Cardiac valvular surgery and history of anorectic drug intake: A retrospective study of a large population of benfluorex-exposed patients

Marcel Laurent, Pierre Vladimir Ennezat, Marie-Christine Malergue, Patrick Bruneval, on behalf of the Members of the Benfluorex Committee for the Office National d’Indemnisation des Accidents Médicaux (ONIAM)

Anorectic drugs are overlooked as a cause of valvular heart disease (VHD).

To describe the characteristics of a large population of patients with severe VHD who underwent cardiac surgery and had a history of benfluorex intake.

Retrospective observational and cross-sectional study of patients from a large French database (Office National d’Indemnisation des Accidents Médicaux). Clinical, echocardiographic, surgical and pathology findings were comprehensively collected from medical files.

From a chart review of 9584 subjects, 1031 patients with VHD underwent cardiac surgery; 453 surgical patients were excluded because of VHD obviously unrelated to benfluorex exposure, six because of missing data and eight declined to participate. The final study population comprised 564 patients who had surgery between 1987 and 2019. Median age was 58 (interquartile range 50—65) years; 85% were female. Median duration of preoperative benfluorex exposure was 5.8 (3.3—10) years. Most patients had aortic and mitral valve disease. Pure or predominant aortic and/or mitral regurgitation were found in 84% of patients (n = 471), and aortic or mitral stenosis (pure or combined with regurgitation) in 12% (n = 67) and 15% (n = 84), respectively. Overall, 403 aortic, 402 mitral and 64 tricuspid valve surgical procedures were collected. Aortic and mitral valves were found to be thickened, rigid and/or restrictive in most cases; restrictive tricuspid valve disease was seldom documented. Pathology was available in half of the population (276 patients); valvular fibrosis suggestive of drug-induced VHD was found in 222 patients, including 146 with expert examination. Mixed VHD aetiologies were discussed in 107 patients, including 54 with available pathology.

Drug-induced VHD features are miscellaneous, including well-known restrictive valvular regurgitation, but also stenosis or combined regurgitation and stenosis. Besides a history of drug taking, thorough echocardiography and comprehensive surgical reports, pathology is key in the diagnostic procedure.