1 M itral regurgitation (MR) comprises ≈25% of all native valvular diseases, and advanced disease is indepen- dently associated with reduced survival. 1,2 According to cur- rent guidelines, mitral valve (MV) repair or replacement through a surgical approach is the preferred treatment in patients with acceptable surgical risk, provided that the MR is because of degenerative disease. Surgery is not as well estab- lished for functional MR (FMR) and is not recommended by guidelines unless other cardiac operations are planned. 3,4 Up to 50% of the patients with symptomatic severe MR are denied for surgical treatment because of high surgical risk or uncertainty about the beneft. 5,6 Until recently, this popu- lation could only receive therapy through conservative man- agement, for which a clear survival beneft has not been well established. 7 However, new minimally invasive percutaneous treatment options like the MitraClip (Abbott Vascular, Abbott Park, IL), of which the working mechanism is based on edge- to-edge valve repair, have been proven to be a valuable treat- ment option for these high-surgical-risk patients. 8 See Editorial by Sorajja and Gossl Safety and feasibility of the MitraClip have been proven in EVEREST I (The Effcacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan), followed by the only randomized controlled trial in this feld so far, EVEREST II (Endovascular Valve Edge-to-Edge Repair Study). For EVEREST II, Feldman et al 9,10 randomized 279 patients in North America to be treated by surgery or MitraClip. The recently published 5-year results showed similar clinical and survival outcomes in the 2 cohorts, even though patients undergoing MitraClip treatment more frequently underwent MV surgery during follow-up. It is important to note that all included patients Received September 29, 2017; accepted March 26, 2018. From the Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands (F.K., J.K., A.B., M.P., F.E., M.S., B.R., J.V.d.H.); Department of Cardiology, Academic Medical Center, Amsterdam, the Netherlands (J.V., B.B., J.B.); Department of Cardiology, University Medical Center, Groningen, the Netherlands (R.S., T.H., P.V.d.H.); Department of Cardiology, Amphia Hospital, Breda, the Netherlands (B.V.d.B.); and Department of Cardiology, Evanston Hospital, NorthShore University Health System, IL (T.F.). Dr Kortlandt and J. Velu contributed equally to this work. Correspondence to Friso Kortlandt, MD, St. Antonius Ziekenhuis, Koekoekslaan 1, 3435 CM Nieuwegein, the Netherlands. E-mail f.kortlandt@ antoniusziekenhuis.nl Background—Survival outcome after MitraClip treatment, compared with surgical or conservative treatment, is not well defned. We examined survival after MitraClip treatment in a large multicenter real-life setting. Methods and Results—We retrospectively formed matched high-risk surgically and conservatively treated control cohorts to compare to a high-risk MitraClip cohort. One thousand thirty-six patients were included in 4 Dutch centers, of which 568 were treated with the MitraClip. The observed survival at 5-year follow-up in our MitraClip cohort was low (39.8%) but was comparable to our conservative cohort (40.5%). Observed 5-year survival for our surgical cohort was 76.3%. However, there were signifcant differences between the baseline characteristics of the 3 studied cohorts, with the MitraClip cohort having the highest comorbidity burden. After adjusting for baseline differences by using Cox regression, the MitraClip and surgical cohorts showed similar survival ratios (hazard ratio, 0.92; 95% confdence interval, 0.67–1.26; P=0.609), whereas both showed a lower mortality hazard when compared with conservative treatment (hazard ratio, 0.61; 95% confdence interval, 0.49–0.77; P<0.001 and hazard ratio, 0.56; 95% confdence interval, 0.42–0.76; P<0.001, respectively). Conclusions—This matched analysis suggests a lower mortality hazard for MitraClip intervention in a high-risk population with symptomatic mitral regurgitation when compared with conservative management alone. (Circ Cardiovasc Interv. 2018;11:e005985. DOI: 10.1161/CIRCINTERVENTIONS.117.005985.) Key Words: comorbidity ◼ conservative treatment ◼ mitral valve ◼ prognosis ◼ uncertainty © 2018 American Heart Association, Inc. Survival After MitraClip Treatment Compared to Surgical and Conservative Treatment for High-Surgical-Risk Patients With Mitral Regurgitation Friso Kortlandt, MD; Juliette Velu, MSc; Remco Schurer, MD; Tom Hendriks, MSc; Ben Van den Branden, MD, PhD; Berto Bouma, MD, PhD; Ted Feldman, MD; Johannes Kelder, MD, PhD; Annelies Bakker, MD; Marco Post, MD, PhD; Pim Van der Harst, MD, PhD; Frank Eefting, MD; Martin Swaans, MD, PhD; Benno Rensing, MD, PhD; Jan Baan Jr, MD, PhD; Jan Van der Heyden, MD, PhD Structural Heart Disease Circ Cardiovasc Interv is available at http://circinterventions.ahajournals.org DOI: 10.1161/CIRCINTERVENTIONS.117.005985 Downloaded from http://ahajournals.org by on May 28, 2020