Banivaheb, Behrooz

Importance Current guidelines recommend consideration of surgical treatment for asymptomatic patients with severe mitral valve regurgitation, but the long-term prognosis and optimal treatment of those with moderate mitral regurgitation (MR) remain uncertain. Objective To evaluate the long-term prognostic value of baseline MR severity and the association of surgery with survival outcomes in asymptomatic patients. Design, Setting, and Participants This was a prospective cohort study with extended follow-up among 449 asymptomatic patients with holosystolic degenerative MR enrolled between January 1991 and November 2000 and followed up with through May 2025 (median [IQR] follow-up, 26 [14-29] years; maximum, 34 years) at a single tertiary referral center (the Mayo Clinic, Rochester, Minnesota). Exposure Baseline MR severity quantified by effective regurgitant orifice area (ERO). Patients were monitored under medical therapy and, when applicable, after subsequent surgical correction. Main Outcomes and Measures All-cause mortality, assessed according to baseline ERO using Cox proportional hazards models adjusted for cardiovascular risk factors. Results Among the 449 patients included, the mean (SD) age was 64 (14) years, and 278 participants (62%) were male. At baseline, 127 patients (28%) had ERO <20 mm 2 , 128 (28%) had ERO 20-39 mm 2 , and 194 (43%) had ERO ≥40 mm 2 . During follow-up, 254 patients (57%) underwent mitral valve surgery. Ten-year cumulative incidence of surgery was 18% for ERO <20 mm 2 , 64% for 20-39 mm 2 , and 88% for ≥40 mm 2 . Survival of medically treated patients declined progressively with increasing ERO category (5-year rate: 88% [<20 mm 2 ], 72% [20-39 mm 2 ], and 55% [≥40 mm 2 ]; P = .01), and multivariable analysis confirmed the incremental risk of higher ERO on a continuous scale (adjusted hazard ratio per IQR increase, 2.53; 95% CI, 1.30-4.93; P = .01). When extending the analysis through subsequent surgical follow-up, the survival difference between patients who did vs did not undergo operation widened with ERO (χ 2 3 = 8.4; interaction P = .04), starting at values above 30 mm 2 . Conclusions and Relevance In this 25-year follow-up cohort study, increasing ERO was associated with an increase in risk of mortality under medical therapy. Patients with upper-moderate MR (ERO 30-39 mm 2 ) at baseline demonstrated a significant association between surgical treatment and improved long-term survival.

Background: Valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) is an increasingly preferred strategy for managing failed surgical bioprosthetic valves, especially in high-risk patients. However, limited data exist comparing outcomes between balloon-expandable (BE) and self-expandable (SE) transcatheter heart valves (THVs) in this setting. The influence of aortic annular area on outcomes by valve type remains poorly understood. This study evaluated the impact of annular area on clinical outcomes following ViV-TAVR with BE vs. SE valves. Methods: We conducted a retrospective, single-center analysis of 353 patients who underwent ViV-TAVR between 2012 and 2024. All had prior surgical bioprosthetic AVR and received either BE (n=267) or SE (n=86) valves. Preprocedural multidetector CT was used to quantify aortic annular area. Transthoracic echocardiography was performed before and after the procedure to assess transvalvular gradients and hemodynamics. The primary endpoint was all-cause mortality. Penalized spline regression was used to model the nonlinear relationship between annular area and mortality and assess interaction by valve type. Results: Median age was 79 (IQR: 72–83) in the BE group and 80 (IQR: 76–85) in the SE group (p=0.07). Female sex was more common in the SE group (32% vs. 22%, p=0.047). Median annular area was 374 mm2 (IQR: 316–440) for BE and 365 mm2 (IQR: 308–432) for SE (p=0.081). Preprocedural gradient and effective orifice area index were 36 mm Hg (IQR: 28–46) and 0.6 cm2/m2 (IQR: 0.5–0.9), respectively, with no significant differences. Median hospital stay was 2 vs. 3 days (p=0.68). Thirty-day mortality was low (1 per group, p=0.36). Median follow-up was 4.0 years (IQR: 1.6–6.4). One- and 5-year survival rates were 94.75% and 61.7%, respectively (p=0.20). Penalized spline analysis showed a nonlinear association between annular area and mortality. The hazard ratio for BE valves declined with increasing annular area and fell below SE valves beyond ~400 mm2. Conclusion: ViV-TAVR is a safe and effective treatment for failed surgical bioprostheses. Smaller annular areas were associated with higher mortality. Outcomes with BE valves improved in larger annuli, suggesting annular area could guide valve selection. Further studies are warranted to validate these observations.