Practice gaps in the care of mitral valve regurgitation: Insights from the American College of Cardiology mitral regurgitation gap analysis and advisory panel

doi:10.1016/j.ahj.2015.11.003

American Heart Journal

Volume 172, February 2016, Pages 70-79

https://doi.org/10.1016/j.ahj.2015.11.003 Get rights and content

Background

The revised 2014 American College of Cardiology (ACC)/American Heart Association valvular heart disease guidelines provide evidenced-based recommendations for the management of mitral regurgitation (MR). However, knowledge gaps related to our evolving understanding of critical MR concepts may impede their implementation.

Methods

The ACC conducted a multifaceted needs assessment to characterize gaps, practice patterns, and perceptions related to the diagnosis and treatment of MR. A key project element was a set of surveys distributed to primary care and cardiovascular physicians (cardiologists and cardiothoracic surgeons). Survey and other gap analysis findings were presented to a panel of 10 expert advisors from specialties of general cardiology, cardiac imaging, interventional cardiology, and cardiac surgeons with expertise in valvular heart disease, especially MR, and cardiovascular education. The panel was charged with assessing the relative importance and potential means of remedying identified gaps to improve care for patients with MR.

Results

The survey results identified several knowledge and practice gaps that may limit implementation of evidence-based recommendations for MR care. Specifically, half of primary care physicians reported uncertainty regarding timing of intervention for patients with severe primary or functional MR. Physicians in all groups reported that quantitative indices of MR severity were frequently not reported in clinical echocardiographic interpretations, and that these measurements were not consistently reviewed when provided in reports. In the treatment of MR, nearly 30% of primary care physician and general cardiologists did not know the volume of mitral valve repair surgeries by their reference cardiac surgeons and did not have a standard source to obtain this information. After review of the survey results, the expert panel summarized practice gaps into 4 thematic areas and offered proposals to address deficiencies and promote better alignment with the 2014 ACC/American Heart Association valvular disease guidelines.

Conclusion

Important knowledge and skill gaps exist that may impede optimal care of the patient with MR. Focused educational and practice interventions should be developed to reduce these gaps.

Section snippets

Background

Mitral regurgitation (MR) is one of the most common valvular lesions. Contemporary treatment options include medical therapy, surgical mitral valve repair or replacement, and recently, percutaneous mitral valve repair. Guidelines on the evaluation and treatment for patients with valvular heart disease (VHD) are important consensus documents that help to standardize and optimize MR care.1, 2 Previous survey-based studies indicate that MR is often undertreated and that practice patterns are often

Phase 1: Literature review

Between June and August 2013, the ACC Education Needs Assessment and Research group compiled and analyzed the published literature as well as existing ACC data sources to characterize knowledge, practice gaps, and potential barriers to optimal practice. The findings from this initial effort informed the subsequent phases of the project.

Phase 2: Physician interviews

The ACC Education Needs Assessment and Research group gathered and analyzed qualitative data via interviews with 16 practicing US cardiologists and

Sample characteristics

A total of 297 US physicians responded to the set of 3 surveys, including 89 respondents to the primary care survey, 105 respondents for the general cardiologist survey, and 103 respondents for the cardiovascular subspecialist survey. Demographic characteristics of respondents for each survey are shown in Table I.

Perceived barriers to MR care

From a broad perspective, perceived, significant barriers to providing optimal care for the patient with MR are shown in Table II. Only 23.6%, 41.9%, and 41.7% of respondents to the

Discussion

Based on the compilation of data analysis, interviews, surveys, and advisory panel meeting led by the ACC Education Needs Assessment and Research group, several high-priority practice gaps were identified. For each practice gap, the expert advisory panel has outlined educational needs aligned with recommendations from the 2014 AHA/ACC valvular disease guidelines² and proposals to improve the care of patients with MR (Table VI).

Acknowledgment

This needs assessment and gap analysis was supported by a grant from Abbott Vascular.

References (24)

R.A. Nishimura et al.
2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
J Am Coll Cardiol
(2014)
K.M. Harris et al.
Practice variation among cardiovascular physicians in management of patients with mitral regurgitation
Am J Cardiol
(2009)
P. Thavendiranathan et al.
Quantitative assessment of mitral regurgitation: validation of new methods
J Am Coll Cardiol
(2012)
S. Uretsky et al.
Discordance between echocardiography and MRI in the assessment of mitral regurgitation severity: a prospective multicenter trial
J Am Coll Cardiol
(2015)
D.D. Glower
Surgical approaches to mitral regurgitation
J Am Coll Cardiol
(2012)
D.S. Lim et al.
Improved functional status and quality of life in prohibitive surgical risk patients with degenerative mitral regurgitation after transcatheter mitral valve repair
J Am Coll Cardiol
(2014)
S. Biner et al.
Reproducibility of proximal isovelocity surface area, vena contracta, and regurgitant jet area for assessment of mitral regurgitation severity
JACC Cardiovasc Imaging
(2010)
W.A. Zoghbi et al.
Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography
J Am Soc Echocardiogr
(2003)
M.H. Picard et al.
American Society of Echocardiography recommendations for quality echocardiography laboratory operations
J Am Soc Echocardiogr
(2011)
T.E. David et al.
A comparison of outcomes of mitral valve repair for degenerative disease with posterior, anterior, and bileaflet prolapse
J Thorac Cardiovasc Surg
(2005)

D.M. Shahian et al.

Public reporting of cardiac surgery performance: part 2—implementation

Ann Thorac Surg

(2011)

D.M. Shahian et al.

The Society of Thoracic Surgeons isolated aortic valve replacement (AVR) composite score: a report of the STS Quality Measurement Task Force

Ann Thorac Surg

(2012)

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Valvular heart diseases (VHDs) pose a significant public health burden, and deciding the best treatment strategy necessitates accurate assessment of heart valve function. Transthoracic echocardiography (TTE) is the key modality to evaluate VHDs, but the lack of standardized quantitative measurements leads to subjective and time-consuming assessments. We aimed to use deep learning to automate the extraction of mitral valve (MV) leaflets and annular hinge points from echocardiograms of the MV, improving standardization and reducing workload in quantitative assessment of MV disease.
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Limited data exists regarding the relationships between resource use and outcomes in patients with mitral regurgitation (MR). We examined resource utilization and outcomes across MR type and severity.
Using the Duke Echocardiography Laboratory Database, we identified patients with an index echo demonstrating moderate or severe MR (2000-2016) and examined 5-year cumulative rates of resources (ie, TTE, TEE, cardiac catheterization, cardiology/CTS referral, MV surgery/TEER, hospitalizations) by severity and type. We performed a multivariable landmark analysis of resource use during a 6 to 12 month period and 5-year mortality; and a multivariable analysis of the association between MR type and 5-year hospitalization costs.
Among 4,511 patients with moderate or severe MR, 84.7% had moderate MR and 42.2% had secondary ischemic MR. The median age was 70 years-moderate, 66 years-severe. The mean 5-year cumulative resource utilization rate was 11.1 encounters/patients. Among patients with moderate or severe MR, there was significant variation in utilization of each resource by MR type (all P < .05). For severe MR, the performance of cardiac catheterization or MV surgery during the landmark period was associated with significantly lower mortality; for moderate MR, CTS referral during the landmark was associated with significantly lower mortality (P < .05). Patients with secondary ischemic and non-ischemic MR had significantly higher 5-year hospitalization costs compared with primary myxomatous MR (P < .05).
Resource utilization and outcomes vary by MR type and severity. Utilization of resources, such as TTE, during guideline-recommended surveillance periods was not associated with a reduction in mortality while other care (catheterization or surgery) was associated with improved survival.
Reply: Misinterpretation of American Society of Echocardiography Mitral Regurgitation Algorithm?
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Citation Excerpt :
To date, auscultation has been the historical tool for detecting VHD, especially in asymptomatic patients. Nevertheless, auscultation may have some limitations in current practice and has limited sensitivity.26,27 In our study, only 54.1% of cases of VHD were identified on auscultation, but its reliability was better in the case of significant VHD.
The authors assessed the performance of pocket-sized transthoracic echocardiography (pTTE) compared with standard transthoracic echocardiography (sTTE) and auscultation for early screening of valvular heart disease (VHD). Early diagnosis of significant VHD is a challenge, but it enables appropriate follow-up and implementation of the best therapeutic strategy.
sTTE, pTTE, and auscultation were performed by three different experienced physicians on 284 unselected patients. All cases of VHD detected by each of these three techniques were noted. sTTE was the gold standard. Each physician performed one examination and was blinded to the results of other examinations.
We diagnosed a total of 301 cases of VHD, with a large predominance of regurgitant lesions: 269 cases (89.3%) of regurgitant VHD and 32 (10.7%) of stenotic VHD. pTTE was highly sensitive (85.7%) and specific (97.9%) for screening for VHD, while auscultation detected only 54.1%. All significant cases of VHD (at least mild severity) were detected on pTTE. The weighted κ coefficient between pTTE and sTTE for the assessment of mitral regurgitation was 0.71 (95% CI, 0.70–0.72), indicating good agreement. The weighted κ coefficients between pTTE and sTTE for the assessment of aortic regurgitation and aortic stenosis were 0.97 (95% CI, 0.96–0.98) and 0.98 (95% CI, 0.97–0.99), respectively, indicating excellent agreement.
pTTE performed by physicians with level III competency in echocardiography is reliable for identifying significant VHD and should be proposed as a new screening tool.
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The Update focuses on chronic MR, specifically, as a result of recognized knowledge and practice gaps related to the management of chronic MR among cardiovascular subspecialists. In a recent ACC survey, up to 32% of participants reported frequent absence of quantitative MR evaluation in their practice, and 26% reported frequent uncertainty about when surgical intervention was needed for functional MR.8 Etiology, mechanism, and severity define MR and guide its management.
The recently published “2020 Focused Update of the 2017 ACC Expert Consensus Decision Pathway on the Management of Mitral Regurgitation” provides a framework for the clinical and echocardiographic assessment of mitral regurgitation and describes considerations for the medical, surgical, and transcatheter treatment of mitral regurgitation. The Update provides guidance for clinicians in light of the significant interim developments since the 2017 recommendations, particularly in the areas of secondary mitral regurgitation and transcatheter mitral valve repair. The present review focuses on the aspects of the Update that are most relevant to the cardiac anesthesiologist, with emphasis on the integrated assessment of mitral regurgitation with echocardiography and the indications and considerations for the surgical and transcatheter management of mitral regurgitation.
Basic Principles of the Echocardiographic Evaluation of Mitral Regurgitation
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Mitral regurgitation (MR) is a common form of valvular heart disease that is associated with significant morbidity and mortality. Treatment decisions are completely dependent on accurate diagnosis of both mechanism and severity of MR, which can be challenging and is often done incorrectly. Transthoracic echocardiography is the most commonly used imaging test for MR; transesophageal echocardiography is often needed to better define morphology and MR severity, and is essential for guiding transcatheter therapies for MR. Multidetector computed tomography has become the standard to assess whether transcatheter valve replacement is an option because of its ability to assess valve sizing, access, and potential left ventricular outflow tract obstruction. Finally, cine cardiac magnetic resonance has been recommended by recent guidelines to quantify MR severity when the distinction between moderate and severe MR is indeterminate by echocardiography. This paper focuses on the main questions to be answered by imaging techniques and illustrates some common tips, tricks, and pitfalls in the assessment of MR.

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Special ArticlePractice gaps in the care of mitral valve regurgitation: Insights from the American College of Cardiology mitral regurgitation gap analysis and advisory panel

Background

Methods

Results

Conclusion

Section snippets

Background

Phase 1: Literature review

Phase 2: Physician interviews

Sample characteristics

Perceived barriers to MR care

Discussion

Acknowledgment

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

JACC Cardiovasc Imaging

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Special Article
Practice gaps in the care of mitral valve regurgitation: Insights from the American College of Cardiology mitral regurgitation gap analysis and advisory panel