Real-world echocardiography in patients referred for mitral valve surgery: the gap between guidelines and clinical practice.
Mitral regurgitation (MR) is a common disorder for which mitral valve surgery is an established therapy. Although surgical indications are clearly defined for the management of valvular heart disease, a gap exists between current guidelines and their effective application. The study aim was to provide an insight into the diagnostic information provided for cardiac surgeons before performing mitral valve surgery. The source documents and echocardiographic studies of 100 patients, referred by nine hospitals, were screened for arguments for MR severity justifying referral for surgery. Details of the documented MR mechanism, mitral annulus (MA) size, tricuspid regurgitation (TR) severity and annulus size were also noted. According to the referring physician, MR was severe in 83% and moderate-to-severe in 17%. In the great majority of patients (98%) the MR mechanism was mentioned, although specific information on the prolapsing scallops was available in only 17% of cases. The recommended primary determinants of MR severity, vena contracta and proximal isovelocity surface area (PISA) were measured in only 22% and 31% of patients, respectively. In 94% of patients with available PISA information this was described only qualitatively. Correct image expansion using the zoom mode was performed in only 25% of these patients, and a correct adaptation of the Nyquist limit in only 6%. Tricuspid annulus measurements guiding the need for concomitant tricuspid valvuloplasty in patients with less than severe TR were reported in only 6% of patients. These data demonstrate a clear and important gap between current guidelines and real-world practice with regards to the echocardiographic diagnostic information provided to the surgeon before performing mitral valve surgery.