Invited Commentary

Abstract

Yazdchi and colleagues [1Yazdchi F. Koch C.G. Mihaljevic T. et al.Increasing disadvantage of “watchful waiting” for repairing degenerative mitral valve disease.Ann Thorac Surg. 2015; 99: 1992-2000Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar] have contributed a 26-year experience describing trends in patient characteristics, surgical approaches, and outcomes in patients with degenerative mitral valve regurgitation. The news is encouraging. The authors document an important shift toward referral for mitral valve operation earlier in the disease process, before the adverse consequences of mitral regurgitation on the heart and pulmonary vasculature compromise long-term outcomes. Patients undergoing mitral valve operations for degenerative disease in this experience have progressively smaller ventricular and atrial dimensions, less manifest heart failure, a lower incidence of atrial fibrillation, and a higher likelihood of presenting without symptoms. The extremely low mortality and high rates of repair are a tribute to the entire perioperative care team, and these outcomes undoubtedly have shifted the equation toward earlier referral. The author’s institution is ahead of the national curve, where fewer than 10% (compared with 44% in this report) of referred patients are asymptomatic (The Society of Thoracic Surgeons Adult Cardiac Surgery Database, accessed October 2013). The repair rate of 93% exceeds the national average of 85% and is a reminder that highly reliable and durable mitral repair is probably best achieved by surgeons with a dedicated subspecialization in mitral valve repair. Key unanswered questions include the worth of “minimally invasive” mitral valve operations, which seem to be driving substantially increased cardiopulmonary and cross-clamp times. The next steps in the therapy of degenerative mitral valve disease include continued earlier referral for operation, truly less invasive (non-cardiopulmonary bypass and catheter-based) interventions, and simplification of repair strategies to increase mitral valve repair rates and enhance durability of repair. We are looking forward to the next era. Increasing Disadvantage of “Watchful Waiting” for Repairing Degenerative Mitral Valve DiseaseThe Annals of Thoracic SurgeryVol. 99Issue 6PreviewSuccessful durable repair of severe degenerative mitral regurgitation with low operative mortality encourages intervention in asymptomatic patients rather than “watchful waiting.” Our objectives were to assess trends in patient characteristics, timing of intervention, and evolving surgical techniques at a high-volume center, and determine effects of these changes on outcomes after mitral valve (MV) repair over a 25-year period. Full-Text PDF