Mitral valve prosthesis choice for patients aged 65 years and over in the UK. Are the guidelines being followed and does it matter?

Abstract

Objective Current guidelines recommend that most patients aged ≥65 years should undergo mitral valve replacement (MVR) using a biological prosthesis. The objectives of this study were to assess whether these guidelines are being followed in UK practice, and to investigate whether the guidelines are appropriate based on in-hospital mortality and mid-term survival. Methods Data from the National Institute for Cardiovascular Outcomes Research Adult Cardiac Surgery Audit database from all National Health Service (NHS) hospitals and some private hospitals performing adult cardiac surgery in the UK between April 2001 and March 2011 were analysed. The overall cohort included 3862 patients aged ≥65 years who underwent first-time MVR. Propensity score matching and regression adjustment were used to compare outcomes between prosthesis groups. Results The mean age was 73.0 years (SD 4.9) with 50% of patients having surgery with a mechanical prosthesis. This proportion decreased over the study period and with increasing patient age with marked variation between hospitals. In the propensity-matched cohort, in-hospital mortality in the biological group was 6.9%, and in the mechanical group it was 5.9% giving an unadjusted OR of 1.17 (95% CI 0.84 to 1.63). There was no significant difference in mid-term survival between the matched groups with an unadjusted HR for biological prosthesis of 1.08 (95% CI 0.93 to 1.24). Similar results were found when using regression adjustment on unmatched data. Conclusions Current guidelines concerning age and mitral valve prosthesis choice are not being followed for patients aged ≥65 years. With regards to in-hospital and mid-term mortality, this study demonstrates that there is no difference between prosthesis types.

Outcomes following repair of anomalous coronary artery from the pulmonary artery in infants: results from a procedure-based national database

“…Nevertheless, the NICOR curated database is sufficiently robust to allow fresh insights into both adult and congenital procedures. 12–14 The main limitations in this study are the lack of clinical, operative and echocardiographic data. At the time of the analysis, CCAD did not differentiate between ALCAPA and ARCAPA, although considering the particularities of infants presenting with this anomaly, it is safe to assume that the majority are indeed patients with ALCAPA.…”

Guidelines is not, and should not be, the Law of the Land

“…However, if a patient has bleeding which necessitates discontinuing warfarin, there is risk of thrombosis of the PHV. In the Dimarakis study,1 the incidence of atrial fibrillation was 52%. In the two randomised trials,4 5 the incidence of atrial fibrillation was 55% and 74%, and the incidence of significant bleeding was 10–37% in the porcine valve group and was 53% in the mechanical valve group.…”

“…Dimarakis et al 1 present data from patients aged ≥65 years who had mitral valve replacement (MVR)±coronary artery bypass graft±concomitant tricuspid valve repair from 2001 to 2011. Data are largely from NHS hospitals in England and Wales.…”