Abstract and Introduction
Abstract
Degenerative mitral valve disease often leads to leaflet prolapse due to chordal elongation or rupture, and resulting in mitral valve regurgitation. Guideline referral for surgical intervention centres primarily on symptoms and ventricular dysfunction. The recommended treatment for degenerative mitral valve disease is mitral valve reconstruction, as opposed to valve replacement with a bioprosthetic or mechanical valve, because valve repair is associated with improved event free survival. Recent studies have documented a significant number of patients are not referred in a timely fashion according to established guidelines, and when they are subjected to surgery, an alarming number of patients continue to undergo mitral valve replacement. The debate around appropriate timing of intervention for asymptomatic severe mitral valve regurgitation has put additional emphasis on targeted surgeon referral and the need to ensure a very high rate of mitral valve repair, particularly in the non-elderly population. Current clinical practice remains suboptimal for many patients, and this review explores the need for a 'best practice revolution' in the field of degenerative mitral valve regurgitation.
Introduction
Degenerative mitral valve disease is a common disorder affecting around 2% of the population. The most common finding in patients with degenerative valve disease is leaflet prolapse due to elongation or rupture of the chordal apparatus, resulting in varying degrees of mitral valve regurgitation due to leaflet malcoaptation during ventricular contraction. The emphasis of clinical decision-making in patients with degenerative disease centres around the severity of regurgitation and its impact on symptom status, ventricular function and dimension, the sequelae of systolic flow reversal such as atrial dilatation/fibrillation and secondary pulmonary hypertension, and the risk of sudden death.
Controversy exists as to whether early surgical intervention in asymptomatic patients, before the onset of ventricular changes, improves the outcome of patients with chronic severe degenerative mitral valve disease. This debate has put emphasis on the lack of predictability of mitral valve repair, despite broad consensus that this is the procedure of choice for patients undergoing surgical intervention. The confidence gap in predicting successful mitral valve repair is one of the factors responsible for the lack of adherence to guidelines directed toward timely referral of patients with indications for surgery. An emerging accord is building that current medical and surgical practice often results in suboptimal care for the individual patient with degenerative mitral valve disease, and indeed a paradigm shift or 'revolution' through education is not only predictable but essential to advance the field. All practicing cardiovascular specialists should have familiarity with the 'state of art' in terms of degenerative disease differentiation, timing of intervention, and surgical techniques and results in order to improve patient care.