Perspective:

This is an important study in that it reveals relatively low operative mortality for patients undergoing MV repair, and good 10-year outcomes associated with MV repair and replacement in the Medicare population. However, some caveats should be noted before broader conclusions are drawn. First, a variety of factors likely affect whether patients undergo MV repair versus replacement; some probably are justified (e.g., patients with an unrepairable valve might have different underlying disease/s than do patients with a repairable valve, and patients with a less favorable mid-term prognosis might preferentially undergo replacement rather than repair), and some might not be justified (e.g., replacement is preferentially performed at lower-volume centers). Second, there is inherent selection bias in studying the outcomes of patients who were referred for and underwent surgery, and it might not be appropriate to extrapolate favorable operative statistics to all older patients with MV disease. Finally, an argument for ‘early intervention’ among patients with mitral regurgitation still needs to be tempered with the age and general health of the patient, as well as the patient’s expectations in later years of life. Any conclusion that elderly patients are better off with ‘early’ intervention should come from a study that compared early intervention to usual clinical indications for surgery.