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Introduction

Mitral regurgitation (MR) has a prevalence of 2% in the general population and is even more common in the elderly.1 Organic (or primary) MR arises as a result of pathology affecting one or more components of the mitral valve (MV) apparatus, whereas functional (or secondary) MR is a consequence of annular dilatation and geometrical distortion of the sub-valvular apparatus secondary to left ventricular (LV) remodelling and dyssynchrony, most usually associated with cardiomyopathy or coronary artery disease.

Primary MR is usually a consequence of degenerative disease, which may remain asymptomatic for many years—intervention has generally been withheld until the onset of symptoms or evidence of haemodynamic decompensation. However, treatment algorithms have been redefined in recent years as a result of the excellent outcomes of surgical repair. International guidelines now recommend risk stratification and earlier intervention when the probability of durable repair is high and when surgery can be undertaken by experienced teams with high repair rates and low operative mortality and morbidity.2

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Current opinion
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Re:"Surgical and interventional management of mitral valve regurgitation: a position statement from the European Society of Cardiology Working Groups on Cardiovascular Surgery and Valvular Heart Disease"De Bonis, et al., 37 (2): 133-139 doi:10.1093/eurheartj/ehv322
2 April 2016
Yskert von Kodolitsch, Cardiology, Evaldas Girdauskas, Heart Surgery, Ullrich Schäfer, Cardiology
Universitäres Herzzentrum Hamburg, Universitäres Herzzentrum Hamburg, Universitäres Herzzentrum Hamburg
With interest we read the position statement on surgical and interventional management of mitral valve regurgitation (MR) [1]. Therein, the Task Force states that choices of treatment are controversial in secondary MR. For individual decision making it is recommended that a multidisciplinary Heart Team evaluates the pros and cons of surgical MR repair (MRR), percutaneous edge-to-edge repair (EER) and conservative approaches in high-risk patients. We introduce I-SWOT as a systematic approach to translate treatment recommendations into individualized medical strategies (IMS) [2, 3]. I-SWOT is an acronym that describes the analysis of evidence on strengths (S) and weaknesses (W) of therapeutic options along with the assessment of opportunities (O) and threats (T) related to individual (I) patients. Cross-tabulation of therapeutic S/T with the patients´ individual O/T identifies four types of therapeutic strategy: “SO-, or maxi-maxi-strategy” maximizing strengths and opportunities, “WT-, or mini-mini-strategy” minimizing weaknesses and threats, “WO-, or mini-maxi-strategy” minimizing weaknesses and maximizing opportunities, and “ST-, or maxi-mini-strategy” maximizing strengths and minimizing threats (Figure). To exemplify I-SWOT, we present a 72 years old male with significant three-vessel coronary artery disease, no angina, with moderate ventricular dysfunction, and with severe MR fulfilling criteria for both MRR and EER (Tables 2-4 in reference [1]). Imagine him to be a sturdy, sharp-minded and optimistic retired senior oil-drilling-engineer without symptoms. An OT-strategy with arterial coronary artery bypass grafting (CABG) and MRR may be ideal. However, if the same man has an artificial aortic valve and previous CABG, a WO-strategy with comprehensive percutaneous treatment including EER and percutaneous coronary intervention (PCI) may be the better choice. Conversely, if the patient is a depressive chain-smoker with fear for surgery who is immobilized with NYHA IV dyspnea for >6 months, only a WT-strategy may be viable. We may opt for optimized medical therapy with psychotherapeutic intervention either to initiate palliative care or to motivate for more effective therapy. With motivating psychotherapeutic intervention, a ST-strategy with immediate EER may become an option. In conclusion, I-SWOT is useful for individualized decision-making in a multidisciplinary Heart Team. Future guidelines may provide strength-weakness matrices to alleviate individualized strategic decision-making. References [1] De Bonis M, Al-Attar N, Antunes M, Borger M, Casselman F, Falk V, Folliguet T, Iung B, Lancellotti P, Lentini S, Maisano F, Messika-Zeitoun D, Muneretto C, Pibarot P, Pierard L, Punjabi P, Rosenhek R, Suwalski P, Vahanian A, Wendler O, Prendergast B. Surgical and interventional management of mitral valve regurgitation: a position statement from the European Society of Cardiology Working Groups on Cardiovascular Surgery and Valvular Heart Disease. European Heart Journal 2016;37(2):133-139. [2] von Kodolitsch Y, Bernhardt AM, Robinson PN, Kölbel T, Reichenspurner H, Debus S, Detter C. Analysis of Strengths, Weaknesses, Opportunities, and Threats as a tool for translating evidence into Individualized medical strategies (I-SWOT). AORTA 2016;3(3):98-107. [3] von Kodolitsch Y, Bernhardt AM, Kölbel T, Detter C, Reichenspurner H, Debus ES. Maximizing therapeutic success: The key concepts of individualized medical strategy (IMS). Cogent Medicine 2015;2(1):1109742.
Submitted on 02/04/2016 12:00 AM GMT