Does urgent or emergent status influence choice in mitral valve operations? An analysis of outcomes from the Virginia Cardiac Surgery Quality Initiative.

BACKGROUND Urgent or emergent status is often associated with increased risk among cardiac operations. The objective of this study was to analyze outcomes and cost differences in patients undergoing elective versus urgent or emergent mitral valve replacement (MVR) and repair operations. METHODS From 2003 to 2008, 1,477 patients underwent isolated, primary mitral valve (MV) operations at 11 different centers in the Commonwealth of Virginia. Patients were stratified into four groups: elective MVR (n = 419), elective MV repair (n = 674), urgent or emergent MVR (n = 261) and urgent or emergent MV repair (n = 123). Preoperative risk, operative features, outcomes, and total costs were evaluated. RESULTS Mitral valve replacement patients had more risk factors, including advanced age. Female sex and severe mitral regurgitation were more common among MV repairs. Mitral valve replacement incurred higher operative mortality (5.2% versus 1.2%; p < 0.001), more major complications (20.6% versus 6.5%; p < 0.001), longer postoperative (10.8 days versus 6.2 days; p < 0.001) and intensive care unit (117.7 hours versus 51.4 hours; p < 0.001) duration, and greater total costs ($45,166 versus $26,229; p < 0.001) compared with MV repair operations. Postoperative length of stay was longer for elective MVR patients compared with elective MV repair patients (p < 0.001) as well as for urgent or emergent MVR patients compared with urgent or emergent MV repair patients (p = 0.001). Total hospital costs were also higher for both elective MVR (p < 0.001) and urgent or emergent MVR (p < 0.001) compared with elective MV repair and urgent or emergent MV repair. Risk-adjusted operative mortality (odds ratio, 11.4; p < 0.001) and major complication rates (odds ratio, 7.6; p < 0.001) were highest for urgent or emergent MVR. CONCLUSIONS Mitral valve repair is associated with lower morbidity, mortality, and total costs compared with MVR. For urgent or emergent operations, the improved outcomes with mitral repair versus replacement are even more profound.