Contemporary prevalence and outcomes of rheumatic mitral valve surgery

Abstract

Objective: Rheumatic mitral valve disease is often viewed as a historic disease in North America with limited contemporary data. We hypothesized that rheumatic pathology remains common and has worse short-term outcomes and higher resource utilization compared to other mitral valve pathologies.Method: All patients undergoing mitral valve repair or replacement (2011)(2012)(2013)(2014)(2015)(2016)(2017)(2018)(2019) were extracted from a regional Society of Thoracic Surgeons database. Resource utilization metrics included inflation-adjusted hospital costs. Patients were stratified by mitral valve pathology for univariate analysis.Result: Out of the 6625 mitral valve procedures, 835 (12.6%) were from rheumatic disease, a proportion that incrementally increased over time (+0.39% per year, p = .032). Among 19 hospitals, there was high variability in number of rheumatic mitral operations (median: 22, interquartile range [IQR]: 5-80) and rate of rheumatic repairs (median: 3%, IQR: 0%-6%). Rheumatic patients were younger (62 vs. 65, p < .0001), more often female (75% vs. 43%, p < .001) and with greater burden of heart failure, multi-valve disease, and lung disease, but less coronary disease. There were no differences in operative mortality (5.2% vs. 5.0%, p = .85) or major morbidity (22.2% vs. 21.8%, p = .83). However, resource utilization was higher for rheumatic patients, including more frequent transfusions (43% vs. 39%, p = .012), longer ICU (73 vs. 64 h, p < .0001) and postoperative length of stay (8 vs. 7 days, p < .0001).Conclusions: Rheumatic mitral disease accounts for a meaningful (12%) and rising percentage of mitral valve operations in the region, with high variability among hospitals. Rheumatic mitral surgery yielded similar short-term outcomes compared to nonrheumatic pathology, but required greater resource utilization.

Out of sight, but not out of heart: The prevailing burden of rheumatic heart disease in high‐income countries

“…2 Although no differences in operative mortality or morbidity were discerned, patients with RHD required longer hospital and intensive care lengths-of-stay. 2 The authors should be congratulated for their compelling study which reminds us that RHD is a disease of inequity and reflects how immigrant, Indigenous, racialized, and lowsocioeconomic status (SES) populations still face barriers to accessing healthcare. Lack of primary care results in delayed treatment for GAS and acute rheumatic fever and thus a greater likelihood of developing RHD that progresses into mitral valve failure requiring surgical intervention.…”

“…Hawkins et al 2 conducted a retrospective cohort study in the United States and found that the proportion of RHD amongst all mitral valvular diseases was 12.6% and increased by 0.39%/year from 2011 to 2019. 2 Although no differences in operative mortality or morbidity were discerned, patients with RHD required longer hospital and intensive care lengths-of-stay. 2 The authors should be congratulated for their compelling study which reminds us that RHD is a disease of inequity and reflects how immigrant, Indigenous, racialized, and lowsocioeconomic status (SES) populations still face barriers to accessing healthcare.…”

“…1 RHD is now perceived as a disease that predominantly affects low-to middle-income countries, 1 but it cannot be forgotten in other settings. Hawkins et al 2 conducted a retrospective cohort study in the United States and found that the proportion of RHD amongst all mitral valvular diseases was 12.6% and increased by 0.39%/year from 2011 to 2019. 2 Although no differences in operative mortality or morbidity were discerned, patients with RHD required longer hospital and intensive care lengths-of-stay.…”

“…Subgroup analysis may find the 0.39%/year proportional increase to be especially pronounced in low-SES communities. 2 Future studies could examine how the prevalence of RHD differs according to immigration rates, household income, and/or demographics. These findings urge researchers, policymakers, and healthcare professionals to consider how social determinants of health and access to care factor into the continued prevalence of RHD in HICs.…”

“…4 If the moral argument is insufficient in itself, the longer hospital stay associated with RHD is a powerful economic incentive to invest in primary prevention. 2 Hawkins et al's study reminds us that RHD will prevail wherever healthcare disparities exist. RHD may be "out of sight, out of mind" in HICs, but it will never be "out of heart" until its underlying social contributors are addressed.…”