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\begin{document}

\title{MITRAL VALVE REPAIR FOR MITRAL REGURGITATION IN THE ELDERLY: YES, WE
HAVE TO, BUT LOOK AT THE ETIOLOGIES!}



\author[1]{Antonio Calafiore}%
\author[2]{Massimo Di Marco}%
\author[3]{Stefano Guarracini}%
\author[4]{Kostas katsavrias}%
\author[5]{Michele Di Mauro}%
\affil[1]{John Paul II Foundation for Research and Treatment}%
\affil[2]{Ospedale Civile dello Spirito Santo}%
\affil[3]{Private Hospital Pierangeli Srl}%
\affil[4]{Henry Dunant Hospital Center}%
\affil[5]{Maastricht UMC+}%


\vspace{-1em}



  
  \date{May 19, 2024}


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\begin{abstract}
The meta-analysis by Di Tommaso et al demonstrated as elderly patients
with mitral regurgitation (MR) undergoing mitral valve repair (MVr) had
lower short-term mortality and higher long-term survival with respect to
patients undergoing mitral valve replacement (MVR). The benefit of
repair is such, that initial surgical strategy is advisable in the
elderly even in case of mild symptoms if compared with conservative
management. However, even if repair can be performed in presence of some
specific etiologies, as degenerative MR or secondary MR, there are
always cases where a replacement can be an acceptable solution compared
to a repair with uncertain future, regardless of our believes and our
technical ability. In this subset of patients, the literature does not
show any improvement in outcome of transcatheter mitral repair. Mitral
valve repair has to be always done, but look at the etiologies and to
the consequences that what is done today can cause tomorrow.%
\end{abstract}%



\sloppy


\textbf{MITRAL VALVE REPAIR FOR MITRAL REGUGITATION IN THE ELDERLY: YES,
WE HAVE TO, BUT LOOK AT THE ETIOLOGIES!}

Antonio M Calafiore, MD (1), Massimo Di Marco (2), MD, Stefano
Guarracini (3), MD, PhD, Kostas Katsavrias (4), MD, Michele Di Mauro
(5), MD, PhD, MSc.

\begin{enumerate}
\tightlist
\item
  Department of Cardiovascular Sciences, Gemelli Molise, Campobasso,
  Italy
\item
  Department of Cardiology, ``Santo Spirito'' Hospital, Pescara, Italy
\item
  Department of Cardiology, ``Pierangeli'' Hospital, Pescara, Italy
\item
  Department of Cardiac Surgery, Henry Durant Hospital, Athens, Greece
\item
  Cardio-Thoracic Surgery Unit,~Heart and Vascular~Centre,~Maastricht
  University Medical~Centre (MUMC),~Cardiovascular Research~Institute
  Maastricht~(CARIM).
\end{enumerate}

\textbf{Corresponding author}

Antonio M. Calafiore, MD

Department of Cardiovascular Diseases

Gemelli Molise

Largo A. Gemelli 1, 86100

Campobasso, Italy

email:\emph{am.calafiore@gmail.com}

Abstract

The meta-analysis by Di Tommaso et al demonstrated as elderly patients
with mitral regurgitation (MR) undergoing mitral valve repair (MVr) had
lower short-term mortality and higher long-term survival with respect to
patients undergoing mitral valve replacement (MVR). The benefit of
repair is such, that initial surgical strategy is advisable in the
elderly even in case of mild symptoms if compared with conservative
management. However, even if repair can be performed in presence of some
specific etiologies, as degenerative MR or secondary MR, there are
always cases where a replacement can be an acceptable solution compared
to a repair with uncertain future, regardless of our believes and our
technical ability.

In this subset of patients, the literature does not show any improvement
in outcome of transcatheter mitral repair.

Mitral valve repair has to be always done, but look at the etiologies
and to the consequences that what is done today can cause tomorrow.

In this issue Di Tommaso et al\textsuperscript{1} report a meta-analysis
of studies comparing mitral valve repair (MVr) and mitral valve
replacement (MVR) for mitral regurgitation (MR) in the elderly. Results
support once again our previous knowledge. Patients undergoing MVr had
lower short-term mortality and higher long-term survival. Moreover, the
incidence of postoperative stroke was 2.1\% in MVr versus 4.8\% in MVR
patients, with a p-value close to statistical significance (0.07).

The benefit of MV repair in the elderly, if compared with
replacement,\textsuperscript{2} has been known since long time, with
survival similar to that of the general population in patients
undergoing repair\textsuperscript{3}. These findings were confirmed by
recent publications\textsuperscript{4}. An analysis of the STS database
performed by Hendrix et al\textsuperscript{5} in patients with
degenerative MR demonstrated lower early mortality in repair compared to
all the techniques of replacement (no, partial or complete chordal
preservation).

The benefit of repair is such, that initial surgical strategy is
advisable in the elderly even in case of mild symptoms if compared with
conservative management\textsuperscript{6}.

These recent results are in contrast with the data previously reported
in a meta-analysis by Andalib et al\textsuperscript{7} in 2014, who
showed, in studies with more than 50 patients [?]80 years who underwent MV
surgery, an early mortality associated with MVr and MVR of 6\% and 16\%,
respectively. One-year and 5-year survival was 69\% and 23\% in case of
MVr, similar to that of MVR patients (67\% and 29\%, respectively). It
is noteworthy that purpose of that paper was to evaluate the possible
role of transcatheter MV repair or replacement in the elderly. The
Authors suggested that, as surgery was associated with high early and
late mortality, transcatheter therapies could be a valid alternative in
selected patients.

However, transcatheter mitral repair in the elderly did not show
improvement in outcome. Buzzatti et al\textsuperscript{8} showed that,
in patients aged 75 years or more and STS PROM [?]8, after weighting, the
use of MitraClip had a rate of postoperative complications lower than
surgical repair, but increased mitral regurgitation. One-year survival
was higher in MitraClip compared to surgical population (97.6\% vs
95.3\%, p=0.09), but 5-year survival was lower (34.5\% vs 82.2\%,
p\textless{}0.001). Five-year MR [?]3 was as well more frequent in
MitraClip patients (36.9\% vs 3.9\%, p\textless{}0.001). Alozie et
al\textsuperscript{9}, in patients aged [?]80 years, showed that the use
of MitraClip was associated to higher 1-year mortality compared to
patients who underwent surgical MVr (21.4\% vs 9.5\%). Residual MR [?]2 at
discharge was present in none of the surgical patients and in 23.8\% of
the patients treated with MitraClip. Superiority of surgical repair over
transcatheter repair, at least in low or intermediate risk elderly
patients, seems to be well demonstrated.

However, even if surgery still remain the golden standard for the
treatment of MR and repair seems to be the most effective technique to
be applied when possible in most elderly patients, we have not to
abandon our common sense. Even if repair can be performed in presence of
some specific etiologies, as degenerative MR or secondary MR, there are
always cases where a replacement can be an acceptable solution compared
to a repair with uncertain future, regardless of our believes and our
technical ability. This meta-analysis\textsuperscript{1} shows that
patients with rheumatic MR have, correctly, a high prevalence of MVR
(87\%) and nobody doubts that MVR is the best solution for this
etiology, irrespective of the global concept of the superiority of
repair on replacement. On the other side, we know that degenerative MR
can be, in expert hands, repaired in many patients (65\% in this
study\textsuperscript{1}) with good long-term freedom from residual MR.
But in patients with ischemic MR repair failure can be high in the
mid-term\textsuperscript{10} and the risk of a reoperation can be often
less acceptable than in younger patients.

Most of the studies deal only with early and late survival, but nothing
is said about functional outcome and problems related to MR return. This
aspect of the decision depends on us, and the best technical procedure
(repair) has to be weighted against higher prevalence of failure of
repair, in particular when repair is complex and a longer pump run can
affect the outcome of a patient with some comorbidities.

Repair has to be always done, but look at the etiologies and to the
consequences that what is done today can cause tomorrow.

\textbf{REFERENCES}

1. Di Tommaso E, Rapetto F, Guida GA, Zakkar M, Bruono VD. Benefits of
mitral valve repair over replacement in the elderly: a systematic review
and meta-analysis. J Card Surg, 2021, in press.

2. Enriquez-Sarano M, Schaff HV, Orszulak TA, Tajik AJ, Bailey KR, Frye
RL. Valve repair improves the outcome of surgery for mitral
regurgitation. A multivariate analysis. Circulation 1995;91:1022-8.

3. Ghoreishi M, Dawood MY, Gammie JS. Mitral valve surgery in elderly
patients with mitral regurgitation: repair or replacement with tissue
valve? Curr Opin Cardiol 2013;28:164-9.

4. Gotte J, Zittermann A, Hakim-Meibodi K, et al. Long-Term Clinical
Outcome in Elderly Patients Undergoing Mitral Valve Repair. Thorac
Cardiovasc Surg 2020.

5. Hendrix RJ, Bello RA, Flahive JM, et al. Mitral Valve Repair Versus
Replacement in Elderly With Degenerative Disease: Analysis of the STS
Adult Cardiac Surgery Database. Ann Thorac Surg 2019;107:747-53.

6. Kang DH, Heo R, Lee S, et al. Initial surgery versus conservative
management of symptomatic severe mitral regurgitation in the elderly.
Heart 2018;104:849-54.

7. Andalib A, Mamane S, Schiller I, et al. A systematic review and
meta-analysis of surgical outcomes following mitral valve surgery in
octogenarians: implications for transcatheter mitral valve
interventions. EuroIntervention 2014;9:1225-34.

8. Buzzatti N, Van Hemelrijck M, Denti P, et al. Transcatheter or
surgical repair for degenerative mitral regurgitation in elderly
patients: A propensity-weighted analysis. J Thorac Cardiovasc Surg
2019;158:86-94 e1.

9. Alozie A, Paranskaya L, Westphal B, et al. Clinical outcomes of
conventional surgery versus MitraClip(R) therapy for moderate to severe
symptomatic mitral valve regurgitation in the elderly population: an
institutional experience. BMC Cardiovasc Disord 2017;17:85.

10. Calafiore AM, Totaro A, Sacra C, Foschi M, Gaudino M, Di Mauro M.
Failure of annuloplasty alone to correct ischemic mitral regurgitation.
What we learned from two randomized controlled trials. J Card Surg
2019;34:155-7.

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