JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
VOL. 67, NO. 5, 2016
ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION PUBLISHED BY ELSEVIER
ISSN 0735-1097/$36.00 http://dx.doi.org/10.1016/j.jacc.2015.12.007
EDITORIAL COMMENT
The Time Has Come to Define Centers of Excellence in Mitral Valve Repair* Robert O. Bonow, MD, MS,a David H. Adams, MDb
A
dvances in surgical repair of the mitral valve
likelihood of successful and durable repair (for that
have revolutionized the management of
patient in that center) exceeds 95% and with an
patients with primary degenerative forms of
operative mortality risk of 25 per surgeon), which would be difficult to meet at many centers in this country, these criteria include training of cardiologists as well as cardiac surgeons and, most importantly, auditing the results to include mortality and rates of residual MR, recurrent MR, and reoperation. The ACC/AHA guidelines
do
recommend
that
asymptomatic
patients be referred to centers experienced in repair to maximize the likelihood of successful, durable results (13). While this is easily stated but difficult to define, it is possible for centers dedicated to valve repair to set the standard (23). As heart valve teams are coalescing throughout the country to develop expert programs in transcatheter valve procedures, the time has come for our respective professional associations and societies to establish what constitutes a center of excellence in mitral valve repair. Criteria should include mitral valve surgery volume requirements (center and surgeon), appropriate periprocedural imaging capabilities, and a willingness to provide patients and referring doctors data regarding expected outcomes based on the center’s recent experience, including repair rates, mortality rates, stroke rates, and evidence of the likelihood of repair durability (Table 1). This effort to concentrate volume and regionalize mitral valve surgery in centers of excellence is particularly relevant now given the current ACC/AHA and European Society of Cardiology/European Association of Cardiothoracic Surgery guidelines’ recommendation to intervene earlier in patients with severe MR on the basis of degenerative valve disease.
published from a select group of high-volume academic centers, such as the current report. It is
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
likely, however, that in addition to experiencing
Robert O. Bonow, Department of Medicine, North-
higher replacement rates, a patient operated on by a
western University Feinberg School of Medicine, 251
less experienced surgeon also will face an increased
East
risk of a nondurable valve repair.
nois 60611. E-mail: [email protected].
Huron
Street,
Galter
3-150,
Chicago,
Illi-
Bonow and Adams
JACC VOL. 67, NO. 5, 2016 FEBRUARY 9, 2016:499–501
Mitral Repair Centers of Excellence
REFERENCES 1. Enriquez-Sarano M, Avierinos JF, MessikaZeitoun D, et al. Quantitative determinants of the outcome of asymptomatic mitral regurgitation. N Engl J Med 2005;352:875–83. 2. Rosenhek R, Rader F, Klaar U, et al. Outcome of watchful waiting in asymptomatic severe mitral regurgitation. Circulation 2006;113:2238–44. 3. Grigioni F, Tribouilloy C, Avierinos JF, et al. Outcomes in mitral regurgitation due to flail leaflets: a multicenter European study. J Am Coll Cardiol Img 2008;1:133–41. 4. Bonow RO. Chronic mitral regurgitation and aortic regurgitation: have indications for surgery changed? J Am Coll Cardiol 2013;61:693–701. 5. Gillinov AM, Mihaljevic T, Blackstone EH, et al. Should patients with severe degenerative mitral regurgitation delay surgery until symptoms develop? Ann Thorac Surg 2010;90:481–8. 6. David TE, Armstrong S, McCrindle BW, Manlhiot C. Late outcomes of mitral valve repair for mitral regurgitation due to degenerative disease. Circulation 2013;127:1485–92. 7. Suri RM, Vanoverschelde JL, Grigioni F, et al. Association between early surgical intervention vs watchful waiting and outcomes for mitral regurgitation due to flail mitral valve leaflets. JAMA 2013;310:609–16. 8. Tribouilloy S, Grigioni F, Avierinos JF, et al.
surgery. J Thorac Cardiovasc Surg 2011;142: 1439–52.
for patients undergoing elective surgery for mitral regurgitation. Circulation 2007;115:881–6.
10. Jokinen JJ, Hipeläinen MJ, Pitkänen OA, Hartikainen JEK. Mitral valve replacement versus repair: propensity-adjusted survival and qualityof-life analysis. Ann Thorac Surg 2007;84:451–8.
17. Bridgewater B, Kinsman R, Walton P, et al. Sixth National Adult Cardiac Surgery Database Report 2008. Reading, England: Dendrite Clinical Systems, 2009.
11. Shuhaiber J, Anderson RJ. Meta-analysis of clinical outcomes following surgical mitral valve repair or replacement. Eur J Cardiothorac Surg 2007;31:267–75.
18. LaPar DJ, Ailawadi G, Isbell JM, et al. Mitral valve repair rates correlate with surgeon and institutional experience. J Thorac Cardiovasc Surg 2014;148:995–1004.
12. Chikwe J, Goldstone AB, Passage J, et al. A propensity score-adjusted retrospective comparison of early and mid-term results of mitral
19. Vassileva, McNeely, Spertus J, Markwell S,
valve repair versus replacement in octogenarians. Eur Heart J 2011;32:618–26. 13. Nishimura R, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:e57–185. 14. Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease (version 2012). Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery. Eur Heart J 2012;33:2451–96.
Survival implication of left ventricular end-systolic diameter in mitral regurgitation due to flail leaflets: a long-term follow-up multicenter study. J Am Coll Cardiol 2009;54:1961–8.
15. Suri RM, Clavel M-A, Schaff HV, et al. Effect of recurrent mitral regurgitation following degenerative mitral valve repair: long-term analysis of competing outcomes. J Am Coll Cardiol
9. Ghoreishi M, Evans CF, deFilippi CR, et al. Pulmonary hypertension adversely affects short- and long-term survival after mitral valve operation for
2016;67:488–98. 16. Gammie JS, O’Brien SM, Griffith BP, Ferguson TB, Peterson ED. Influence of hospital
mitral regurgitation: implications for timing of
procedural volume on care process and mortality
Hazelrigg S. Hospital volume, mitral repair rates, and mortality in mitral valve surgery in the elderly: an analysis of US hospital treating Medicare feefor-service patients. J Thorac Cardiovasc Surg 2015;149:762–8. 20. Chikwe J, Adams DH. Megaphone message: discouraging low-volume mitral surgery. J Thorac Cardiovasc Surg 2015;149:769–70. 21. Bolling SF, Li S, O’Brien SM, Brennan JM, Prager RL, Gammie JS. Predictors of mitral valve repair: clinical and surgeon factors. Ann Thorac Surg 2010;90:1904–12. 22. Bridgewater B, Hooper T, Munsch C, et al. Mitral repair best practice: proposed standards. Heart 2006;92:939–44. 23. Castillo JG, Anyanwu AC, Fuster V, Adams DH. A near 100% repair rate for mitral valve prolapse is achievable in a reference center: implications for future guidelines. J Thorac Cardiovasc Surg 2012; 144:308–12.
KEY WORDS degenerative mitral regurgitation, left ventricular, mitral valve replacement, outcomes
501
VOL. 67, NO. 5, 2016
ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION PUBLISHED BY ELSEVIER
ISSN 0735-1097/$36.00 http://dx.doi.org/10.1016/j.jacc.2015.12.007
EDITORIAL COMMENT
The Time Has Come to Define Centers of Excellence in Mitral Valve Repair* Robert O. Bonow, MD, MS,a David H. Adams, MDb
A
dvances in surgical repair of the mitral valve
likelihood of successful and durable repair (for that
have revolutionized the management of
patient in that center) exceeds 95% and with an
patients with primary degenerative forms of
operative mortality risk of 25 per surgeon), which would be difficult to meet at many centers in this country, these criteria include training of cardiologists as well as cardiac surgeons and, most importantly, auditing the results to include mortality and rates of residual MR, recurrent MR, and reoperation. The ACC/AHA guidelines
do
recommend
that
asymptomatic
patients be referred to centers experienced in repair to maximize the likelihood of successful, durable results (13). While this is easily stated but difficult to define, it is possible for centers dedicated to valve repair to set the standard (23). As heart valve teams are coalescing throughout the country to develop expert programs in transcatheter valve procedures, the time has come for our respective professional associations and societies to establish what constitutes a center of excellence in mitral valve repair. Criteria should include mitral valve surgery volume requirements (center and surgeon), appropriate periprocedural imaging capabilities, and a willingness to provide patients and referring doctors data regarding expected outcomes based on the center’s recent experience, including repair rates, mortality rates, stroke rates, and evidence of the likelihood of repair durability (Table 1). This effort to concentrate volume and regionalize mitral valve surgery in centers of excellence is particularly relevant now given the current ACC/AHA and European Society of Cardiology/European Association of Cardiothoracic Surgery guidelines’ recommendation to intervene earlier in patients with severe MR on the basis of degenerative valve disease.
published from a select group of high-volume academic centers, such as the current report. It is
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
likely, however, that in addition to experiencing
Robert O. Bonow, Department of Medicine, North-
higher replacement rates, a patient operated on by a
western University Feinberg School of Medicine, 251
less experienced surgeon also will face an increased
East
risk of a nondurable valve repair.
nois 60611. E-mail: [email protected].
Huron
Street,
Galter
3-150,
Chicago,
Illi-
Bonow and Adams
JACC VOL. 67, NO. 5, 2016 FEBRUARY 9, 2016:499–501
Mitral Repair Centers of Excellence
REFERENCES 1. Enriquez-Sarano M, Avierinos JF, MessikaZeitoun D, et al. Quantitative determinants of the outcome of asymptomatic mitral regurgitation. N Engl J Med 2005;352:875–83. 2. Rosenhek R, Rader F, Klaar U, et al. Outcome of watchful waiting in asymptomatic severe mitral regurgitation. Circulation 2006;113:2238–44. 3. Grigioni F, Tribouilloy C, Avierinos JF, et al. Outcomes in mitral regurgitation due to flail leaflets: a multicenter European study. J Am Coll Cardiol Img 2008;1:133–41. 4. Bonow RO. Chronic mitral regurgitation and aortic regurgitation: have indications for surgery changed? J Am Coll Cardiol 2013;61:693–701. 5. Gillinov AM, Mihaljevic T, Blackstone EH, et al. Should patients with severe degenerative mitral regurgitation delay surgery until symptoms develop? Ann Thorac Surg 2010;90:481–8. 6. David TE, Armstrong S, McCrindle BW, Manlhiot C. Late outcomes of mitral valve repair for mitral regurgitation due to degenerative disease. Circulation 2013;127:1485–92. 7. Suri RM, Vanoverschelde JL, Grigioni F, et al. Association between early surgical intervention vs watchful waiting and outcomes for mitral regurgitation due to flail mitral valve leaflets. JAMA 2013;310:609–16. 8. Tribouilloy S, Grigioni F, Avierinos JF, et al.
surgery. J Thorac Cardiovasc Surg 2011;142: 1439–52.
for patients undergoing elective surgery for mitral regurgitation. Circulation 2007;115:881–6.
10. Jokinen JJ, Hipeläinen MJ, Pitkänen OA, Hartikainen JEK. Mitral valve replacement versus repair: propensity-adjusted survival and qualityof-life analysis. Ann Thorac Surg 2007;84:451–8.
17. Bridgewater B, Kinsman R, Walton P, et al. Sixth National Adult Cardiac Surgery Database Report 2008. Reading, England: Dendrite Clinical Systems, 2009.
11. Shuhaiber J, Anderson RJ. Meta-analysis of clinical outcomes following surgical mitral valve repair or replacement. Eur J Cardiothorac Surg 2007;31:267–75.
18. LaPar DJ, Ailawadi G, Isbell JM, et al. Mitral valve repair rates correlate with surgeon and institutional experience. J Thorac Cardiovasc Surg 2014;148:995–1004.
12. Chikwe J, Goldstone AB, Passage J, et al. A propensity score-adjusted retrospective comparison of early and mid-term results of mitral
19. Vassileva, McNeely, Spertus J, Markwell S,
valve repair versus replacement in octogenarians. Eur Heart J 2011;32:618–26. 13. Nishimura R, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:e57–185. 14. Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease (version 2012). Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery. Eur Heart J 2012;33:2451–96.
Survival implication of left ventricular end-systolic diameter in mitral regurgitation due to flail leaflets: a long-term follow-up multicenter study. J Am Coll Cardiol 2009;54:1961–8.
15. Suri RM, Clavel M-A, Schaff HV, et al. Effect of recurrent mitral regurgitation following degenerative mitral valve repair: long-term analysis of competing outcomes. J Am Coll Cardiol
9. Ghoreishi M, Evans CF, deFilippi CR, et al. Pulmonary hypertension adversely affects short- and long-term survival after mitral valve operation for
2016;67:488–98. 16. Gammie JS, O’Brien SM, Griffith BP, Ferguson TB, Peterson ED. Influence of hospital
mitral regurgitation: implications for timing of
procedural volume on care process and mortality
Hazelrigg S. Hospital volume, mitral repair rates, and mortality in mitral valve surgery in the elderly: an analysis of US hospital treating Medicare feefor-service patients. J Thorac Cardiovasc Surg 2015;149:762–8. 20. Chikwe J, Adams DH. Megaphone message: discouraging low-volume mitral surgery. J Thorac Cardiovasc Surg 2015;149:769–70. 21. Bolling SF, Li S, O’Brien SM, Brennan JM, Prager RL, Gammie JS. Predictors of mitral valve repair: clinical and surgeon factors. Ann Thorac Surg 2010;90:1904–12. 22. Bridgewater B, Hooper T, Munsch C, et al. Mitral repair best practice: proposed standards. Heart 2006;92:939–44. 23. Castillo JG, Anyanwu AC, Fuster V, Adams DH. A near 100% repair rate for mitral valve prolapse is achievable in a reference center: implications for future guidelines. J Thorac Cardiovasc Surg 2012; 144:308–12.
KEY WORDS degenerative mitral regurgitation, left ventricular, mitral valve replacement, outcomes
501
