To make appropriate decisions, it is important to analyse the postoperative outcome, in particular the implications of delaying surgery until overt alterations occur.
Waiting for left ventricular dysfunction (ejection fraction < 60%, end systolic diameter > 45 mm) imposes an excess rate of mortality7 and of heart failure9 compared to patients with more normal function at surgery.
Waiting for severe symptoms to occur before surgery is also not benign. In the Mayo experience, the more severe the preoperative symptoms were, the lower the postoperative ejection fraction2 and the higher the incidence of congestive heart failure9 were during follow up. Adjusting for age at surgery and all other determinants of outcome, severe preopera-tive symptoms are associated with a worse long term survival18 28 and excess incidence of heart failure.9 Even in the privileged subgroup of patients with an ejection fraction > 60% where the survival is not different from the expected survival, patients operated at an early stage with minimal symptoms have a better survival than patients with severe symptoms.7 Therefore, waiting for severe symptoms is associated with a higher incidence of complications after the surgery is performed (fig 11.3)
Waiting for atrial fibrillation to occur and persist more than three months before surgery was associated with a high risk of postoperative persistence of atrial fibrillation and therefore of requiring long term anticoagulation. Conversely, recent atrial fibrillation tends to revert to sinus rhythm postoperatively.29 Therefore, waiting for chronic atrial fibrillation preoperatively is associated with residual postoperative morbidity
There is no randomised trial comparing the outcome after early surgery for organic mitral regurgitation to the outcome with medical management. In patients with flail mitral leaflets the long term outcome after early surgery was compared to that of patients managed conservatively and operated on whenever it was judged necessary. Although many patients initially treated conservatively eventually underwent surgery, the early surgical approach was associated with an improved long term survival through a pronounced reduction in cardiac mortality, and a decreased morbidity (less heart failure and less atrial fibrillation) during follow up.30 These results underline the potential for eliminating most of the cardiac complications caused by mitral regurgitation through an early surgical approach as long as the operative mortality remains low (< 2%).
Timing of surgery in organic mitral regurgitation
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