Mitral regurgitation: determinants of referral for cardiac surgery by Canadian cardiologists

Abstract

Purpose: Advances in surgery permit for earlier intervention with improved outcomes for patients with mitral regurgitation (MR). Many patients still appear to be referred to surgery late in their course. Consensus guidelines were compared with the surgical referral practices for MR among Canadian cardiologists.

Methods: A self-administered questionnaire was mailed to all adult cardiologists in Canada. This included seven case scenarios, as well as direct questions designed to establish the influence of factors including atrial fibrillation, pulmonary hypertension, left ventricular (LV) dilation, experience of the cardiac surgeon, symptoms and ejection fraction (EF) on referral.

Results: There were 319 respondents; LVEF was rated as extremely important in 71.5% of patients and moderately important in 26% of patients. In asymptomatic patients, EF of 50% to 60% was correctly identified as a trigger for surgery by 57.2 % of cardiologists, while only 15.6% of cardiologists correctly referred New York Heart Association class II patients with normal LV function. The group complied in only 4.77 of the seven case scenarios. Compliance was inversely related to years in practice for asymptomatic patients with mild LV dysfunction, as well as in overall compliance. Referral practices were similar among clinicians, echocardiographers, interventional cardiologists and researchers, with no differences in geographic region or academic affiliation.

Conclusion: Compliance with published guidelines for patients with MR and either New York Heart Association class II or mild LV dysfunction among Canadian cardiologists was poor. Compliance was somewhat better in more recent graduates, suggesting the need to institute programs geared at enhancing knowledge of published standards and introduce practical tools to aid in their implementation.