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July 2019 - Robert Zilberszac

Dr. Robert Zilberszac


Long-Term Outcome of Active Surveillance in Severe But Asymptomatic Primary Mitral Regurgitation.


Since the optimal timing of mitral valve surgery in asymptomatic primary mitral regurgitation (MR) remains controversial, this study sought to assess the long-term outcome of active surveillance in these patients.


Between 1997 and 2015, 280 consecutive patients with severe asymptomatic primary MR were enrolled in our heart valve clinic follow-up program. They were prospectively followed up every 6 months clinical and echocardiographical examinations until surgical criteria were reached. Event-free survival and overall survival as compared with the age- and gender-matched general population were assessed.


During a median potential follow-up of 93.4  months, 161 patients developed an indication for surgery and 13 patients died. Overall survival of patients managed according to an active surveillance strategy was comparable with the expected cumulative survival and early survival rates were even better in the study population (standardized mortality ratio: 0.667; 95% CI: 0.463 to 0.963; p = 0.013).


Patients with severe asymptomatic primary MR may remain free of indications for surgery for extensive periods of time. In such patients, active surveillance performed in experienced centers is associated with a favorable prognosis, resulting in timely referral to surgery, excellent long-term survival, and good surgical outcomes.

Selected Literature

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2.         Rosenhek R, Rader F, Klaar U, et al. Outcome of watchful waiting in asymptomatic severe mitral regurgitation. Circulation. May 9 2006;113(18):2238-2244.
3.         Enriquez-Sarano M, Avierinos JF, Messika-Zeitoun D, et al. Quantitative determinants of the outcome of asymptomatic mitral regurgitation. N. Engl. J. Med. Mar 03 2005;352(9):875-883.
4.         Suri RM, Vanoverschelde JL, Grigioni F, et al. Association between early surgical intervention vs watchful waiting and outcomes for mitral regurgitation due to flail mitral valve leaflets. JAMA. Aug 14 2013;310(6):609-616.
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6.         Baumgartner H, Falk V, Bax JJ, et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur. Heart J. Sep 21 2017;38(36):2739-2791.
7.         Zilberszac R, Heinze G, Binder T, Laufer G, Gabriel H, Rosenhek R. Long-Term Outcome of Active Surveillance in Severe But Asymptomatic Primary Mitral Regurgitation. JACC Cardiovasc. Imaging. Sep 2018;11(9):1213-1221.
8.         Zilberszac R, Gleiss A, Binder T, et al. Prognostic relevance of mitral and tricuspid regurgitation in patients with severe aortic stenosis. European Heart Journal - Cardiovascular Imaging. 2018:jey027-jey027.
9.         Zilberszac R, Gabriel H, Schemper M, Laufer G, Maurer G, Rosenhek R. Asymptomatic Severe Aortic Stenosis in the Elderly. JACC Cardiovasc. Imaging. Jan 2017;10(1):43-50.
10.       Zilberszac R, Lancellotti P, Gilon D, et al. Role of a heart valve clinic programme in the management of patients with aortic stenosis. Eur. Heart J. Cardiovasc. Imaging. Aug 12 2016.
11.       Zilberszac R, Gabriel H, Schemper M, et al. Outcome of combined stenotic and regurgitant aortic valve disease. J. Am. Coll. Cardiol. Apr 9 2013;61(14):1489-1495.
12.       Rosenhek R, Zilberszac R, Schemper M, et al. Natural history of very severe aortic stenosis. Circulation. Jan 5 2010;121(1):151-156.

Dr. Robert Zilberszac

Medizinische Universität Wien
Universitätsklinik für Innere Medizin II
Klinische Abteilung für Kardiologie
Währinger Gürtel 18-20
1090 Wien

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