Transcatheter versus Surgical Mitral Valve Repair in Patients Younger than 70 Years in the United States.

Abstract

Mitral transcatheter edge-to-edge repair (m-TEER) use has increased, yet its outcomes compared to surgical mitral repair in younger patients are undefined. We evaluated practice trends and three-year outcomes of m-TEER versus surgical repair for mitral regurgitation (MR) in patients <70 years. Patients <70 years with functional or degenerative MR undergoing primary, elective m-TEER or surgical repair from 2013-2022 were identified in four state admissions databases. The primary outcome was freedom from major adverse valve related events (MAVRE), a composite of death, stroke, mitral re-intervention or heart failure readmission, at 3 years compared using a multivariable Cox-proportional hazard model adjusting for baseline differences. Among 9,542 patients with MR, 1,210 (12%) underwent m-TEER and 8,332 (88%) underwent surgery. Patients undergoing surgery were younger (59 vs 63 years, p<0.01), had fewer comorbidities, and had degenerative disease (92% vs 46%, p<0.01). From 2016-2022, m-TEER use increased from 7% to 21% (Annual Percent Change:21.4%, p<0.01), predominantly among patients with functional MR. Hospital-level factors accounted for 24% of practice variation (Intraclass Correlation Coefficient 0.24, 95% CI 0.14-0.34, p<0.01). Freedom from MAVRE at 3-years was higher after surgery (91% vs 78%, aHR 1.45, 95% CI: 1.14-1.84, p<0.01). In degenerative MR, m-TEER was associated with increased risk of MAVRE (aHR: 1.90,p<0.01). Among patients <70 years with MR, m-TEER use was associated with substantial institutional variability and higher MAVRE, especially among patients with degenerative MR. These findings support the need for prospective studies to better define anatomic selection criteria and comparative effectiveness in younger patients.