Lack of awareness affects surgery referrals

Sep 14 2009

Overblown fears about surgical risk and lack of awareness about the risk of not operating are among the reasons only half of eligible patients were referred for mitral valve repair, according to a study by doctors at the University of Michigan Cardiovascular Center.

A leaking mitral valve, known as mitral regurgitation or mitral insuffiency, can lead to fatigue, abnormal heart rhythms with irregular heart beats, and congestive heart failure. The longer the leak continues, the more likely there will be permanent heart damage.

Among those who were not operated on, three-fourths of patients met at least one indication for surgery, according to guidelines from the American College of Cardiology and the American Heart Association.

"In general, cardiologists tend to overestimate the risks of surgery and underestimate the potential benefits for patients," says lead author David S. Bach, professor of internal medicine at the U-M Medical School and cardiologist at the U-M Cardiovascular Center.

Researchers identified 300 patients with moderate to severe mitral regurgitation for the study in the Journal of the American College of Cardiology. Patients had been screened in the University of Michigan Echocardiography Laboratory.

Among them, 188 patients had functional mitral regurgitation, of whom just 30 underwent surgery. Of the 112 patients with severe organic mitral valve regurgitation, only half had surgery.

Surgical risk scores were no different among patients who underwent surgery compared to those who did not.

Existing data show deaths among patients undergoing mitral valve surgery have decreased dramatically in recent years, making the procedure a feasible option.

"I think there remains something of a bias in medicine and cardiology that surgery is risky, and surgery is a failure of our ability to manage the patient medically," Bach says in an interview. "Mitral valve diseases are not as benign as they were once thought to be, and surgery is not as morbid as it was thought of in the past."

A review of patient charts showed the most common reasons for not referring patients for surgery were stable heart functioning, an absence of symptoms or presence of other major health problems.

Bach sees mitral valve conditions - even relatively common ones like mitral regurgitation - as prime examples of conditions that might best be treated in specialized centers with the volume and familiarity to use appropriate interventions and minimize inappropriate ones.

Meanwhile, Bach suggests cardiologists become more familiar with guideline recommendations and the data on which they are based, discuss options more fully with patients, and when possible, involve a surgeon in consultation.