Management of less-than-severe XXXX : should guidelines recommend earlier surgical intervention?

@entity1 @entity3454 @entity339 @entity1002
OBJECTIVE: It is well accepted that @entity1 with severe @entity339 ( @entity339 ) benefit from mitral valve repair; however, the management of those with less than severe leakage is controversial. Watchful waiting is often advocated and considered safe, but the risk of developing left ventricular (LV) dysfunction under medical management is unknown. METHODS: Using a population-based County-wide study database, we analyzed echocardiograms during clinical follow-up and medical management of 204 @entity1 with @entity3454 and less-than-severe @entity339 . @entity1002 was defined per American Heart Association guidelines as an ejection fraction (EF) <60% or LV end-systolic dimension > 40 mm. RESULTS: At index examination, mean age was 57 years and 121 (59%) were @entity1 . The mean EF was 62%, and 62 (30%) had evidence of @entity1002 . @entity339 severity was mild in 121 (59%), mild-moderate in 23 (11%), moderate in 36 (18%) and moderate-severe in 24 (12%). During follow-up (mean 8.6 years), 79 @entity1 (39%) demonstrated progression of @entity339 by at least one grade. Greater degrees of regurgitation at index echocardiogram were associated with greater progression during follow-up (P=0.0001). After adjusting for age, sex, body surface area (BSA), and baseline regurgitation grade, multivariable modeling revealed that larger LV end-diastolic dimension (odds ratio (OR)=1.14; P=0.0018) and greater diastolic septal thickness (OR=1.40; P=0.0211) predicted greater progression of @entity339 with time. From initial diagnosis to follow-up echocardiography, EF declined, while left-heart dimensions and pulmonary arterial pressure increased. Of the 142 @entity1 with normal baseline LV function, 52% developed either worsening @entity339 or de novo @entity1002 . Importantly, even in the 87 @entity1 with stable regurgitation, 18 (21%) developed new @entity1002 during follow-up. Fifty-two @entity1 (25%) eventually underwent mitral valve repair. Following surgery, there were significant decreases in EF, LV end-diastolic dimensions and LV mass; while 11 developed de novo @entity1002 . CONCLUSIONS: Over half of @entity1 with chronic persistent, but sub-severe @entity339 due to @entity3454 develop @entity1002 or worsening regurgitation despite optimal medical management. LV deterioration can occur even in the absence of @entity339 progression. These data advocate for the development of detailed guidelines supporting frequent echocardiographic monitoring and the identification of earlier triggers for surgical consideration prior to the development of @entity1002 in this @entity1 population.
