5.1 Interventional vs Surgical Mitral Repair: Are Valve Centers of Excellence Needed?

These proceedings summarize the educational activity of the 16th Biennial Meeting of the International Andreas Gruentzig Society held January 31-February 3, 2022 in Punta Cana, Dominican Republic

Faculty Disclosures     Vendor Acknowledgments

2022 IAGS Summary Document

Statement of problem or issue

Approaches to mitral valve disease are undergoing re-evaluation as both technologies and clinical experiences evolve.

Gaps in knowledge

There are 3 major gap areas:

1. Is valve durability better with one approach over the other?

2. Do Centers of Excellence permit better patient selection—resulting in better outcomes?

3. Would Centers of Excellence limit access to care?

Do patients really care about “valve durability?” The patients’ priorities are: (1) recovery time and (2) getting back to their lives sooner. If a percutaneous approach fails then the patient faces having to undergo a surgical mitral valve replacement and consequent anticoagulation. Also, a large meta-analysis showed similar mortality rates but higher rates of residual regurgitation and reoperation in percutaneous approach patients.¹

Centers of Excellence that offer both surgery and percutaneous approaches have greater transparency with their procedure outcomes, and more often engage in public reporting initiatives.² But since they are fewer in number and farther from patients, do these Centers of Excellence unnecessarily limit or restrict access to therapies?

Possible solutions and future directions

Mitral valve disease is not a single entity, and subsets may each require different approaches. One paramount consideration is public reporting of outcome metrics. This will help ensure program integrity. Multihospital organizations will need to develop regionalization and true systems of care, with resource-sharing and referral networks.

References

1. Oh NA, Kampaktsis PN, Gallo M, et al. An updated meta-analysis of MitraClip versus surgery for mitral regurgitation. Ann Cardiothorac Surg. 2021;10(1):1-14. doi:10.21037/acs-2020-mv-24

2. Nishimura RA, O’Gara PT, Bavaria JE, et al. 2019 AATS/ACC/ASE/SCAI/STS Expert Consensus Systems of Care Document: a proposal to optimize care for patients with valvular heart disease: a joint report of the American Association for Thoracic Surgery, American College of Cardiology, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2019;73(20):2609-2635. doi:10.1016/j.jacc.2018.10.007