Rethinking Mitral Valve Surgery During the Golden Years

The benefit of mitral valve (MV) surgery in elderly patients remains a major area of controversy in the treatment of mitral regurgitation (MR). The article by Vassileva et al1 in this issue of Circulation examines contemporary data from Medicare to determine how older patients fare after undergoing isolated MV surgery. This topic has important health and economic implications, given the high prevalence of hemodynamically significant MR in patients >75 years of age.2 Older studies have shown high mortality in elderly patients undergoing MV replacement in excess of 14%, even >20% in low-volume centers.3 However, concomitant coronary artery bypass graft surgery is common in older patients, and previous MV surgery studies in the elderly contained a mix of patients often needing coronary artery bypass graft surgery or interventions on other valves. In addition, the studies included both MV repair and MV replacement patients, undoubtedly skewing the risk profile because mortality and adverse outcomes for MV replacement have consistently been shown to be higher in most studies.4–8Article see p 1870Because of this higher mortality, the most recent American College of Cardiology/American Heart Association valve guidelines9 suggest that a different standard of care should be applied for elderly patients with asymptomatic or minimally symptomatic MR. The guidelines suggest a conservative, medical management approach in these patients. This recommendation is based on natural history studies and expert consensus rather than randomized trial data of surgical versus conservative management. In contrast to asymptomatic or mildly symptomatic patients, the recommendation is for operative repair in symptomatic patients, regardless of age, when the patient is a reasonable candidate.Over the years, increasing numbers of patients have received MV repair as opposed to replacement, with a rate of 69% in the Society of Thoracic Surgeons (STS) database in 2007 …