This was on Yahoo today, word is getting around...

[Yaps]

Study Suggests Earlier Valve Leak Surgery

7 minutes ago Health - AP


By STEPHANIE NANO, Associated Press Writer

People with severely leaky heart valves that cause no symptoms — a situation thought to be relatively harmless — actually are in danger of dying and should consider surgery to get the problem fixed right away, a new study suggests.

Yahoo! Health
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Such people are five times more likely to die of a heart problem or develop heart failure or an irregular heartbeat than those with mild leakage, researchers at the Mayo Clinic reported in Thursday's New England Journal of Medicine (news - web sites).


Their study involved the mitral valve, which connects the upper left chamber with the heart's main pumping chamber. If the valve's two flaps don't close tightly, blood can leak back into the upper chamber when the heart contracts.


Most people don't feel anything, but if it gets gets worse, they can develop shortness of breath, fatigue, dizziness and palpitations.


Doctors can detect the condition by listening to the heart, but usually don't recommend surgery to repair or replace the valve unless it causes symptoms or damages the heart itself.


The Mayo researchers used a relatively new ultrasound technique to take measurements of the hearts of 456 patients who had leaky valves but no symptoms and found that the size of the hole in the valve was the strongest predictor of how the patient would fare. Without surgery, those with bigger holes — about the width of a pencil — did the worst.


"When it's severe, it's fixable. And we can determine when it's severe now with new techniques," said Dr. Maurice Enriquez-Sarano, who led the study.


Of the estimated 2.7 million Americans with notable leakage, about 600,000 are probably candidates for early surgery, Sarano said.


Study participants were enrolled between 1991 and 2000. All had leaky heart valves without symptoms and no other heart problems. Their disorder was classified mild, moderate or severe based on the volume of their leakage and the size of the valve hole.


Participants were monitored and treated independently by their own physicians, and updated information on the patients was collected by the researchers in 2002.


Their findings showed age, diabetes and the valve hole were strong predictors of survival.


Eventually, 232 had heart surgery, all but two for valve repair or replacement. The researchers said surgery reduced the patients' risk of heart failure and death and their life expectancy returned to normal.


Dr. Catherine Otto of the University of Washington in Seattle, said the study is a big step forward because physicians can use the measurement to tell patients what to expect if they have a valve problem. But she said the measurements are challenging to make, and the data apply only to those without any other heart problem.


"I don't want every patient to rush off and demand surgery tomorrow," said Otto, co-author of an accompanying editorial in the journal. "Some people will go to surgery earlier if their surgery risk is low and their valve is repairable."


The editorial writers and Sarano said the next step is a randomized study in severe cases that compares early surgery with surgery done when symptoms appear.


___

[Wise]

Study Suggests Earlier Valve Leak Surgery

7 minutes ago Health - AP


By STEPHANIE NANO, Associated Press Writer

People with severely leaky heart valves that cause no symptoms — a situation thought to be relatively harmless — actually are in danger of dying and should consider surgery to get the problem fixed right away, a new study suggests.

Yahoo! Health
Have questions about your health?
Find answers here.






Such people are five times more likely to die of a heart problem or develop heart failure or an irregular heartbeat than those with mild leakage, researchers at the Mayo Clinic reported in Thursday's New England Journal of Medicine (news - web sites).


Their study involved the mitral valve, which connects the upper left chamber with the heart's main pumping chamber. If the valve's two flaps don't close tightly, blood can leak back into the upper chamber when the heart contracts.


Most people don't feel anything, but if it gets gets worse, they can develop shortness of breath, fatigue, dizziness and palpitations.


Doctors can detect the condition by listening to the heart, but usually don't recommend surgery to repair or replace the valve unless it causes symptoms or damages the heart itself.


The Mayo researchers used a relatively new ultrasound technique to take measurements of the hearts of 456 patients who had leaky valves but no symptoms and found that the size of the hole in the valve was the strongest predictor of how the patient would fare. Without surgery, those with bigger holes — about the width of a pencil — did the worst.


"When it's severe, it's fixable. And we can determine when it's severe now with new techniques," said Dr. Maurice Enriquez-Sarano, who led the study.


Of the estimated 2.7 million Americans with notable leakage, about 600,000 are probably candidates for early surgery, Sarano said.


Study participants were enrolled between 1991 and 2000. All had leaky heart valves without symptoms and no other heart problems. Their disorder was classified mild, moderate or severe based on the volume of their leakage and the size of the valve hole.


Participants were monitored and treated independently by their own physicians, and updated information on the patients was collected by the researchers in 2002.


Their findings showed age, diabetes and the valve hole were strong predictors of survival.


Eventually, 232 had heart surgery, all but two for valve repair or replacement. The researchers said surgery reduced the patients' risk of heart failure and death and their life expectancy returned to normal.


Dr. Catherine Otto of the University of Washington in Seattle, said the study is a big step forward because physicians can use the measurement to tell patients what to expect if they have a valve problem. But she said the measurements are challenging to make, and the data apply only to those without any other heart problem.


"I don't want every patient to rush off and demand surgery tomorrow," said Otto, co-author of an accompanying editorial in the journal. "Some people will go to surgery earlier if their surgery risk is low and their valve is repairable."


The editorial writers and Sarano said the next step is a randomized study in severe cases that compares early surgery with surgery done when symptoms appear.


___

Thank you so much for the info! I have mitral valve prolapse and bicuspid aortic valve and all the information I can get that may help me with decision making later is greatly valued. Thanks again. Wise

[barry70]

I read this article and saw a story on the local NBC station here in NYC yesterday. It is very interesting and changes the thinking for those with Asymptomatic Severe Mitral Regurgitation (like me!). I encourage anyone in my shoes to read it.

[catwoman]

My employer, the Fort Worth Star-Telegram, published the story Thursday, March 3, on Page 5A...

[Baldrick]

It was also in the WSJ this morning.....

[Wise]

After I read this, my wife called me to tell me she heard on SRN news. I guess it is everywhere.

[catwoman]

In case anyone wants it, the researcher's e-mail is: sarano.maurice@mayo.edu

I e-mailed my thanks to him for doing the research and publishing it -- got a response back within 90 minutes! He seemed quite pleased I e-mailed him. I told him the results of his research had been posted here...

[barry70]

Yep, he responded to me very quickly too. I was very impressed. Now I have to go get another echo where they can measure my "efficient regurgitant orifice", which according to the study, is the new key for determaining whether early surgery is a good idea in an asympomatic pateint with severe MR like myself.

[barry70]

I meant "effective regurgitant orifice"

[Yaps]

was a very informative article , one that could help many...love the pup :o

[Ross]

I meant "effective regurgitant orifice"http://home.neo.rr.com/blebs99/Smilies/censored2.gif Hmm somehow that sounds dirty. :D

[Yaps]

It does.... :eek:

[strawberry]

OK, it said 232 eventually had surgery but I can't find the number of people they studied. Am I missing it?

[Yaps]

456 patients;The Mayo researchers used a relatively new ultrasound technique to take measurements of the hearts of 456 patients ...

[Sherry]

Ya beat me to it -- posting the article that is... My brother forwarded it to me at work today. Quite interesting, isn't it?

[perkicar]

Ya beat me to it -- posting the article that is... My brother forwarded it to me at work today. Quite interesting, isn't it?

Has anybody had a chance to look at the actual article? I wonder what actual valve area they're talking about?

[Sherry]

Here's a link to it, Carolyn.

http://www.wtopnews.com/index.php?nid=106&sid=435164

[barry70]

I paid $10 to read the article on the NEJM web site. An effective regurgitent orifice of over 40 mm2 is the magic number.

[tobagotwo]

...or they could have learned it by reading it here. We knew. :rolleyes:

Now, which one of those knuckle-draggers is is sitting on the mirror study they should be doing on aortic valves?

Duh!

[Ross]

2nd post on the same subject. Moving to the main thread.

Hey, its' the talk of the town today!

[PapaHappyStar]

The NEJM has an editorial on the topic as well in this months issue -- since it is an editorial its ok to quote it whole I guess --


Timing of Surgery in Asymptomatic Mitral Regurgitation
Catherine M. Otto, M.D., and Christopher T. Salerno, M.D.


The use of an evidence-based approach to the treatment of valvular heart disease has been hampered by the lack of rigorous data on predictors of the clinical outcome. The timing of surgery in patients with asymptomatic mitral regurgitation has been especially controversial for two reasons: the various causes of valve dysfunction and the lack of a precise measure of disease severity.1

Clinical outcomes and approaches to treatment depend on the cause of valve dysfunction. For example, in patients with secondary mitral regurgitation owing to dilated cardiomyopathy or ischemic disease, the prognosis depends mainly on the underlying disease and valve surgery remains controversial.2,3 In contrast, in patients with primary disease of the valve leaflets, such as mitral-valve prolapse, clinical outcomes are largely a consequence of backflow across the valve, so that restoration of valve competency is the logical treatment. In these patients, the main clinical question is when in the natural history of the disease the benefits of valve surgery outweigh the risks.

Until now, the timing of surgery for asymptomatic primary mitral-valve regurgitation has been based on both the appearance of symptoms and the hemodynamic consequences of the lesion, defined by the response of the left ventricle to chronic volume overload.4 In patients with symptomatic severe mitral regurgitation, surgical intervention is clearly needed. However, we cannot just wait for symptoms, because irreversible left ventricular systolic dysfunction may develop in the interim. Once left ventricular contractility is impaired, outcomes after surgical intervention are poor, with persistent symptoms of ventricular dysfunction and progressive heart failure. Thus, the goal in patients with severe mitral regurgitation is to identify the onset of left ventricular dysfunction so that surgical intervention can be performed promptly. Although there is no ideal measure of ventricular contractility, the empirical values that have been accepted as markers of early ventricular dysfunction in patients with severe mitral regurgitation are an end-systolic dimension of more than 40 or 45 mm and an ejection fraction of less than 60 percent.4 Other factors that suggest decompensation include pulmonary hypertension and new atrial fibrillation.

Now, we need to rethink our approach to the follow-up and treatment of patients with asymptomatic chronic mitral regurgitation. In this issue of the Journal, Enriquez-Sarano and colleagues5 present a landmark study of the natural history of mitral regurgitation in a large series of adults with asymptomatic isolated mitral regurgitation due to primary disease of the valve leaflets. The data strengthen the concept that asymptomatic mitral regurgitation is a serious disease, with a five-year rate of death from any cause of 22 percent and a 33 percent incidence of adverse cardiovascular events, including death from cardiac causes, heart failure, and new atrial fibrillation. Furthermore, this study focuses on regurgitant severity, instead of the ventricular response, as a predictor of the clinical outcome in patients with primary mitral regurgitation. As compared with patients with an effective regurgitant orifice of less than 20 mm2, patients with an effective regurgitant orifice area of at least 40 mm2 had more than five times the risk of death from cardiac causes and cardiac events. Those with an orifice area of 20 to 39 mm2 had intermediate outcomes.

Doppler detection of valve regurgitation has been a standard clinical tool for more than 20 years, but typically only a qualitative grade of severity (0 to 4+) is reported, and there is considerable interobserver variability in this grading scale. Color Doppler echocardiography still serves as a screening tool, with the narrowest segment of the proximal-flow stream, or vena contracta, used to identify patients who require further evaluation, but quantitation of valve regurgitation now includes calculation of the volume of backflow across the valve (regurgitant volume), the percent regurgitation as compared with the total stroke volume (regurgitant fraction), and the effective regurgitant orifice area, which is based on the same principles as the more familiar valve area for stenotic valves.6 Even though the regurgitant volume and fraction both depend on the driving pressure across the valve and the effective regurgitant orifice area may vary with valve dynamics, all these measures are far more accurate and reproducible than older approaches, such as the jet length or area on color Doppler echocardiography.

Although the predictive value of the effective regurgitant orifice appears to be high, caution is needed as we generalize this approach, for several reasons. First, the data of Enriquez-Sarano et al. apply only to patients with isolated primary mitral regurgitation; in patients with mixed-valve lesions, secondary mitral regurgitation, or left ventricular dysfunction, the situation is more complex. Second, quantitative evaluation of the severity of mitral regurgitation is time-consuming and technically demanding; accurate results depend on a meticulous approach by an experienced laboratory. Small errors in data recording or measurement lead to large calculation errors in the effective regurgitant orifice area. In addition, quantitation is more challenging when regurgitation is present only in late systole, as is often seen in patients with mitral-valve prolapse and in patients with atrial fibrillation. Finally, echocardiographic evaluation of the severity of regurgitation should integrate several anatomical and Doppler variables; reliance on a single measure for clinical decision making is hazardous. Ideally, quantitative variables should be reassessed at more than one time to ensure accurate data.

The decision to recommend surgery for an asymptomatic patient is always difficult; we need to be sure that earlier intervention results in better long-term outcomes than watchful waiting with prompt intervention based on conventional indications for surgery. Certainly, patients with an effective regurgitant orifice area of 40 mm2 or more should be monitored more closely. In addition, we may wish to offer selected patients earlier intervention after discussing the expected clinical outcomes, considering the effects of coexisting conditions, and weighing patients' preferences.7 A key factor in this decision is the likelihood that the valve can be repaired rather than replaced, a judgment that experienced echocardiographers can make.8 In a patient with a valve that can be repaired and a low expected perioperative risk of complications or death, earlier intervention might be reasonable. However, if valve replacement is likely to be needed or if the surgical risk is higher, the balance shifts toward watchful waiting. Ideally, the next step should be a prospective, randomized clinical study of early surgery as compared with surgery for conventional indications in patients with severe asymptomatic mitral regurgitation, defined on the basis of the effective regurgitant orifice area.

[catwoman]

I certainly hope that PCPs, internists & cardiologists will look at patients with MV problems much more closely and get them into surgery quicker ...

Yesterday I chatted with another Weight Watchers member, who asked about my beautifully blackened left eye. I told her how & why it became blackened, and she said she has MVP. Hasn't had an echo in 10 years. Has changed doctors a couple of times since then because of insurance changes.
Her MVP was diagnosed (with echo) when she was training for a rather lengthy bike ride (seems like 100+ miles) and became winded.
I told her about vr.com and suggested that she ask for a follow-up echo. She didn't think it necessary to recheck the MVP.

[McCln]

Yaps, I had a leaky valve since birth. Had repair on the aortic valve at age eight and had a heck of time then, shortness of breathe, tiredness, etc. After surgery, still had a little leak that would progress later in life. I am a firm beliver in regular checkups. I had to wait due to not working at times when I was younger and inusrance issues. Having a steady job and insurance help a great deal. I am monitored every six-months and feel better after replacement. I was told at age 9 that it would be done in future. So leaks, even mild, can be a problem. Be sure to be monitored and tested when needed. Leaks can cause a lot of problems as the article indicates. Thanks for sharing yaps and keep it up.

[catwoman]

I'm in shock today (3/7).
When this thread was posted last Thursday, I went to the newsroom to give my thanks for the Fort Worth Star-Telegram running the story. One of the editors I saw was Erny Makovy, a great person.
Erny collapsed yesterday (3/6) while working in his yard at home and died. He was 55 (I'm 4MO away from turning 55). When I was copy desk chief for our evening edition, I worked directly with him since he was city editor.
Our entire paper's staff -- editorial and other departments -- is devastated.