Early Mitral Valve Surgery and Survival in Asymptomatic Severe Primary Mitral Regurgitation
12 affiliations
- 1Division of Data Science, University of Suwon, Hwaseong, Republic of Korea
- 2Institute of Health and Environment, Seoul National University, Seoul, Republic of Korea
- 3Division of Cardiology and Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- 4Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- 5Division of Cardiology, Heart Vascular Stroke Institute, Sungkyunkwan University School of Medicine and Samsung Medical Centre, Seoul, Republic of Korea
- 6Division of Cardiology, College of Medicine, University of Ulsan and Asan Medical Centre, Seoul, Republic of Korea
- 7Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Korea
- 8Department of Public Health Sciences, Seoul National University, Seoul, Republic of Korea
- 9Interdisciplinary Program of Bioinformatics, Seoul National University, Seoul, Republic of Korea
- 10RexSoft Inc, Seoul, Republic of Korea
- 11Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- 12Center for Precision Medicine, Seoul National University Hospital, Seoul, Republic of Korea
Abstract
Importance: The optimal timing of mitral valve (MV) surgery in patients with asymptomatic severe primary mitral regurgitation (MR) remains uncertain because randomized clinical trials are lacking.
Objective: To evaluate the association of early MV surgery with long-term survival in patients with asymptomatic severe primary MR using a target trial emulation framework.
Design, Setting, and Participants: This cohort study used a clinical valve registry from 3 tertiary hospitals in South Korea between 2000 and 2022. Patients with asymptomatic severe primary MR were analyzed using a clone-censor-weight approach to emulate a target trial. A 6-month grace period after diagnosis was used to define treatment strategies. This analysis was conducted from September 2024 to January 2025.
Exposure: Early MV surgery (within 6 months of diagnosis) vs watchful waiting.
Main Outcomes and Measures: The primary outcome was all-cause mortality and the secondary outcome, a composite of all-cause mortality or heart failure hospitalization. Inverse probability of censoring-weighted estimates of the per-protocol effect size included restricted mean survival time (RMST) differences as the primary measure and hazard ratios (HRs) as secondary measures.
Results: Among 802 patients (mean [SD] age, 55 [16] years; 476 men [59%]), 344 underwent early surgery, and 458 received watchful waiting. During a median (IQR) follow-up of 7.4 (4.1-11.6) years, 27 deaths occurred in the early surgery group and 103 in the watchful waiting group. At 5 years, early surgery was associated with an RMST gain of 66 days (95% CI, 19-129 days). The survival benefit persisted up to 15 years. Early surgery was also associated with a lower risk of all-cause mortality compared with watchful waiting (HR, 0.69; 95% CI, 0.41-0.94; P = .02). Similar associations were observed in patients without left ventricular decompensation (HR, 0.61; 95% CI, 0.31-0.96; P = .04) and in those with degenerative MR (HR, 0.66; 95% CI, 0.36-0.98; P = .04).
Conclusions and Relevance: In this multicenter cohort study with a target trial framework, early surgery was associated with improved long-term survival among patients with asymptomatic severe primary MR. These findings support consideration of earlier surgical intervention in contemporary clinical practice.
Related
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- Impact of Tricuspid Regurgitation on Outcomes After Transcatheter Edge-to-Edge Repair for Primary Mitral Regurgitation: The PRIME-MR Registry
- Five-year outcomes of chordal replacement therapy for primary mitral regurgitation: The CHAGALL (CHordArt System Study for the Treatment of Mitral ReGurgitAtion due to Leaflet ProLapse or fLail) study.
- Influence of concomitant mitral valve intervention on late survival in patients with moderate ischemic mitral regurgitation undergoing surgical revascularization.
BibTeX
@article{ahn2026early,
title = {{Early Mitral Valve Surgery and Survival in Asymptomatic Severe Primary Mitral Regurgitation}},
author = {Juhee Ahn and Soongu Kwak and Jaehyun Lim and Kyu Kim and Jihoon Kim and Byung Joo Sun and Dae-Hee Kim and Kyung Hwan Kim and Chi Young Shim and Sung-Ji Park and Sungho Won and Seung-Pyo Lee},
journal = {JAMA Network Open},
year = {2026},
month = oct,
doi = {10.1001/jamanetworkopen.2026.37061},
url = {https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2854832},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Early Mitral Valve Surgery and Survival in Asymptomatic Severe Primary Mitral Regurgitation
AU - Juhee Ahn
AU - Soongu Kwak
AU - Jaehyun Lim
AU - Kyu Kim
AU - Jihoon Kim
AU - Byung Joo Sun
AU - Dae-Hee Kim
AU - Kyung Hwan Kim
AU - Chi Young Shim
AU - Sung-Ji Park
AU - Sungho Won
AU - Seung-Pyo Lee
PY - 2026
DA - 2026/10/05
JO - JAMA Network Open
DO - 10.1001/jamanetworkopen.2026.37061
UR - https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2854832
AB - Importance: The optimal timing of mitral valve (MV) surgery in patients with asymptomatic severe primary mitral regurgitation (MR) remains uncertain because randomized clinical trials are lacking. Objective: To evaluate the association of early MV surgery with long-term survival in patients with asymptomatic severe primary MR using a target trial emulation framework. Design, Setting, and Participants: This cohort study used a clinical valve registry from 3 tertiary hospitals in South Korea between 2000 and 2022. Patients with asymptomatic severe primary MR were analyzed using a clone-censor-weight approach to emulate a target trial. A 6-month grace period after diagnosis was used to define treatment strategies. This analysis was conducted from September 2024 to January 2025. Exposure: Early MV surgery (within 6 months of diagnosis) vs watchful waiting. Main Outcomes and Measures: The primary outcome was all-cause mortality and the secondary outcome, a composite of all-cause mortality or heart failure hospitalization. Inverse probability of censoring-weighted estimates of the per-protocol effect size included restricted mean survival time (RMST) differences as the primary measure and hazard ratios (HRs) as secondary measures. Results: Among 802 patients (mean [SD] age, 55 [16] years; 476 men [59%]), 344 underwent early surgery, and 458 received watchful waiting. During a median (IQR) follow-up of 7.4 (4.1-11.6) years, 27 deaths occurred in the early surgery group and 103 in the watchful waiting group. At 5 years, early surgery was associated with an RMST gain of 66 days (95% CI, 19-129 days). The survival benefit persisted up to 15 years. Early surgery was also associated with a lower risk of all-cause mortality compared with watchful waiting (HR, 0.69; 95% CI, 0.41-0.94; P = .02). Similar associations were observed in patients without left ventricular decompensation (HR, 0.61; 95% CI, 0.31-0.96; P = .04) and in those with degenerative MR (HR, 0.66; 95% CI, 0.36-0.98; P = .04). Conclusions and Relevance: In this multicenter cohort study with a target trial framework, early surgery was associated with improved long-term survival among patients with asymptomatic severe primary MR. These findings support consideration of earlier surgical intervention in contemporary clinical practice.
SN - 2574-3805
ER -