P5811Real-life management of mitral regurgitations. Lesson from a European survey

Abstract

Background: Guidelines provide recommendations for the treatment of primary and secondary mitral regurgitation (MR) but their actual knowledge and level of implementation in clinical practice is not well known. Purpose: The Education Committee of the ESC and AXDEV Group performed a mixed-methods educational needs assessment, which included a case-based evaluation of the diagnosis and management of MR in a wide panel of practitioners in Europe. Methods: The quantitative portion of the needs assessment included 3 case scenarios (severe asymptomatic primary MR, severe symptomatic primary MR in the elderly and severe secondary MR) and was conducted online from March to May 2016 in 7 countries: France, Germany, Italy, Poland, Spain, Sweden and United Kingdom. 554 practitioners participated in the study, 51 in the exploratory qualitative phase, and 503 in the quantitative phase. The quantitative phase case scenarios were answered by 108 primary care physicians (PCP), 203 general and 192 sub-specialized cardiologists. Results: Medical therapy was over-used by 19% of cardiologists as first-line treatment in asymptomatic patients with primary MR. Conversely in a patient with severe symptomatic secondary MR, optimization of medical therapy was advised as a first step by only 51% of PCPs and by only 33% of cardiologists. An asymptomatic patient with severe primary MR and an indication for surgery was not referred by the PCP to a cardiologist in 27% of cases. In asymptomatic primary MR, 73% of cardiologists appropriately stated that ESC guidelines recommend surgery and 86% recommended repair over replacement. However, only 11% recommended tricuspid annuloplasty while indicated. In an elderly patient with comorbidities and severe symptomatic primary MR, intervention on the mitral valve was considered by 72% of cardiologists. Riskbenefit analysis was appropriate for 76% of cardiologists. 75% of cardiologists considered that the MitraClip was an alternative to surgery. In a patient with severe symptomatic secondary MR and suboptimal medical therapy, cardiologists considered surgery in 28% of cases and MitraClip in 35%. When the patient remained symptomatic after optimization of medical therapy, surgery was considered in 30% of cases and MitraClip in 64% Conclusions: The management of severe MR is characterized by an over-use of medical therapy in primary MR and its under-use in secondary MR. Indications for interventions are appropriate in most asymptomatic or symptomatic patients with severe primary MR. Conversely, intervention is unexpectedly often considered for secondary MR. The use of MitraClip is frequently proposed in high-risk patients with primary or secondary MR. These findings highlight the need for educational programs to improve guideline implementation.