Management of asymptomatic patients with severe non-ischaemic mitral regurgitation. Are practices consistent with guidelines?

OBJECTIVE: For asymptomatic patients with severe mitral regurgitation, guidelines recommend surgery in selected patients. However, little is known on how the current practice fits with guidelines.

METHODS: Of the 5001 patients prospectively included in the Euro Heart Survey on valvular heart disease, 877 had isolated mitral regurgitation and 546 had severe mitral regurgitation (grade >or=3/4 with Doppler echocardiography). Of them, 101 were asymptomatic and had non-ischaemic mitral regurgitation. The decision to refer the patients to surgery or not operate was analysed by comparing patient characteristics with American College of Cardiology/American Heart Association guidelines.

RESULTS: Coronary angiography was performed in 21 out of 33 patients (64%) who were considered for surgery. Catheterisation was performed in 27 patients (27%). A decision to operate was taken in 33 patients (33%). Decisions to refer to surgery or not were in accordance with guidelines in 63 patients (62%). Regarding discordant decisions, intervention was considered 'over-used' in 9 patients (9%) and 'under-used' in 29 patients (29%), of whom 24 had a class I or IIa indication for surgery. Of the 68 non-operated patients, 44 (65%) received at least one drug with haemodynamic effect.

CONCLUSIONS: In asymptomatic patients with severe mitral regurgitation, preoperative coronary angiography seems under-used and cardiac catheterisation is frequently used. Regarding the decision to operate or not, a large number of patients were not referred to surgery even though they fulfilled recommendation for surgery. Thus, to avoid too late surgical referral, implementation of existing guidelines should be improved.