Impact of ageing on presentation and outcome of mitral regurgitation due to flail leaflet: A multicentre international study

Aims: Define the impact of age at diagnosis on degenerative mitral regurgitation (MR) prognosis. Methods and results: The Mitral regurgitation International DAtabase (MIDA) is a multicentre registry of MR due to flail leaflets including 862 patients (65 ± 12 years) diagnosed by echocardiography. The 498 older patients (≥ 65 years at diagnosis) were compared with the 364 younger (< 65) with regard to presentation and the outcome was compared with that expected in the general population. Older vs. younger patients had MR of similar severity and ventricular overload but presented with more MR consequences and incurred higher mortality [risk ratio (rr) 95% confidence interval (95% CI) 4.7 (2.5 - 10.0), P < 0.001] independently of co-morbidity. Compared with expected survival [relative risk (95% confidence interval)], excess mortality, non-significant in younger patients [1.1 (0.6 - 2.0), P = 0.65], was prominent in older patients [1.4 (1.2 - 1.7), P < 0.001]. Compared with expected, excess heart failure (HF) occurred in younger [9.3 (6.5 - 13.3), P < 0.0001) and in older patients [6.7 (5.6 - 8.1), P < 0.0001]. Excess atrial fibrillation (AF) was even higher in younger [6.9 (4.5 - 10.6), P < 0.0001] than in older patients [3.5 (2.6 - 4.7), P < 0.0001; P < 0.001 for comparison between age groups]. Subsequent excess mortality [rr (95% CI)] was associated with occurrence of HF and/or AF in both age groups [13.5 (7.4 - 24.6), P < 0.001]. Mitral surgery was associated with reduced long-term mortality in older patients and lower rate of HF in both the age groups (all P < 0.01). Conclusions: Both older and younger patients incurred excess risk of complications. Older patients suffered excess mortality, AF, and HF, whereas younger incurred excess morbidity linked to subsequent long-term excess mortality. The excess risks of uncorrected degenerative MR should be considered in deliberating surgical management, which significantly reduced mortality in older patients and HF in younger patients.