What is the clinical evidence from this study?

Study design: Other. Population: Adult patients with asymptomatic severe primary mitral regurgitation and preserved left ventricular function (n=99). Intervention: Early mitral valve repair surgery vs. Active surveillance with facilitated surgery as indicated. Primary outcome: Composite of cerebrovascular accidents (CVA), mitral valve reoperations, and cardiovascular and non-cardiovascular deaths.

What does this research mean for the field?

Early mitral valve repair surgery led to 14% of patients reaching a primary endpoint compared to 7% in the active surveillance group after a median follow-up of 5.1 years. Novelty: ClaimNovelty.CONFIRMATORY. Consensus alignment: ConsensusAlignment.NEUTRAL.

February 11, 2026Netherlands Heart Journal1 citationsOpen Access

Early mitral valve repair surgery versus active surveillance in asymptomatic severe primary mitral regurgitation—insights from the Dutch AMR registry

SMSulayman El Mathari EHEinar A. HartUniversity Medical Center Utrecht RJRosemarijn JansenSt. Antonius Ziekenhuis

Key Result

Early mitral valve repair surgery and facilitated surgery after active surveillance had comparable rates of primary endpoints (14% vs 15%) over 5.1 years in asymptomatic severe primary mitral regurgitation patients.

Key Points

The study aims to compare clinical outcomes of early mitral valve repair surgery versus active surveillance in asymptomatic severe mitral regurgitation patients.
Included patients from the Dutch AMR registry between 2013–2019.
Evaluated primary endpoints: cerebrovascular accidents, reoperations, and mortality.
Facilitated surgery performed after developing surgical indications during active surveillance.
Follow-up time averaged 5.1 years.
51% of active surveillance patients required facilitated surgery during follow-up.
Both surgery groups experienced one perioperative cerebrovascular accident.
7% of active surveillance patients died, including 2 after facilitated surgery.
14% of early surgery patients reached a primary endpoint, with 7% each for CVAs and deaths.
No reoperations in the early surgery group.

Structured PICO

Does early mitral valve repair surgery improve clinical outcomes compared to active surveillance in adult patients with asymptomatic severe primary mitral regurgitation?

Population

99 adult patients with asymptomatic severe primary mitral regurgitation, mean age 56.9, 77.8% male. Included from 5 Dutch heart centers between 2013-2019. Asymptomatic defined as having no complaints regarding exercise tolerance and normal exercise capacity measured by cardiopulmonary exercise testing (CPET). Excluded paroxysmal AF.

Intervention

Early mitral valve repair surgery (within 6 weeks after allocation)

Comparator

Active surveillance with vigilant annual monitoring for overt signs of deterioration (cardiac symptoms, LA dilatation, AF or PH), prompting facilitated surgery before LV dysfunction ensues

Outcome

Composite of cerebrovascular accidents (CVA), mitral valve (MV) reoperations, and cardiovascular and non-cardiovascular deathscomposite

In patients with asymptomatic severe primary mitral regurgitation, active surveillance is a feasible strategy with comparable clinical outcomes to early surgery, though approximately half will require facilitated surgery within 5 years.

Main Result

Absolute Event Rate: 14% vs 15%

Limitations

Small sample size limiting statistical power and precluding statistical testing
Early termination of RCT leading to registry design and selection bias
Difficulty defining truly asymptomatic status and onset of severe MR
Incomplete baseline NT-proBNP data limiting biomarker analysis
Potential underestimation of asymptomatic period prior to surgery
Results may reflect random chance due to low event numbers and should be interpreted cautiously

Abstract

Abstract Background Management of asymptomatic severe mitral regurgitation (MR) is challenging. Both early mitral valve repair surgery and active surveillance with facilitated surgery are possible strategies. The DutchAMR registry compares clinical outcomes between these two strategies. Methods Patients were included between 2013–2019. Primary endpoints were cerebrovascular accidents (CVA), reoperations, and mortality. Facilitated surgery was defined as mitral valve repair surgery performed after developing a surgical indication during active surveillance. Results Ninety-nine patients were enrolled; 71 in active surveillance and 28 in early surgery. Over a median follow-up time of 5.1 years, 51% of active surveillance patients underwent facilitated surgery due to ESC guideline triggers. Both the early and facilitated surgery groups had one perioperative CVA. During follow-up, in the active surveillance group, 5 (7%) patients died (3 without surgery and 2 after facilitated surgery), and 3 (4%) underwent reoperations. In the early surgery group, 4 (14%) patients reached a primary endpoint, including 2 (7%) CVAs (without residual symptoms) and 2 (7%) deaths. No reoperations occurred in the early surgery group. Baseline additional testing parameters based on CPET, Holter monitoring, and CMR showed no differences between the groups. Conclusions After 5.1 years, half of the active surveillance patients required facilitated surgery, with comparable postoperative outcomes to early surgery. Clinical endpoints were comparable between the early and facilitated surgery strategies. There were no differences in baseline additional testing parameters, suggesting no clear targets for upfront stratificatio. Thus, shared decision making weighing the different risks can be used to determine the strategy per patient.

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