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When to refer a patient with mitral valve disease?

Mitral valve disease is one of the most under-treated medical conditions in all of medicine.  Studies have shown that mitral regurgitation not only leads to symptoms of heart failure, but can be lethal.  A recent study from Mayo Clinic demonstrated that under-treatment even symptomatic severe mitral regurgitation is associated with a lower long-term survival (Suri, R et al.  JAMA. 2013 Aug 14;310(6):609-16).

ACC/AHA 2017 Guidelines Valve Disease Mitral Regurgitation
2017 ACC/AHA Guidelines for Treatment of Valve Disease: Mitral Valve Regurgitation

 

All patients with moderate-severe or severe mitral regurgitation should be evaluated by a multi-speciality team consisting of cardiovascular surgeons, imaging specialists, invasive cardiologists, and others.  Referral to such a team does not mean the patient will get surgery!  It does mean that the patient will be thoroughly evaluated and counseled regarding relevant guidelines and options for treatment, whether they be medical, surgical, or catheter-based.  Such referrals also help the general cardiologist and internist more effectively manage their mitral valve patients.

Survival much better after mitral valve repair even in asymptomatic patients
Survival in asymptomatic patients with severe mitral valve regurgitation significantly better with surgery than with medical management. JAMA. 2013;310(6):609-616.

 

The truth is that there are a large number of patients with Class I and IIa ACC/AHA guideline indications for surgical or catheter-based treatment who are not referred at all.  Many cardiologists think that there is no indication for referring an asymptomatic patient for instance.  In fact, many patients who have no symptoms have a Class I or IIa indication for intervention.

The decision not to refer a patient with clear indications for intervention is not benign.  Progressive and often irreversible heart failure occurs.  Survival is lowered.  The risk of surgical intervention goes up.

So why do good clinicians not refer earlier?  There are understandable reasons:

  1.  Most mitral valve surgery in the U.S. is performed by surgeons who do fewer than 4-10 mitral valve procedures per year and with a high rate of replacement versus repair.
  2.  Heart surgery has short term risk while medical management has longer term risk.

  3.  Lack of familiarity with current ACC/AHA guidelines for mitral valve treatment.

That being said, referral of patients with severe mitral disease to a multidisciplinary team with a high-volume experience and access to the latest in technology has many benefits for the patient and their doctors:  knowing the options and making an informed decision is always good.