Socioeconomics Affect Mitral Valve Repair Outcomes

Investigators from the Smidt Heart Institute at Cedars-Sinai have found that community-level socioeconomic disparities are associated with worse three-year survival rates for patients with degenerative mitral regurgitation who had valve repair surgery.

The findings, recently published in the Journal of Thoracic and Cardiovascular Surgery, showed that patients from socioeconomically distressed communities had an approximate 20% increased risk of three-year mortality after their mitral valve repair, and an almost 30% increased risk of heart failure readmission.

Previous studies had demonstrated mixed results regarding racial disparities in mitral valve repair rates and short-term outcomes, and little was known about the midterm impact of socioeconomic distress on repair outcomes.

“Our findings add to the growing body of literature highlighting that racial and socioeconomic disparities exist in cardiovascular health and in cardiac surgical outcomes and that they impact overall long-term care,” said Jad Malas, MD, a  cardiothoracic surgery resident in the Smidt Heart Institute and lead author of the study. “Even when narrowing our research to focus on a very specific population of patients undergoing a very specific surgery, disparities still exist.”  

To conduct the study, investigators used data from the Centers for Medicare and Medicaid Services to identify 10,322 patients who were undergoing first-time isolated surgical repair for degenerative mitral regurgitation between 2012 and 2019.

They used the Distressed Communities Index, which has previously predicted poor cardiac surgical outcomes, to classify distressed patients. The Distressed Communities Index incorporates education level, poverty, unemployment, housing security, median income and business growth.

Of the 10,322 patients, 1,003 (9.7%) came from distressed communities and were more often female (55.3% from distressed communities vs. 50.5% from nondistressed communities) and Black (11.6% vs. 2.7%). Additionally, they had mitral valve surgery at lower-volume centers (11 cases per year vs. 16 cases per year) and traveled farther for surgery (40 miles vs. 17 miles).

Post-repair survival rates at three years in patients from socioeconomically distressed communities and nondistressed communities was 85.4% and 89.7%, respectively.

Investigators noted that potential ways to address this disparity could include improving access to high-volume centers and earlier referral for mitral valve surgery, before the disease worsens. But, they added that access to high-volume centers alone would likely not be sufficient to resolve the disparity in midterm outcomes, which is influenced by other factors.

“Ultimately, this study demonstrates that socioeconomic status matters,” said senior and corresponding author Michael Bowdish, MD, vice chair of the Department of Cardiac Surgery. “It is important that we continue to recognize that inequities exist among patients undergoing mitral valve repair, and we hope that by understanding these disparities, we can better support these patients and ensure they continue on the right path after surgery.”

Mitral valve regurgitation affects more than 2 million Americans. Historically, heart surgeons corrected a faulty mitral valve by replacing it with an artificial one via open-heart surgery. Today, specialists are able to repair, rather than replace, the valve through minimally invasive surgery. It is low risk and successful in nearly 100% of patients having degenerative mitral valve repair in the United States.

Since 2017, the Smidt Heart Institute has received the highest national ratings for mitral valve surgery from the Society of Thoracic Surgeons, and it was recently designated a Mitral Valve Repair Reference Center by the Mitral Foundation. The institute is highly regarded for its record of superior clinical outcomes resulting from evidence-based, guideline-directed degenerative mitral valve repair.

Study author Joanna Chikwe, MD, chair of the Department of Cardiac Surgery at Cedars-Sinai, noted that the Smidt Heart Institute’s health outcomes research program is working to better understand disparities and how they impact the field and society at large.  

“The findings from the mitral outcomes study are a call to action to consider how we effectively care for patients,” said Chikwe, who also holds the Irina and George Schaeffer Distinguished Chair in Cardiac Surgery. 

“As physicians, we can work to better understand our patients—their background, where they live, the support they have at home. We can remind them about the importance of getting an echocardiogram every year and encourage follow-up visits after surgery. We need to identify factors that can help our patients have better outcomes in the long term.” 

Other Cedars-Sinai investigators involved in the study include Qiudong Chen, MD; Dominic Emerson, MD; George Gill, MD; Georgina Rowe, MD; and Alfredo Trento, MD.

Funding: The study was funded by the National Institutes of Health for advanced heart disease research (award number T32HL116273).

Read more from the Cedars-Sinai Blog: Heart Disease: When to Get a Second Opinion