Structured Abstract:
Objective:
Ventricular arrhythmias occur in a subset of patients with mitral valve prolapse. However, their impact on post-operative survival after degenerative mitral repair is unclear.
Methods:
We compared long-term survival after degenerative mitral repair in patients presenting with and without arrhythmic mitral valve prolapse (defined by degenerative mitral regurgitation and ventricular arrhythmias) in a national insurance database. Our primary outcome was survival up to 5 years: our secondary outcomes were implantable cardiac defibrillator (ICD) and ventricular arrhythmia related readmissions. Multivariable adjustment accounted for baseline differences. Median follow-up was 3.8 years (IQR: 1.5–6.6).
Results:
Among 20,980 patients, 1,745 (8.3%) had arrhythmic mitral valve prolapse, of whom 1,121 (64%) underwent surgical repair and 624 (36%) underwent transcatheter edge-to-edge repair (TEER). The 5-year survival after surgical repair was 86% in patients with arrhythmic mitral valve prolapse compared to 81% in patients without (HR: 0.79, 95% CI: 0.64–0.97, p = 0.02). The 5-year survival after TEER was 34% in patients with arrhythmic mitral valve prolapse compared to 43% in patients without (HR: 1.26, 95% CI: 1.07–1.49, p < 0.001). Rates of ICD were higher following surgery in patients with arrhythmia (1.3% vs. 0.4%, p<0.01) and similar following TEER (0.6% vs. 0.4%, p=0.5).
Conclusions:
Arrhythmic mitral valve prolapse is not associated with worse survival after surgical mitral repair. However, arrhythmic mitral valve prolapse is associated with significantly worse survival after TEER. Prospective mechanistic studies are needed to elucidate the pathophysiology of and inform treatment choice in patients with arrhythmic mitral valve prolapse.
Keywords: degenerative mitral regurgitation, ventricular arrhythmia, arrhythmic prolapse, mitral repair, mitral valve surgery, transcatheter edge-to-edge repair
Central message:
Arrhythmic mitral prolapse does not increase the risk of mortality following surgical repair. Arrhythmic mitral prolapse is associated with worse survival following transcatheter edge-to-edge repair.
Central Picture:
Survival after surgical or transcatheter mitral repair stratified by arrhythmia status
Introduction
Degenerative mitral regurgitation, or mitral valve prolapse, is the most common valvopathy in the U.S, affecting over 2 million individuals and serving as the leading indication for surgical intervention for mitral regurgitation in developed countries.1 Despite increasing evidence linking mitral valve prolapse to ventricular arrhythmias and sudden cardiac death,2–4 the underlying mechanisms and optimal management strategies for arrhythmic mitral valve prolapse remain poorly understood. Mechanistic studies using magnetic resonance imaging5,6 and speckle-tracking echocardiography5,7 suggest that myxomatous changes in a prolapsed valve contribute to mechanical stretch and fibrosis in the left ventricular myocardium, creating a substrate for arrhythmias.7 It is not known whether this process is reversible following repair of the prolapsed valve thereby reducing the risk of mortality in this patient population, nor is there any data comparing the impact of repair approach on clinical outcomes. Thus, we sought to quantify the prevalence of ventricular arrhythmias in patients undergoing surgical and transcatheter repair of mitral valve prolapse and compare outcomes between those with and without a history of ventricular arrhythmia.
Methods
Study Overview
In this retrospective cohort study, we evaluated 5-year outcomes in patients undergoing mitral valve repair with degenerative mitral regurgitation using the Centers for Medicare and Medicaid Services Fee-for-Service administrative database. International Classification of Diseases, Ninth Revision (ICD-9) or International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10) diagnosis and procedure codes were used to identify patients who underwent isolated surgical or transcatheter mitral valve repair between 2011 and 2019, as well as to capture baseline comorbidities documented during the index hospitalization, inpatient admissions, and outpatient visits within two years preceding the repair (Supplementary tables 1–3). Patients without Medicare continuous enrollment or at least 1-year of Medicare coverage and patients with a history of cardiac surgery or who underwent concomitant procedures, including aortic, valve (aortic, tricuspid, pulmonic) coronary artery bypass grafting, ventricular assist device implantation, or heart transplantation were excluded (Supplementary figure 1). We did not exclude patients with concomitant atrial ablation or appendage closure or prior percutaneous coronary intervention.
Patients were further excluded if they did not have degenerative mitral regurgitation, which we identified by excluding patients with a history of endocarditis, congenital heart disease, rheumatic heart disease, myocardial infarction or cardiomyopathy. Patients were separately considered to have degenerative mitral regurgitation if they carried an ICD-10 diagnosis of mitral valve prolapse. Arrhythmic mitral valve prolapse was defined as the presence of degenerative mitral regurgitation and a history of ventricular arrhythmias.
Presence of mitral valve prolapse, and ventricular arrhythmia was validated against clinical records of 1,911 patients that underwent mitral valve repair at a single institution between 2004 and 2024 (Supplementary table 4). We defined the “true” presence of arrhythmic mitral prolapse based on the European Heart Rhythm Association and European Society of Cardiology consensus statement which requires the following for diagnosis: the presence of mitral valve prolapse (with or without mitral annular disjunction) with the presence of ventricular arrhythmia that is either frequent (≥5% burden of total premature ventricular contractions) or complex (nonsustained ventricular tachycardia, ventricular tachycardia or ventricular fibrillation) and the absence of any other well-defined arrhythmic substrate.8 ICD coding for identifying ventricular arrhythmia had a 78.4% positive predictive value and 94.1% negative predictive value (Supplementary table 4) while ICD coding of degenerative mitral regurgitation had a 92.2% positive predictive value and 71.4% negative predictive value. This study was approved by Cedars-Sinai Internal Review Board with waiver of informed consent (STUDY00001188; approved 2/19/2021).
Study endpoints
The primary end point was all-cause mortality through 5 years follow-up. Secondary endpoints included cumulative incidence of new ICD placement and first ventricular arrhythmia related readmission as well as 30-day mortality and cardiac arrest. Deaths were identified from the Master Beneficiary Summary File. All secondary end points were defined using ICD-9 or ICD-10 diagnosis and procedure codes. Ventricular arrhythmia readmission was defined as time to first readmission with ventricular arrhythmia as the primary diagnosis on hospital admission. Median follow up time was 4.5 years [2.1, 7.1] in the surgical groups and 1.33 [0.5, 2.6] years in the TEER group.
Primary Unadjusted Analysis
Patient characteristics were summarized as frequencies and percentages for categorical variables, and as median [Q1, Q3] for continuous variables. Baseline characteristics were compared in the surgical and TEER groups between those with ventricular arrhythmia and without.
Five-year survival, cumulative incidence of new ICD placement and first-time readmission for ventricular arrhythmia was reported as hazard ratios (HR) or adjusted hazard ratio (aHR) with 95% confidence intervals (CI). Competing risk analysis was used to estimate the probability of five-year secondary outcomes with death as the competing risk event, as previously described, and the results are reported as sub-distribution HRs with 95% CI.9 The proportional hazard assumption for all competing risk analyses was tested using the Supremum test. For all-cause mortality, Kaplan-Meier survival curves were estimated in all patients, to test the equality of the survival curves by ventricular arrhythmia status.
Sensitivity Analysis
The primary outcome was assessed following multivariable adjustment and balancing score weighting and balancing score matching to evaluate sensitivity. We calculated the Charlson index, a previously validated score that allows mortality assessment based on 19 comorbid conditions weighted according to the degree to which they predicted mortality among an inpatient cohort, then summed to produce an index score.10 Multivariable adjustment was performed across 22 baseline characteristics that were prognostically important for the outcome including age, sex and race but not prior ICD placement (Table 1). Balancing score was computed on the same 22 baseline characteristics as well as Charleson comorbidity index.11 Balancing score weighting was performed by inverse probability weighting excluding those with inverse probability weight>10 and matching weights.12 Matching was performed with a greedy nearest neighbor approach, using a 1:1 ratio and a caliper width of 0.1 of the balance score. Standardized mean differences were reported for all variables before and after balance score weighting and matching. Standardized mean differences were used to evaluate covariate balance, with thresholds of ≤10% indicating good balance and ≤20% indicating acceptable balance.
Table 1.
Baseline characteristics of patients with and without ventricular arrhythmias (VA) undergoing surgical repair and TEER. Descriptive statistics are reported as either median [Q1, Q3] or count
| Surgical Repair | TEER | |||||
|---|---|---|---|---|---|---|
|
|
||||||
| Variable | Ventricular Arrhythmia (n= 1121) | No Ventricular Arrhythmia (n=15974) | Standardized difference (%) | Ventricular Arrhythmia (n= 624) | No Ventricular Arrhythmia (n=3261) | Standardized difference (%) |
|
|
|
|
|
|
|
|
| Age | 72 [68,77] | 72 [68,77] | 1.2 | 83 [77, 87] | 84 [78, 87] | 8.0 |
| Female Sex | 528(47) | 7907 (50) | 6 | 303 (48) | 1885 (58) | 5.0 |
| Atrial fibrillation | 609 (54) | 6064 (38) | 33 | 450 (72) | 2038 (63) | 20 |
| Prior ICD | 127 (11) | 502 (3) | 32 | 101 (16) | 68 (2.1) | 50 |
| Myocardial Infarction | 86 (8) | 237 (2) | 30 | 147 (23) | 339 (10) | 34 |
| Coronary Artery Disease | 672 (60) | 6898 (43) | 34 | 491 (77) | 2139 (66) | 25 |
| Chronic kidney disease | 214 (19) | 2003 (13) | 18 | 297 (47) | 1234 (38) | 17 |
| Heart failure | 677 (60) | 7712 (48) | 25 | 596 (93) | 2773 (85) | 26 |
| Obstructive lung disease | 247 (22) | 2707 (17) | 13 | 272 (43) | 1107 (34) | 18 |
| Hypertension | 920 (82) | 10079 (63) | 44 | 595 (95) | 2992 (92) | 14 |
| Hyperlipidemia | 792 (71) | 8173 (51) | 41 | 503 (81) | 2418 (74) | 16 |
| Urgent | 87 (8) | 1579 (10) | 7.0 | 87 (14) | 453 (14) | 0.1 |
| Charleson Index | 2 [1,3] | 1 [0,2] | 34 | 3 [2,6] | 1 [1,4] | 34 |
| Liver Disease | 171 (15) | 1380 (9) | 44 | 148 (24) | 527 (16) | 19 |
| Cancer | 314 (28) | 2903 (18) | 24 | 282 (45) | 1231 (38) | 15 |
| Prior permanent pacemaker | 154 (13) | 887 (5.6) | 27 | 211 (31) | 591 (18) | 35 |
| Immobility | 96 (8) | 866 (5.6) | 12 | 187 (29) | 824 (25) | 9 |
| Cognitive Dysfunction | 61 (5.3) | 465 (2.9) | 12 | 105 (17) | 445 (14) | 8 |
| Dialysis | <10 (0.7) | 161 (1.0) | 3.3 | 22 (3.4) | 93 (2.9) | 3 |
| Diabetes | 194 (17) | 2146 (14) | 9.7 | 192 (30) | 823 (25) | 11 |
| Stroke | 33 (2.9) | 341 (2.1) | 0.05 | 66 (10) | 208 (6.4) | 14 |
| Peripheral Vascular Disease | 243 (21) | 2017 (13) | 23 | 227 (36) | 967 (30) | 12 |
| Cerebrovascular Disease | 255 (20) | 2153 (14) | 17 | 207 (32) | 876 (27) | 12 |
| Thromboembolism | 59 (5.1) | 305 (1.9) | 18 | 79 (12) | 240 (7) | 17 |
A significance level of 5% was utilized. All analyses were conducted using SAS version 9.4 (SAS Institute, Cary, NC) and R Studio (version 2024.12.0+467).
Results
A total of 20,980 mitral valve repairs for degenerative mitral regurgitation were performed during the study period, of which 1,745 (8.3%) were in patients with arrhythmic mitral valve prolapse (Supplementary Figure 1). Of those with arrhythmic mitral valve prolapse, 1,121 (64%) underwent surgical repair, while 624 (36%) underwent TEER.
Patients with arrhythmic prolapse were more likely to have a history of heart failure (72% vs. 55%, p<0.01), prior ICD placement (17% vs. 4.7%, p<0.01), and a higher burden of clinical comorbidities (Charlson Score 3 (1,5) vs. 1 (1,4) p<0.01) compared with those without ventricular arrhythmias (Table 1, Table 2).
Table 2.
Unadjusted primary and secondary outcomes at 5 years in patients undergoing degenerative mitral valve repair in the Medicare cohort.
| Variable | Surgical Repair | TEER | ||||
|---|---|---|---|---|---|---|
|
| ||||||
| Ventricular Arrhythmia (n= 1121) | No Ventricular Arrhythmia (n=15974) | Hazard Ratio* | Ventricular Arrhythmia (n= 624) | No Ventricular Arrhythmia (n=3261) | Hazard Ratio* | |
|
| ||||||
| Survival | 82.8 (78.4–86.4) | 81.0 (80.3–81.7) | 0.79 [0.60–0.97] | 33.4 (22.5 –45.2) | 42.7 (39.3–46.0) | 1.26 [1.07–1.49] |
| New ICD Placement | 5.75 (3.90–8.13) | 3.30 (3.0–3.61) | 1.83 [1.33–2.54] | 2.63 (1.25–4.87) | 2.09 (1.23–2.52) | 1.70 [0.87–3.31] |
| Ventricular Arrhythmia Re-admissions | 13.7 (11.3–16.4) | 4.96 (4.62–5.31) | 2.59 [2.17–3.10] | 2.57 (1.92–3.37) | 1.23 (3.61–8.42) | 2.30 [1.50–3.53] |
Compared with no ventricular arrhythmia. Incidence statistics are reported as (%, 95% CI) or HR [95% CI].
Effect of Ventricular Arrhythmia on Outcomes following Surgical Repair
In the unadjusted analysis, patients with arrhythmic mitral valve prolapse had better survival following surgical mitral valve repair compared to those with non-arrhythmic mitral valve prolapse (86% vs 81%; HR: 0.79, 95% CI: 0.64–0.97, p = 0.02, Figure 1A,). However, there was no significant difference in five-year survival after adjustment (aHR: 1.02, 95% CI: 0.82–1.27, p = 0.8, Figure 1A).
Figure 1.
Survival in patients undergoing a) surgical repair and b) TEER stratified by ventricular arrhythmia status. 95% confidence limits shown.
At 5 years ICD implantation was significantly higher in patients with arrhythmic mitral prolapse compared to those without (5.8% vs. 3.1%, p = 0.0001, Table 2), even after adjusting for competing risk of death (Figure 2). Similarly, patients with arrhythmic mitral prolapse were more likely to have a ventricular arrhythmia-related readmission (14% vs. 4.9%, p < 0.0001, Table 2, Figure 2).
Figure 2.
Cumulative incidence of ICD implantation in patients undergoing a) surgical repair b) TEER after adjusting for competing risk of death. 95% confidence limits shown.
Effect of Ventricular Arrhythmia on Outcomes following TEER
Among patients undergoing TEER, those with ventricular arrhythmias had worse survival than those without in both the unadjusted analysis (34% vs 43%; HR: 1.26, 95% CI: 1.07–1.49, p < 0.001, Figure 1B) and adjusted analysis (aHR: 1.19, 95% CI: 1.01–1.41, p = 0.04, Figure 1B).
At five years, ICD implantation rates remained comparable between groups (2.8% vs. 2.1%, p = 0.09, Table 2) after adjusting for competing risk of death (Figure 2). However, ventricular arrhythmia-related readmission was more likely in patients with ventricular arrhythmias compared to those without (5.8% vs. 2.4%, p < 0.001, Table 2, Figure 3).
Figure 3.
Cumulative incidence of ventricular arrhythmia related readmissions in patients undergoing a) surgical repair b) TEER after adjusting for competing risk of death. 95% confidence limits shown.
Sensitivity analysis on primary outcome of death
The primary outcome of death was analyzed following inverse probability balancing score weighting, matching weights and balancing score matching (Table 3). Following weighting, survival was similar between patients with vs without arrhythmic mitral valve prolapse following surgical but worse following TEER (Table 3). Balancing score matching on arrhythmic prolapse status yielded 1,108 well-matched patient pairs in the surgical repair group and 606 well-matched patient pairs in the TEER group (Supplementary figure 2, 3). Unmatched patients with arrhythmic mitral valve prolapse in the surgical group were more likely to have coronary artery disease and atrial fibrillation (Supplementary figure 2) while unmatched patients in the TEER group were also more likely to have heart failure and previous pacemaker (Supplementary figure 3). Matched survival rates were 83% for patients with arrhythmic prolapse and 79% for those without after surgical repair (HR: 0.78, 95% CI: 0.60–1.01, p = 0.06, Supplementary figure 4, Table 3). Following TEER, matched survival was not significantly different between those with and without arrhythmic mitral prolapse (34% vs 41%; HR: 1.10, 95% CI: 0.89–1.36, p = 0.4, Supplementary figure 4, table 3).
Table 3.
Sensitivity analysis for primary outcome of survival following adjustment, balancing score weighting and balancing score matching.
| Analysis | Surgical Repair | TEER |
|---|---|---|
| Hazard Ratio* | Hazard Ratio* | |
| Unadjusted survival | 0.79 [0.60–0.97] | 1.26 [1.07–1.49] |
| Adjusted survival | 1.02 [0.84–1.27] | 1.19 [1.01–1.41] |
| Truncated inverse-probability weighted survival | 0.92 [0.63–1.35] | 1.21 [1.01–1.46] |
| Matching weights-weighted survival | 0.82 [0.64– 1.05] | 1.31 [1.01–1.56] |
| Balancing score-matched survival | 0.78 [0.60–1.01] | 1.10 [0.89–1.36] |
Compared to non-arrhythmic mitral valve prolapse. Hazard ratio reported with [95% CI].
Interaction Between TEER and Arrhythmic Mitral Prolapse in Adjusted Analysis
In the adjusted analysis, patients with ventricular arrhythmias had worse adjusted survival with TEER compared to surgical repair (aHR: 3.33 [95% CI: 2.36–4.71]). This difference was less pronounced in patients without ventricular arrhythmias (aHR: 2.38 [95% CI: 1.75–3.25]). Additionally, a significant interaction was found between TEER and ventricular arrhythmias for the risk of death (p=0.04).
Discussion
This analysis represents the first population-level analysis of outcomes following repair of arrhythmic mitral valve prolapse (defined as a history of ventricular arrhythmias and degenerative mitral regurgitation) in patients over 65 years and yielded three key findings. First, the prevalence of pre-operative ventricular arrhythmias was 8.3%. Second, despite the known association between ventricular arrhythmias and adverse outcomes, five-year survival following surgical repair did not significantly differ between patients with and without arrhythmias. Third, arrhythmic mitral valve prolapse was associated with worse survival following TEER.
The 8.3% prevalence of ventricular arrhythmias in this cohort is approximately threefold higher than that reported in healthy older adults13,14 yet lower than the rates observed in broader cohorts with degenerative mitral valve prolapse, where the prevalence of ventricular arrhythmias—typically defined by ≥5% premature ventricular contractions or nonsustained ventricular tachycardia—ranges from 21% to 42%.15–17 Among patients referred for surgical mitral valve repair, the prevalence is closer to 11%.18 Notably, only about 35% of patients with arrhythmic mitral prolapse have severe mitral regurgitation15 and the majority of sudden cardiac deaths in this population occur in those without severe regurgitation.3,19 Current guidelines recommend valve repair for patients with severe mitral regurgitation but do not include ventricular arrhythmias as an indication for intervention.20 As a result, many patients with arrhythmic mitral prolapse—particularly those without severe regurgitation—are not referred for valve repair, which likely contributes to the relatively low prevalence of arrhythmia observed among those undergoing surgical repair or TEER.
Patients with arrhythmic mitral valve prolapse who underwent surgical mitral valve repair had similar five-year survival to those without arrhythmia. This aligns with findings from prior smaller-scale studies, including one by Essayagh et al., which demonstrated that in a cohort of 257 patients, arrhythmic mitral valve prolapse was associated with higher long-term mortality in the overall cohort, but not in those who underwent surgical repair.15,21 Our national analysis suggests that surgical mitral valve repair may normalize life expectancy in patients with arrhythmic mitral valve prolapse. Interestingly, patients with ventricular arrhythmias in the surgical group had better survival than those without, potentially due to increased utilization of long-term cardioprotective therapies, including beta blockers and implantable cardioverter-defibrillators. However, this difference was not statistically significant after adjusting for confounding. Surgical repair may modify risk factors for ventricular arrhythmia, although the effect of repair type on arrhythmic burden is unknown.
Compared to those without arrhythmia, patients with ventricular arrhythmia have 7% lower survival following TEER, while survival was 4% higher after surgical repair. These trends persisted after multivariable adjustment, balancing score weighting and matching, though statistical significance was reduced after matching due to a smaller sample size. As the use of TEER continues to grow among patients who would have traditionally been considered for surgery, future prospective studies should re-evaluate the arrhythmic risks associated with this approach.22 As the use of TEER continues to grow among patients who would have traditionally been considered for surgery, future prospective studies should re-evaluate the arrhythmic risks associated with this approach. There are currently three ongoing randomized clinical trials—MITRA HR for high-risk patients, REPAIR MR for patients over 75 or at intermediate surgical risk, and PRIMARY for patients over 65 regardless of surgical risk— that are expected to provide comparative data on transcatheter mitral valve repair versus surgery.23–25 In the PRIMARY trial, we will be collecting detailed rhythm monitoring and cardiac magnetic resonance imaging data from participants to assess the relationship between valve intervention, ventricular arrhythmias, and myocardial fibrosis.
Unmatched patients were more likely to have complex cardiac disease, including atrial fibrillation (with pacemaker placement), heart failure, and coronary artery disease, along with risk factors such as hypertension and hyperlipidemia. These unmatched cases may represent more severe forms of ventricular arrhythmias, potentially linked to irreversible fibrosis associated with these comorbidities.26,27 Notably, the number of unmatched patients was low in both the surgical and TEER groups, suggesting that they do not represent the broader patient population. Nevertheless, these findings may not be generalizable to patients with severe arrhythmic mitral valve prolapse. Further risk stratification is necessary to identify which patients with arrhythmic mitral valve prolapse remain at high risk for malignant arrhythmias and may benefit from more aggressive therapies.28,29
Strengths and Limitations
The key strengths of this study include its large sample size, representing roughly 50% of patients undergoing mitral valve repair, its use of clinically validated codes and its evaluation of morbidity and mortality outcomes beyond 30 days. As the study design is retrospective and observational, we are not able to eliminate confounding due to selection bias, particularly for assessing treatment choice. We did try to address this concern by utilizing both multivariable regression balance score weighting, and matching, but these methods can only control for variables available in the dataset. Additionally claims databases have limited capacity to capture important clinical and anatomical characteristics, specifically in classifying mitral regurgitation etiology and degree of ventricular arrhythmias. Consequently, our ability to accurately identify cases of arrhythmic mitral prolapse is restricted, which may have resulted in an underestimation of the true prevalence.
Conclusion
Preoperative ventricular arrhythmia is present in 8.3% of patients over 65 undergoing mitral valve repair for degenerative disease. At five years, survival following surgical repair was similar regardless of arrhythmia status. However ventricular arrhythmia was associated with worse survival following TEER. Surgery may help normalize survival in this population; prospective studies are needed to clarify the impact of treatment choices on survival and arrhythmic burden.
Supplementary Material
Supplemental Figure 3. Quality of balancing matching of patients with and without arrhythmic mitral valve prolapse undergoing TEER. A) Mirrored histogram of distribution of balancing scores for arrhythmic prolapse and non-arrhythmic prolapse groups. Shaded areas represent 606 in the TEER group. Unshaded areas represent unmatched patients. B) Standardized difference of selected variables before and after matching, illustrating good matching.
Supplemental Figure 2. Quality of balancing score matching of patients with and without arrhythmic mitral valve prolapse undergoing surgical repair. A) Mirrored histogram of distribution of balancing scores for arrhythmic prolapse and non-arrhythmic prolapse groups. Shaded areas represent 1108 matched patient pairs in the surgical group. Unshaded areas represent unmatched patients. B) Standardized difference of selected variables before and after matching, illustrating good matching.
Supplemental Figure 4. Balancing score- matched survival in patients undergoing a) surgical repair and b) TEER stratified by ventricular arrhythmia status. 95% confidence intervals shown.
Supplemental Figure 1. Consort diagram of patients >65 years with and without ventricular arrhythmia undergoing surgical or transcatheter mitral valve repair for degenerative mitral regurgitation in the Medicare claims database. Cardiac surgeries and procedures excluded include all valve procedures and surgeries (aortic, pulmonic, tricuspid), aortic surgery and coronary artery bypass grafting. We did not exclude patients with concomitant atrial ablation or appendage closure or prior percutaneous coronary intervention.
Perspective statement:
Patients with arrhythmic mitral prolapse have similar survival to those without following degenerative mitral repair surgery. However, survival after transcatheter edge-to-edge repair is worse in patients with arrhythmic mitral prolapse compared to those without. Surgical repair may be a safe treatment for these patients; prospective studies are needed to clarify its effect on arrhythmic prolapse.
Glossary
- TEER
transcatheter edge-to-edge repair
- VA
Ventricular arrhythmia
- ICD
Implantable cardiac defibrillator
- HR
hazard ratio
- aHR
adjusted hazard ratio
- CI
confidence interval
Footnotes
The Institutional Review Board at Cedars-Sinai Medical Center approved this study, with waiver of informed consent (STUDY00001188; approved 2/19/2021). The others have no disclosures and no conflicts of interest.
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Associated Data
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Supplementary Materials
Supplemental Figure 3. Quality of balancing matching of patients with and without arrhythmic mitral valve prolapse undergoing TEER. A) Mirrored histogram of distribution of balancing scores for arrhythmic prolapse and non-arrhythmic prolapse groups. Shaded areas represent 606 in the TEER group. Unshaded areas represent unmatched patients. B) Standardized difference of selected variables before and after matching, illustrating good matching.
Supplemental Figure 2. Quality of balancing score matching of patients with and without arrhythmic mitral valve prolapse undergoing surgical repair. A) Mirrored histogram of distribution of balancing scores for arrhythmic prolapse and non-arrhythmic prolapse groups. Shaded areas represent 1108 matched patient pairs in the surgical group. Unshaded areas represent unmatched patients. B) Standardized difference of selected variables before and after matching, illustrating good matching.
Supplemental Figure 4. Balancing score- matched survival in patients undergoing a) surgical repair and b) TEER stratified by ventricular arrhythmia status. 95% confidence intervals shown.
Supplemental Figure 1. Consort diagram of patients >65 years with and without ventricular arrhythmia undergoing surgical or transcatheter mitral valve repair for degenerative mitral regurgitation in the Medicare claims database. Cardiac surgeries and procedures excluded include all valve procedures and surgeries (aortic, pulmonic, tricuspid), aortic surgery and coronary artery bypass grafting. We did not exclude patients with concomitant atrial ablation or appendage closure or prior percutaneous coronary intervention.