United States and Europe showed that in patients with severe symptoms, surgery is often delayed or denied,9,40,41 leading to subsequent high mortality. Furthermore, symptoms and EF <60%, although associated with high rates of sudden death, detect only a minority of patients who incur this devastating complication, demonstrating their insensitivity.35 Thus, these traditional markers should lead to prompt rescue surgery, but more sensitive markers of risk under medical management are warranted.New Markers of OutcomeNew markers of outcome have been recently described that require more in-depth assessment but are important in the consideration of early surgery: Atrial fibrillation, although known as a traditional complication of MR, is currently not mentioned as a class I indication for surgery.5 However, in organic MR, it is frequent and is associated with excess subsequent mortality under medical management (Figure 3).42 Thus, atrial fibrillation should be considered a formal indication for surgery in organic MR. Atrial fibrillation is caused and predicted by left atrial enlargement,42,43 the role of which in predicting outcome and in defining timing of surgery should be further investigated. The long-term postoperative consequences of preoperative atrial fibrillation are not well defined, and whether surgery performed for atrial fibrillation is "early" or "rescue" surgery is a matter of semantics. The essential clinical point is that the link between MR and arrhythmia should be established and surgery should be promptly considered. Download figureDownload PowerPoint Figure 3. Nontraditional risk markers under medical management in organic MR. Left, Survival after diagnosis; right, cardiac events after diagnosis according to specific risk factors. A, Long-term survival under medical management in patients with flail leaflets in sinus rhythm at diagnosis according to maintenance of sinus rhythm (solid line) or development of atrial fibrillation (AF; dashed line), permanent or paroxysmal, which increases mortality markedly (reprinted from Grigioni F, Avierinos JF, Ling LH, Scott CG, Bailey KR, Tajik AJ, Frye RL, Enriquez-Sarano M. Atrial fibrillation complicating the course of degenerative mitral regurgitation: determinants and long-term outcome. J Am Coll Cardiol. 2002;40:84–92 with permission of the publisher. Copyright © 2002, the American College of Cardiology). B, Survival after diagnosis of organic MR according to the absence (solid line) or presence (dotted line) of B-type natriuretic peptide (BNP) activation, which is associated with independent excess mortality (reprinted from Detaint D, Messika-Zeitoun D, Avierinos JF, Scott C, Chen H, Burnett JC Jr, Enriquez-Sarano M. B-type natriuretic peptide in organic mitral regurgitation: determinants and impact on outcome. Circulation. 2005;111:2391–2397 with permission of the publisher. Copyright © 2005, the American Heart Association). C, High cardiac event rates associated with an ERO ≥40 mm2. In the same study, an ERO ≥40 mm2 was also predictive of mortality (reprinted from Enriquez-Sarano M, Avierinos JF, Messika-Zeitoun D, Detaint D, Capps M, Nkomo V, Scott C, Schaff HV, Tajik AJ. Quantitative determinants of the outcome of asymptomatic mitral regurgitation. N Engl J Med. 2005;352:875–883 with permission of the publisher. Copyright © 2005, Massachusetts Medical Society. All rights reserved). D, Higher cardiac event rates in asymptomatic patients who at diagnosis have a reduced functional capacity by cardiopulmonary exercise testing (reprinted from Messika-Zeitoun D, Johnson BD, Nkomo V, Avierinos JF, Allison TG, Scott C, Tajik AJ, Enriquez-Sarano M. Cardiopulmonary exercise testing determination of functional capacity in mitral regurgitation: physiologic and outcome implications. J Am Coll Cardiol. 2006;47:2521–2527 with permission of the publisher. Copyright © 2006, the American College of Cardiology). F-U indicates follow-up.The severity of MR is a major predictor of outcome in patients with mitral valve prolapse36 and organic MR in general.15 Recent guidelines emphasize the need for comprehensive assessment not limited to jet size assessment.44 Furthermore, echocardiographic laboratories are encouraged to become proficient in MR quantification to measure regurgitant volume as a marker of volume overload and ERO as a marker of lesion severity. Multiple methods are available that allow quantitative assessment of organic MR under most clinical circumstances, and quality control allowing reliable data to be obtained is relatively simple.44 Quantitative assessment defines progression of MR, which color-flow imaging does not detect well.45 ERO ≥40 mm2 is associated with approximate doubling of the mortality risk (Figure 2) and quadrupling of the risk of cardiac events (Figure 3), superseding jet-based measures and marking risk of excess mortality compared with expected survival.15 With an ERO of 20 to 39 mm2, long-term progression is associated with worsening of outcome, but for the first few years, risk is low,15 allowing monitoring of progression under medical management. The association of ERO with subsequent cardiac events was confirmed independently.11,37,39Hormonal activation with B-type natriuretic peptide elevation is determined by the consequences (atrial and ventricular) of the MR and not by its severity. Hormonal activation is a marker of excess risk under medical management (Figure 3).46 This observation has recently been independently confirmed,37 so hormonal activation should alert clinicians about subsequent risk under medical management.Functional capacity can be assessed through the use of cardiopulmonary exercise with oxygen consumption measurement. Marked reduction of functional capacity (<84% of expected for age and sex) is frequent and unexpected, affecting 20% of asymptomatic patients with severe MR.47 Event-free survival is lower in patients who present with reduced functional capacity than in those with normal exercise capacity (Figure 3).47 Other indexes such as pulmonary pressure or left atrial volume are intuitively attractive but are not yet established enough relative to outcome implications and need further outcome studies. Hence, there are markers of serious outcome under medical management that allow the detection of patients at notable risk and the performance of restorative surgery that reestablishes the life expectancy of patients with organic MR.Rationale 5: No Alternative Treatment of Organic MR Is EstablishedMedical treatment with angiotensin blockade has some promise in stabilizing organic MR,48 and β-blockade has an interesting experimental suggestion of ventricular protection,49 but these currently are not alternatives to surgery. Treatment of MR by percutaneous clipping of the 2 leaflets, analogous to the surgical stitch proposed by Alfieri, is currently under investigation50 but will apply, if successful, to a minority of bileaflet prolapse with persistent coaptation. Although investigation of other potential therapies for MR should proceed, there are no currently approved alternatives to mitral surgery for organic MR.Rationale 6: Comparative Studies Favor Early SurgeryRandomized clinical trials are not the only way to compare therapy and are not available for all existing therapies. The benefit of surgery compared with medical management can be estimated by comparisons of patients treated a priori by early surgery or conservative management or can be estimated with a time-dependent approach that judges the risk reduction for surgery whenever it is performed. These studies, summarized in the Table, concur in demonstrating that mitral surgery markedly reduces mortality and morbidity in patients with severe organic MR defined by a specific anatomic feature—flail leaflet—or by quantitative assessment.11,14,15,51 The magnitude of risk reduction was considerable whether analyzed by direct comparison (Figure 4)11,51 or by time-dependent method.14,15 Short of a randomized clinical trial, coherent and considerable risk reductions show that early surgery is indeed the preferred approach to severe organic MR. Download figureDownload PowerPointFigure 4. Direct comparison favors early surgical management of organic MR. A, Among patients diagnosed with MR resulting from flail leaflet and all surgical candidates, better long-term survival was seen in patients treated by early surgery vs patients initially treated conservatively with the plan of proceeding to surgery if required later (reprinted from Ling L, Enriquez-Sarano M, Seward J, Orszulack T, Schaff H, Bailey K, Tajik A, Frye R. Early surgery in patients with mitral regurgitation due to partial flail leaflet: a long-term outcome study. Circulation. 1997;96:1819–1825 with permission of the publisher. Copyright © 1997, the American Heart Association). B, Among young patients in whom the severity of MR was prospectively defined by quantitative assessment, those treated by early surgery incurred much lower rates of cardiovascular events during follow-up than patients treated conservatively with the plan of proceeding to surgery if required later (reprinted from Kang DH, Kim JH, Rim JH, Kim MJ, Yun SC, Song JM, Song H, Choi KJ, Song JK, Lee JW. Comparison of early surgery versus conventional treatment in asymptomatic severe mitral regurgitation. Circulation. 2009;119:797–804 with permission of the publisher. Copyright © 2009, the American Heart Association).Conduct of Early Surgery for Organic MRIn view of overwhelmingly coherent data obtained worldwide, we consider early surgery the preferred option for treatment of organic MR, and patients' evaluations focus on gathering information critical to offering this option. Table. Studies Reporting Direct Comparison Between Medical and Surgical ManagementStudyStudy TypeCenterAnalysisnAge, yOutcomesOutcome With SurgeryCHF indicates congestive heart failure; CVD, cardiovascular death; and RR, risk ratio associated with surgical management. RRs <1.0 indicate risk reduction by surgical management (values in parentheses are the 95% confidence intervals). Event rates are presented for surgical vs medical management. Analysis by direct comparison defines outcomes with surgical and medical management according to the decision made at diagnosis. Analysis using surgery as a time-dependent variable defines the change in risk provided by surgery after it is performed compared with the risk under medical management after diagnosis.Ling et al,52 1997Retrospective; flail leafletsSingle, USDirect comparison22165Survival CHF79% vs 65% at 10 y, RR=0.31; 27% vs 59% at 10 y, RR=0.38Kang et al,11 2009Prospective; quantified MRSingle, KoreaDirect comparison44750Event-free survival99% vs 85% at 7 yEnriquez-Sarano et al,15 2005Prospective; quantified MRSingle, USTime dependent45663Survival CHFRR=0.28 (0.14–0.55); RR=0.37 (0.17–0.79)Grigioni et al,14 2008Retrospective; flail leafletsMulticenter, EuropeTime dependent39464Survival CVD/CHFRR=0.42 (0.21–0.84); RR=0.26 (0.08–0.89)Process of Evaluation for Early SurgeryProcess 1: Precisely Characterize the Patient's StatusThis involves standard assessment of age, comorbidity and associated non–mitral valve diseases. It also involves assessment of valve reparability (cause, mechanism, and calcification of lesions), of MR severity (at best by comprehensive assessment that includes multimethod MR quantification), and of the severity of MR consequences (symptoms, signs of heart failure, atrial fibrillation, LV dimensions and EF, left atrial enlargement, pulmonary pressure, hormonal activation, functional capacity by exercise testing). This assessment requires blood tests, ECG, chest radiography, transthoracic echocardiography, and often exercise testing. Transesophageal echocardiography and LV angiogram are rarely necessary for decision making. Assessment of associated coronary disease is made usually once the surgical decision is reached.Process 2: Consider the Repair CenterThe level of services of the repair center considered for the specific patient should be characterized, focusing on operative mortality, repair feasibility, and durability for the lesions described by echocardiography.Process 3: Patient ParticipationPatient participation in the decision is essential. Factual description of the patient's status, risks, and repair possibility should be obtained, and the patient's aspirations and point of view should be discussed.Specific Management of Organic MRRescue SurgeryPatients with symptoms attributable to MR, EF 84% of expected for age), no hormonal activation, and ERO <40 mm2 can be followed up, but many will in time require surgery. The intensity of follow-up depends on the severity of MR and consequences.Early SurgeryPatients with organic MR with no symptoms and with an EF ≥60% should be considered for early surgery if the valve is reparable in the presence of strong predictors such as an ERO ≥40 mm2 or atrial fibrillation (even paroxysmal) resulting from MR. Other indicators suggestive that early surgery is warranted are end-systolic LV dimension of 36 to 39 mm,22 hormonal activation (B-type natriuretic peptide), or reduced functional capacity. Future studies should add to the list of these markers. Early surgery consid
Referência(s)