Surgical mitral valve repair is unbeaten also in the elderly

In their article ‘Clinical Outcomes of Mitral Valve Repair for Degenerative Mitral Regurgitation in Elderly Patients’, Kawajiri et al. [1] from the Mayo Clinic analysed the short- and long-term results of mitral valve (MV) repair for degenerative disease in an elderly population. The results in respect to operative (1.2%) short- and long-term mortality were excellent given a median patient age close to 80 years and 50% of the population being between 76.9 and 82.9 years old. The reoperation rate was low (2.2%, 3.2% and 3.2% at 1, 5 and 10 years, respectively). Comparison with an age- and sex-matched population demonstrated improved survival of the patients receiving MV repair. The authors conclude correctly that ‘these results should be used as a standard against which new transcatheter procedures should be compared’. But can these results indeed be taken as a bench mark for newer treatment strategies? Concerning patient selection: given the age of the population a repair rate of 45.7% in the total population (out of 751 MV surgeries for degenerative MV disease 343 patients had successful repair) possibly might be acceptable (given the increased chance of severe calcifications in this age group), a repair failure rate requiring MV replacement in 23%, however, definitely is not. If we want to compete with interventional techniques, we cannot accept anything than a close—and I would claim a very close to 100% repair rate. Especially, as the fate of those patients being converted to MV replacement is not revealed to the reader in this article [1]. Regarding durability of results: competing with interventional MV treatment the durability of repair has to be proven. The reoperation rate at 10 years of 3.2% may not truly reflect the real recurrence rate of severe regurgitation since the same rate was reported at 5 years and it is reasonable to assume that at 90 years age (median age at surgery was close to 80) reoperation was simply not indicated for age reasons with the associated risk at reoperation. Concerning repair techniques: most patients received leaflet resection which is a proven method for long-lasting repair. Nevertheless, modern techniques (‘Respect—rather than resect’) should be taken into account to achieve optimal long-term results. Competing with interventional techniques the exclusive use of 60-year-old techniques should be reconsidered. Concerning surgical trauma: results of minimally invasive approaches are well documented. Without any compromise of surgical results, the reduced operative trauma has been proven to allow shorter recovery at any point in time postoperative. Moreover, the acceptance of surgery may be much higher by patients as well as referring cardiologists if a minimally invasive approach—fully endoscopic—video assisted—or partial sternotomy—which is feasible in the vast majority of patients is offered. In our hands and after investigating more than 1000 patients after minimally invasive mitral repair via mini-thoracotomy, we could not identify any difference in perioperative mortality or morbidity between patients below and above 70 years of age. Long-term results signal that elderly patients benefit from an anatomical mitral repair at least as much as younger patients do and that a surgical repair can be performed with an adequate safety profile. Nevertheless, by comparing mitral patient groups at different ages one should consider patient selection as a major predictor on the occurrence of perioperative complications. Signs of advanced left ventricular disease and especially concomitant right ventricular dysfunction leading to relevant tricuspid regurgitation have been identified as limiting factors for operative success [2]. However, elderly patients with an early-stage mitral disease especially on the grounds of primary mitral pathology can be considered as good candidates for a minimally invasive repair. In conclusion, as demonstrated by Kawajiri et al. [1], MV repair is the best option to treat degenerative MV regurgitation also in the elderly population. But repair rates need to be far above the reported rate of 45.7% in the total population and 76.7% in the patient group selected for repair. More and increased efforts to achieve these goals are needed to offer our patients the best treatment available.