Valve Repair For Mitral Regurgitation Research Articles

Successful launch of robot-assisted mitral valve repair in Japan under universal health coverage

ObjectivesWe compared the clinical outcomes of mitral valve repair for mitral regurgitation via the robot-assisted approach and small right thoracotomy approach 3 years after the reimbursement of the robot-assisted approach in Japan. MethodsPatients who underwent isolated mitral valve repair by minimally invasive approach between 2018 and 2020 from the Japan Cardiovascular Surgery Database were included. Patients in the robot-assisted approach group were matched to the small right thoracotomy approach group based on propensity scores estimated from patient and surgical characteristics. Perioperative outcomes were compared among all cases as well as in subgroups categorized on the basis of the yearly number of robot-assisted approach cases and small right thoracotomy approach cases (≥10 or <10) at the hospital. ResultsWe identified 2443 patients who had undergone isolated mitral valve repair at 250 institutions in the database, and analysis of propensity-matched 577 patient-pairs demonstrated that operation time, cardiopulmonary bypass time, and aortic crossclamp time were significantly shorter with the robot-assisted approach. Although the intensive care unit stay was longer in the robot-assisted approach, the time to discharge was significantly shorter in the robot-assisted approach. There was no meaningful difference in the in-hospital mortality. The incidences of postoperative stroke, renal failure, and prolonged ventilation, and the number of patients who converted to mitral valve replacement were similarly low. Procedural time, blood transfusions, explorative procedures for bleeding, postoperative stroke, and prolonged ventilation occurred at a lower rate in the high-volume institutions. ConclusionsThe study found that the robot-assisted approach is just as effective as the small right thoracotomy approach. The introduction of robot-assisted mitral valve repair in Japan has been successful.

Transcatheter edge-to-edge mitral valve repair for mitral regurgitation in patients with cardiogenic shock: A systematic review and meta-analysis.

There is currently little evidence for transcatheter edge-to-edge mitral valve repair (TEER) for mitral regurgitation (MR) in patients with cardiogenic shock (CS). Therefore, this study investigated the characteristics and outcomes of CS patients who underwent TEER for MR. PubMed, EMBASE were searched in July 2023. Case series and observational studies reporting clinical characteristics and outcomes in CS patients with MR who underwent TEER were included. We performed a one-group meta-analysis using a random effects model. A total of 4060 patients from 7 case series and 5 observational studies were included. The mean age was 68.2 (95% confidence interval [CI]: 64.1-72.2) years, and 41.4% of patients (95% CI: 39.1%-43.7%) were female. Pre-TEER, severe MR was present in 85.3% (95% CI: 76.1%-91.3%) of patients. Mean left ventricular ejection fraction was 36.7% (95% CI: 29.2%-44.2%), and 54.6% (95% CI: 36.9%-71.2%) of patients received mechanical circulatory support. The severity of MR post-TEER was less than 2+ in 88% (95% CI: 87%-89%) of patients. In-hospital mortality was 11% (95% CI: 10%-13%), whereas 30-day and 1-year mortality rates were 15% (95% CI: 13%-16%), and 36% (95% CI: 21%-54%), respectively. This systematic review and meta-analysis assessed the clinical characteristics and outcomes of TEER in CS patients with MR. TEER for MR in patients with CS has been successful in reducing MR in most of the patients, but with a high mortality rate. Randomized controlled trials of TEER for MR and CS are needed.

Mitral regurgitation in atrial fibrillation: Is a simple repair enough to tackle a complex problem?

BackgroundClinical and echocardiographic results of valve repair for mitral regurgitation in the setting of atrial fibrillation are poorly studied. MethodsBetween January 2008 and December 2020, 89 patients underwent valve repair for mitral regurgitation in the setting of atrial fibrillation. Clinical and echocardiographic follow-up data were collected and studied. The primary composite endpoint consisted of all-cause mortality or hospitalization for heart failure. ResultsValve repair with true-sized annuloplasty was performed in 83 (93 %) and restrictive annuloplasty in 6 (7 %) patients. Early mortality occurred in 3 (3 %) and residual mitral regurgitation in 1 (1 %) patient. During a median follow-up of 5.4 years (interquartile range 3.4–9.5), 25 patients died, 6 due to end-stage heart failure. Ten patients were hospitalized for heart failure. The estimated event-free survival rate at 10 years was 48.2 % (95 % CI 33.5 %–62.9 %). Recurrent mitral regurgitation was observed in 14 patients and most often caused by leaflet tethering. When analyzed as a time-dependent variable, recurrent regurgitation was related to the occurrence of the primary endpoint (hazard ratio 3.192, 95 % CI 1.219–8.359, p = 0.018). On exploratory sub-analyses, no recurrent regurgitation was observed after restrictive annuloplasty or in patients with paroxysmal atrial fibrillation. Moreover, recurrent regurgitation was observed more often when signs of left ventricular impairment were present preoperatively. ConclusionsDespite good initial results, recurrent regurgitation was a frequent observation after valve repair for mitral regurgitation in atrial fibrillation and had an effect on heart failure related morbidity and mortality. Refinements in the timing of surgery and surgical technique might help improve outcomes.

PO-02-203 IMPACT OF MITRACLIP IMPLANTATION ON THE BURDEN OF ATRIAL FIBRILLATION

Patients presenting for valve repair for mitral regurgitation (MR) have a 30-40% prevalence of atrial fibrillation (AF). AF and MR share an intricate bidirectional relationship. With the increasing use of MitraClip in contemporary practice, data on its impact on AF burden remains lacking. To study the impact of MitraClip implantation on AF burden using implanted device interrogation data. We performed a single center, retrospective analysis of all patients undergoing MitraClip implantation between, 4/2014 and 3/2022 (n=289). Of these, 60 patients (36%; 33 pacemakers, 27 defibrillators) had pre-existing implanted devices. Amongst these, 15 patients had interrogation data available within 6 months prior, and 12 months after MitraClip implantation - they were included for final analysis. Wilcoxon sum rank test was performed for comparison of variables. A total of 15 patients were included in the final analysis (mean age 76 ±12), with a male predominance (66%) and mean LVEF of 35%. Pre-existing AF was reported in 73% of patients with an AF burden (mean-IQR) of 39.9±48%, pre-MitraClip. A substantial, halving of AF burden to 16.2±34% was observed post-MitraClip (p=0.1). A similar decline in the prevalence of persistent AF from 40% to 20% was noted post-MitraClip. MitraClip implantation is associated with a substantial reduction in AF burden as well as rates of persistent AF. Larger studies are required to further analyze this association.

Transcatheter Edge-to-Edge Repair of Mitral Valve Regurgitation: Closing the Gap to Broaden the Coverage.

Transcatheter edge-to-edge repair of mitral valve (M-TEER) is reasonable consideration in symptomatic patients with severe degenerative mitral regurgitation (MR) who are at high or prohibitive risk of surgical repair or replacement. In symptomatic patients on maximally tolerated medical therapy with severe secondary MR from left ventricular systolic dysfunction, M-TEER is reasonable therapeutic option. In this review, we present a comprehensive overview of the most recent literature and considerations for M-TEER in patients excluded from key trials. These include patients with cardiogenic shock, acute ischemic MR, atrial functional MR, failed surgical mitral valve prosthesis and pulmonary hypertension. M-TEER is feasible and a reasonable alternative option for these patient populations with a significant clinical benefit. However, randomized clinical trials are needed to ascertain findings from these observational studies.

Midterm Outcomes After Surgical Management for Mitral Valve Regurgitation in Infancy.

Mitral valve repair is preferred for pediatric mitral valve disease. However, it is technically difficult because of complex lesions, poor surgical exposure, and tissue fragility, especially in infants. We investigated the midterm outcomes of mitral valve surgery for mitral regurgitation in infancy. We retrospectively reviewed 18 patients (aged <12 months old) undergoing mitral valve surgery for mitral regurgitation at our institution between October 2005 and March 2019. The patients had 10 acquired and 8 congenital valve lesions as follows: torn chordae (n = 6), leaflet prolapse (n = 4), posterior leaflet hypoplasia (n = 3), anterior leaflet cleft (n = 2), infective endocarditis (n = 1), papillary muscle rupture (n = 1), and hammock valve (n = 1). All patients initially underwent mitral valve repair. There was no operative mortality, and 1 case of late death. The median follow-up period was 7 years and 9 months. Reoperation was performed in 3 patients, re-repair (twice) in 1 patient with a hammock valve, and mitral valve replacement in 2 patients. Fifteen patients had at most mild mitral regurgitation at the last follow-up. A transmitral mean pressure gradient of over 5 mm Hg was observed in 3 cases, including the patient with a hammock valve. Postoperative mitral annular diameter increased within the normal range in all patients. Survival and reoperation-free rates at 5 and 10 years were 94.4% and 83.0%, respectively. Mitral valve repair for mitral regurgitation in infancy is safe and feasible with satisfactory midterm outcomes, even under serious preoperative conditions.

Chordal Replacement With Expanded Polytetrafluoroethylene Sutures to Correct Leaflet Prolapse

In this issue of The Annals of Thoracic Surgery, Lang and associates1 from the German Heart Center in Munich have a paper on mitral valve repair for mitral regurgitation due to leaflet prolapse using exclusively chordal replacement with expanded polytetrafluoroethylene (ePTFE) sutures and mitral annuloplasty in a cohort of 346 patients followed for 10 or more years. These patients were identified from a much larger group of 807 patients who had mitral valve repair by three surgeons over 7- to 8-year interval, indicating a high volume of this type of heart valve surgery.

Surgical Results of Mitral Valve Repair for Mitral Regurgitation in Pediatric Patients with Mitral Valve Prolapse.

The rare incidence of mitral regurgitation (MR) caused by mitral valve prolapse in children lacks clinical management experience. In this study, we present our experience in surgical management and the difference between isolated anterior mitral leaflet (AML), posterior mitral leaflet (PML), and bileaflet prolapse in pediatric patients. Between January 2014 and February 2021, 52 pediatric patients, aged 7.04 ± 4.02years (ranged from 0.17 to 14years), were diagnosed as moderately severe (11, 21.2%) or severe (41, 78.8%) MR, of which, 34 (65.4%) were owing to AML prolapse, one (1.9%) was PML prolapse, and 17 (32.7%) caused by bileaflet prolapse. All had received mitral valve repair, and were divided into the group of AML prolapse and bileaflet prolapse. Demographic and clinical characteristics of all patients were retrospectively collected and analyzed. The left ventricular diameter in the bileaflet group was significantly larger than the AML group (4.04 ± 0.73cm vs. 3.45 ± 0.75cm, P = 0.026). The median follow-up time was 33months (ranged from 6 to 88months). The postoperative and follow-up results had no significant difference between two groups. And only 2 patients received reoperation due to posterior annuloplasty ring dehiscence. For pediatric patients, the majority of the patients had isolated AML prolapse instead of PML prolapse. There was no difference in recurrent regurgitation or reoperation between isolated AML and bileaflet prolapse after MV repair, and we suggest more aggressive surgical strategy should be considered in pediatric patients with bileaflet prolapse than AML prolapse.

Mitral valve repair for mitral regurgitation in pediatrics and children: Initial experience

IntroductionMitral valve repair in pediatrics has been slow because of the great variety in congenital mitral valve malformations and the still unknown growing effect over the mitral valve. The aim of this study is to evaluate the early and mid-term results in surgical repair of mitral valve regurgitation in pediatrics and children.Patients and methodsA total of 16 patients had mitral valve repair for mitral regurgitation (MR) between November 2016 and December 2020 at the National Heart Institute. There were seven (43.75%) males and nine (56.25%) females. The mean age was 7.5 years (5 months and 14 years). The mean weight was 19.9 kg (5.5–40 kg). Concomitant procedures were done in 11 (68.75%) patients. The mean cardiopulmonary bypass time was 82 min (40–150 min), and the mean aortic cross-clamp time was 59 min (25–110 min).ResultsThere was only one (6.25%) early mortality after 3 months. The number of patients who had posterior patch annuloplasty was six (37.5%), rigid rings was four (25%), whereas suture annuloplasty was five (31.25%). The mean postoperative mitral valve gradient was 5 mmHg (3.5–8 mmHg). More than 50% of patients with suture annuloplasty had moderate MR, whereas posterior patch annuloplasty had trivial to mild MR and rigid ring annuloplasty had trivial MR. Aortic valve surgery was done in two (12.5%) cases. The mean hospital stay was 7.2 days (4–14 days) and ICU mean stay was 2.9 days (1–7 days), with a mean mechanical ventilation time of 6 h (2–15 h). Reoperation was done in four (26.6%) patients, with 81.25% freedom from reoperation for mitral valve prosthetic replacement.ConclusionMitral valve repair for mitral valve regurgitation in pediatrics and children improves symptoms, valve function, and myocardial performance and delays replacement. Posterior patch and ring annuloplasty have satisfactory early and mid-term results, low mortality, and a high freedom from reoperation.

Totally endoscopic aortic valve replacement with concomitant trans-aortic mitral valve repair for mitral regurgitation

BackgroundMinimally invasive aortic valve procedures through a hemi-sternotomy or a right anterior mini-thoracotomy have gained popularity over the last several years. Totally endoscopic aortic valve replacement (TEAVR) is an innovative and a less invasive (incision-wise) surgical aortic valve replacement technique. The operative steps of TEAVR have been reported previously from our group. Mitral regurgitation (MR) frequently accompanies aortic valve disease that at times may also require repair. Totally endoscopic surgery in such cases has not been tested.Presentation of the techniqueWe present a surgical technique for a totally endoscopic approach to aortic valve replacement and concomitant mitral valve repair for primary and secondary MR. An aortotomy incision was used avoiding an atriotomy, which results in an increase in cross-clamp (XC) and cardiopulmonary bypass (CPB) times that could be associated with higher mortality and morbidity. Neochords (artificial chordae tendineae) were used for primary MR and an edge-to-edge approach for secondary MR.ConclusionTEAVR and concomitant mitral valve repair can be performed successfully with reasonable XC and CPB times with excellent short-term results.

Percutaneous edge-to-edge mitral valve repair for mitral regurgitation improves heart failure symptoms in heart failure with preserved ejection fraction patients.

AimsTherapeutic options for patients with heart failure with preserved ejection fraction (HFpEF) are sparse. Mitral regurgitation (MR) is a common feature of HFpEF and worsens heart failure symptoms and prognosis. Our study examines the outcome of patients with preserved left ventricular ejection fraction (LVEF) and elevated left atrial (LAP) or left ventricular filling pressures (LVEDP), indicative of HFpEF, after undergoing percutaneous edge‐to‐edge mitral valve repair (pMVR) for moderate–severe MR.Methods and resultsTwo hundred eleven patients with preserved LVEF (>50%), who underwent pMVR, were dichotomized by LAP (< / ≥15 mmHg) and LVEDP (< / ≥16 mmHg). Forty‐nine per cent of patients showed elevated LAP, and LVEDP was elevated in 55%, both indicating HFpEF. Patients with elevated filling pressures featured typical clinical characteristics of HFpEF, higher N‐terminal pro‐brain natriuretic peptide levels (5544.9 pg/mL in high LAP group vs. 3071.7 pg/mL in normal LAP group, P = 0.06; 5061.0 pg/mL in high LVEDP group vs. 3230.3 pg/mL in normal LVEDP group, P = 0.08), and higher prevalence of pulmonary hypertension (mean pulmonary artery pressure 36.4 mmHg in high LAP group vs. 26.3 mmHg in normal LAP group, P < 0.001; 35.2 mmHg in high LVEDP group vs. 29.7 mmHg in normal LVEDP group, P = 0.004) and atrial fibrillation (78.8% in normal LAP group vs. 61.0% in high LAP group, P = 0.04; 75.3% in high LVEDP group vs. 67.5% in normal LVEDP group, P = 0.25). Pre‐treatment MR grade and New York Heart Association (NYHA) class were similar in both normal filling pressure and HFpEF groups. pMVR in HFpEF patients achieved effective heart failure symptom relief comparable with patients with normal filling pressures: significant decrease of MR grade and NYHA class, as well as significant reduction of heart failure hospitalizations 12 months after compared with 12 months before MitraClip.ConclusionPercutaneous edge‐to‐edge mitral valve repair for moderate–severe MR is an effective treatment option for symptom relief in HFpEF patients.

A Double-Envelope Mitral Inflow Spectral Doppler Profile After MitraClip

A Double-Envelope Mitral Inflow Spectral Doppler Profile After MitraClip

Comparison of identifiable and non-identifiable data linkage: health technology assessment of MitraClip using registry, administrative and mortality datasets

ObjectivesThe UK MitraClip registry was commissioned by National Health Service (NHS) England to assess real-world outcomes from percutaneous mitral valve repair for mitral regurgitation using a new technology, MitraClip. This...

Transcatheter valve repair in congenitally corrected transposition of the great arteries.

Introduction In congenitally corrected transposition of the great arteries (CCTGA) the right ventricle (RV) is the systemic ventricle. RV dysfunction and significant regurgitation of the systemic tricuspid valve are common and associated with worse outcomes. Management of tricuspid regurgitation (TR) in CCTGA is challenging. In acquired cardiovascular disease, percutaneous repair of mitral valve regurgitation (MR) is established. Data on CCTGA with TR are limited1. We report our experience with this technique in these patients. Methods CCTGA patients with moderate-severe TR were eligible if surgery was deemed high-risk. Interventional therapy was offered, and patients provided written informed consent. ...

The antegrade reperfusion test avoids the risk of mitral regurgitation recurrence optimizing valve repair.

Saline injection into the left ventricle trough mitral valve (saline test) is the most commonly used intraoperative assessment method in mitral valve repair. However, potential discrepancies between the saline test findings and intraoperative transesophageal echocardiography results after the weaning of cardiopulmonary by-pass, remain significant. Here, we describe a new antegrade reperfusion test, reproducing intraoperatively, the physiologic conditions of loaded and beating heart for direct transatrial evaluation of valve tightness. The proposed test is performed by perfusing warm oxygenated blood into the aortic root under cross-clamping. From February 2016 to December 2018, 91 patients (mean age: 63 ± 11 years) underwent mitral valve repair for mitral regurgitation. In all of them, the classic saline test was completed with the newly proposed antegrade test. We report our results with this combined approach. Data were obtained from the medical records and our mitral valve repair database. In 32 (35.1%) patients, evident or undetectable minor regurgitation at the saline test were respectively unconfirmed or detected by the antegrade reperfusion test leading to their complete correction. In only three patients (3.2%) major discrepancies was present between the intraoperative evaluation and the post-pump transesophageal echocardiography. Two of them (2.1%) required a second cardiopulmonary bypass run to fix the residual regurgitation. The antegrade reperfusion test is a simple dynamic intraoperative approach mimicking the physiological conditions of ventricular systole for mitral valve repair evaluation. Combined with the classic saline test, it seems to be a valuable additional intraoperative tool, enabling a more predictable repair result.

Iatrogenic Atrial Septal Defect After Mitral Valve Repair for Mitral Regurgitation

Iatrogenic Atrial Septal Defect After Mitral Valve Repair for Mitral Regurgitation

Mitigating cardiac dysfunction by TOE-guided cardioplegia and mitral valve repair.

Based on current guidelines, 15% to 20% of patients undergoing mitral valve repair for regurgitation develop left ventricular dysfunction (ejection fraction < 50%-55%) despite a normal baseline. Two schools of thought have been debated: preexisting myocardial disease or suboptimal intraoperative myocardial protection. In our view, they could be reconciled. It is well recognized that left ventricular ejection fraction with a standard cut off at 50%-55% has limited sensitivity in detecting early systolic impairment in mitral regurgitation patients. Mitral regurgitation also leads to mitochondrial oxidative stress, thus rendering the myocardium more susceptible to ischemia-reperfusion injury and precipitating postoperative cardiac dysfunction. The fall in left ventricular ejection fraction early after mitral valve repair was shown to be caused by the reduction in both myocardial contractility and left ventricular stroke volume. To mitigate the risk to myocardial reperfusion injury, appropriate cardioplegia volume and distribution and well-defined surgical repair processes are equally important. We use transesophageal echocardiography-guided cardioplegia delivery, imaging the intramyocardial flow and ensuring adequate protection of the subendocardium during mitral valve repair. Mild aortic regurgitation on a beating heart often leads to left ventricular dilatation with diminished cardioplegia flow in the myocardium, thus requiring direct ostia cardioplegia. Systematic transesophageal echocardiography assessment before surgery is essential for establishing the mitral regurgitation mechanisms and translating them into precise surgical repair strategies. The benefits of transesophageal echocardiography-guided cardioplegia delivery warrant further clinical trials in order to evolve into part of a high surgical standard.

Added Value of Interactive 3-D Stereo Vision Echocardiography in the Heart Valve Team: A Post Hoc Analysis for Optimal Decision Making in Patients With Mitral Valve Regurgitation.

We assessed the added value of advanced echocardiography post hoc analysis for optimal decision-making in the Heart Valve Team (HVT) using an interactive, dynamic, live visualization system with true three-dimensional (3-D) stereo vision. HVT scrutinized the incremental value of 3 consecutive methods of presentation of full-volume echocardiographic data sets in terms of diagnosis and possibility of repair in 11 selected patients having mitral regurgitation (MR)(Table 1). The questionnaire investigated consecutively (a) standard two-dimensional (2-D) transesophageal echocardiography, (b) single-beat 3-D zoom of the surgical view of the mitral valve, and (c) advanced 3-D volumetric rendering technology (Personal Space Station, Vesalius 3D software, PS-Medtech, Netherlands). In 4 of 11 reviews (36%), single-beat 3-D zoom had additional value over 2-D echocardiography in terms of mechanism/adjustments or adjustment of confirmation of diagnosis. Single-beat 3-D zoom had no additional value over 2-D echocardiography in terms of proposal/probability of repair. In 7 out of 11 (64%) reviews, true stereo 3-D visualization had additional value in terms of mechanism of pathology compared to 2-D and 3-D zoom and in 5 out of 11 (45%) reviews in confirmation of diagnosis. In 3 out of 11 (27%) reviews, true stereo 3-D visualization had additional value in terms of proposal of repair and in 4 of 11 (36%) in probability of repair over 2-D and 3-D zoom. Advanced easy-to-use true 3-D echocardiography limited differences in interpretation and strengthened the confidence in understanding the mechanisms and suitability for repair of mitral valve regurgitation, typically in more complex valve pathology.

Long-Term Results of Mitral Valve Repair for Regurgitation Due to Leaflet Prolapse

BackgroundMitral valve (MV) repair has become the standard therapy for mitral regurgitation (MR) due to degenerative diseases, but information on late outcomes is limited. ObjectivesThe purpose of this study was to examine the late results of MV repair for MR in a large cohort of patients. MethodsA total of 1,234 consecutive patients (median age 59 years; 70.4% men) had MV repair for MR due to leaflet prolapse and were followed prospectively for a median of 13 years (interquartile range: 8 to 34 years) with periodical echocardiographic studies. There were 163 patients still at risk at 20 years. Cumulative incidences of adverse events and associated factors were examined with death as a competing outcome. ResultsAt 20 years, reoperation-free survival was 60.4% (95% confidence interval: 56.2% to 64.2%) and the cumulative incidence of cardiac and valve-related deaths was 12%, noncardiac deaths 21.3%, reoperation on the MV 4.6%, infective endocarditis 1.1%, thromboembolism 10.3%, and bleeding 6.4%. The probability of recurrent moderate or severe MR was 12.5%, persistent or new moderate or severe tricuspid regurgitation (TR) 20.8%, and new atrial fibrillation (AF) 32.4%. Multivariable analysis identified older age, complete heart block, MV repair without annuloplasty ring, and the degree of myxomatous degeneration of the MV to be associated with recurrent MR. The development of AF and TR was unrelated to recurrent MR. ConclusionsMV reoperation was uncommon after MV repair, but there was an increasing incidence of recurrent MR, TR, and new AF over time.

Tricuspid annulus diameter does not predict the development of tricuspid regurgitation after mitral valve repair for mitral regurgitation due to degenerative diseases

BackgroundHeart valve surgery guidelines suggest that tricuspid valve annuloplasty may be beneficial in patients with a tricuspid annulus (TA) ≥40 mm even in the absence of functional tricuspid regurgitation (TR) at the time of surgery for left-sided valve lesions (class 2a). Given the broad spectrum of degenerative diseases that affect the atrioventricular valves, we hypothesize that this measurement might not be predictive of TR after mitral valve (MV) repair. MethodsThe diameter of the TA was measured preoperatively in a cohort of 312 consecutive patients who had isolated MV repair for degenerative diseases. The mean TA diameter was 36 mm (95% confidence interval [CI], 35-37 mm). TA ≥40 mm was present in 80 patients. The median duration of echocardiographic follow-up was 6.7 years (interquartile range, 5.4-8.4 years), and was 100% complete. The main study endpoint was postoperative TR of moderate or greater degree. ResultsThirty patients had new or persistent TR at some point during follow-up. The probability of postoperative TR at 7 years was 6.6% (95% CI, 4.6%-9.4%) for all patients, 6.8% (95% CI, 4.6%-10.4%) for TA <40 mm, and 6.0% (95% CI, 2.9%-12.2%) for TA ≥40 mm. Preoperative TA diameter was not associated with the odds of postoperative TR in either the univariable or multivariable regression models. In these analyses, preoperative TR was the strongest predictor of postoperative TR. ConclusionsTA ≥40 mm is not predictive of the development of postoperative TR after MV repair for degenerative diseases.