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Timing of mitral valve surgery
  1. Maurice Enriquez-Sarano
  1. Correspondence to:
    Dr Maurice Enriquez-Sarano, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA;
    sarano.maurice{at}mayo.edu

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Mitral valve surgery has changed considerably in the past decades and is now indicated mostly for pure or predominant mitral regurgitation. This is the result of the regression of rheumatic disease, of the efficacy of mitral balloon valvuloplasty for mitral stenosis, and of the aging of the population with increasing degenerative or ischaemic disease causing mitral regurgitation. Mitral regurgitation can be “organic” (that is, caused by intrinsic mitral disease such as rheumatic disease, ruptured chord, perforation of leaflet) or be “functional” (that is, where a normal valve regurgitates because of ventricular dysfunction).

The timing of mitral surgery has remained one of the most vexing problems of clinical cardiology because symptoms can remain absent or minimal despite severe regurgitation caused by adaptive remodelling of left ventricle and atrium, or because of patient adaptation to the disease. However, recent advances in the understanding of the natural history of the disease and of the impact of left ventricular dysfunction on outcome, in the echocardiographic evaluation of mitral diseases and in the risk and success of mitral repair, have resulted in a widespread evolution towards earlier surgery.

POOR OUTCOME OF SEVERE MITRAL REGURGITATION

Mitral regurgitation is a progressive disease

The new quantitative techniques have allowed the progression of mitral regurgitation to be defined. As was clinically suspected, mitral regurgitation is a progressive disease,1 with an increase on average of 7.5 ml per year for regurgitant volume and of 5.9 mm2 per year for the effective regurgitant orifice. The determinants of progression are anatomic changes, with more rapid progression in patients with mitral valve prolapse, in particular new flail leaflet, and in patients with an enlarging mitral annulus.1 Importantly, progression is not uniform and if half of the patients see notable progression, 11% see also spontaneous regression of mitral regurgitation, related to improved loading conditions. The progression of mitral regurgitation also causes progression of …

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