Clinical research study
Impact of Severe Mitral Regurgitation on Postoperative Outcomes After Noncardiac Surgery

https://doi.org/10.1016/j.amjmed.2012.12.005Get rights and content

Abstract

Objective

Preoperative cardiac risk assessment scoring systems traditionally do not include valvular regurgitation as a criterion for adverse outcome prediction. We sought to determine the impact of significant mitral regurgitation on postoperative outcomes after planned noncardiac surgeries.

Methods

Patients with significant mitral regurgitation (moderate-severe or severe) undergoing noncardiac surgery were identified using surgical and echocardiographic databases at the Cleveland Clinic. The mechanism of mitral regurgitation was identified and classified as ischemic or nonischemic. By using propensity score analysis, we obtained 4 matched controls (patients undergoing noncardiac surgery without mitral regurgitation) for each case. The primary outcome was defined as a composite of 30-day mortality, myocardial infarction, heart failure, and stroke. Secondary outcomes included 30-day mortality, myocardial infarction, heart failure, stroke, and atrial fibrillation.

Results

A total of 298 cases and 1172 controls were included in the study. The incidence of primary outcome was significantly higher among patients with mitral regurgitation (22.2%) compared with controls (16.4%, P = .02). Analysis of the secondary outcomes revealed significant differences in perioperative heart failure (odds ratio, 1.4; 95% confidence interval, 1.02-2.0) and perioperative myocardial infarction (odds ratio, 2.9; 95% confidence interval, 1.2-7.3). Of patients with mitral regurgitation, those with ischemic mitral regurgitation had significantly more events than those with nonischemic mitral regurgitation (39.2% vs 13.3%, P < .001).

Conclusions

Patients undergoing noncardiac surgery with significant ischemic mitral regurgitation are at higher risk of a composite adverse postoperative outcome, including short-term mortality, heart failure, myocardial infarction, and stroke.

Section snippets

Patient Population

All adults (aged > 18 years) undergoing any noncardiac surgery between January 2005 and February 2009 with echocardiographically diagnosed moderate-severe or severe mitral regurgitation (referred to as “significant mitral regurgitation”) before surgery were identified from the echocardiography and surgical databases maintained at the Cleveland Clinic. We determined the mechanism of mitral regurgitation by reviewing electronic medical records, echocardiograms, and coronary angiograms. The

Patient Characteristics

A total of 7510 patients underwent planned noncardiac surgery between January 2005 and February 2009 at the Cleveland Clinic. Significant mitral regurgitation was present in 298 patients. Of 298 patients, 102 (34%) had ischemic mitral regurgitation and 196 (66%) had nonischemic mitral regurgitation. Nonischemic mitral regurgitation was of varied cause, including 94 (31%) functional, 41 (14%) degenerative, 15 (5%) hypertrophic cardiomyopathy–induced, 10 (3%) rheumatic heart disease, 8 (3%)

Discussion

Our study investigated the impact of significant mitral regurgitation on the postoperative outcomes after noncardiac surgeries stratified by mechanism of mitral regurgitation. We observed that the patients with significant mitral regurgitation experienced higher primary adverse outcome consisting of 30-day mortality, heart failure, myocardial infarction, and stroke. The significant difference in the primary outcome was accounted for, largely, by an increased incidence of heart failure and

Conclusions

Patients with significant mitral regurgitation undergoing noncardiac surgery experienced higher rates of primary outcome consisting of 30-day mortality, heart failure, myocardial infarction, and stroke, in comparison with patients without mitral regurgitation. The significant difference in the primary outcome was largely accounted for by an increased incidence of heart failure and myocardial infarction in the postoperative period among patients with significant ischemic mitral regurgitation.

References (19)

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Funding: None.

Conflict of Interest: None.

Authorship: All authors had access to the data and played a role in writing this manuscript.

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