1 1 1 1 2 1 2 Abstract Objective Methods st n n n Results vs P vs P vs P vs. vs vs. P Conclusions J Geriatr Cardiol 2018; 15: 428?433. doi:10./ 1 Introduction In industrialized countries, mitral regurgitation (MR) is the second most frequently identified valvular heart disease overall and the leading valvular heart disease in elderly patients over the age of 65 years. [1,2] [3] [4] [5] 2 Methods 2.1 Study population This was a retrospective single-centre study conducted at Fuwai Hospital, National Centre for Cardiovascular Disease, the well-known cardiovascular centre in China. Patients hospitalized in Fuwai hospital from May 1 st n n n To analyse factors that may influence decisions regarding the treatment of elderly MR patients, we categorized the elderly group into the following two subgroups based on surgical status: the medication group ( n n 2.2 Statistical analysis Quantitative variables are expressed as the mean ± SD. Comorbidities were analysed individually and in combination using the EuroSCORE-II system. Univariable comparisons were performed using the unpaired Student t P P 3 Results 3.1 Clinical characteristics The baseline character of elderly MR patients was list in Table 1. The mean age of the 680 elderly patients was 66.98 ± 5.94 years. Of these patients, 159 (23.38%) were aged 70–80 years, and 30 (4.41%) were> 80 years. Male patients accounted for 58.99% in the elderly group. In total, 275 (40.44%) elderly MR patients were graded as severe regurgi-tation by echocardiography. Among the elderly MR, degene-rative aetiologies were most commonly identified (41.18%), followed by rheumatic aetiologies and ischaemic aetiologies. 45.29% elderly patients were denied surgery, and surgery denial rate increased with age (Figure 1). Comparisons be-tween different age groups were showed in Table 2. 3.2 Clinical characteristics and treatment decision comparisons The two groups differed significantly by aetiology (Table 3). Degenerative mitral regurgitation (DMR) was most com-monly observed in both the elderly group and control group, but DMR accounted for a greater percentage of cases in the elderly group (41.18% vs P n * # n Atherosclerotic risk factors such as hypertension, diabetes or hyperlipidaemia were more commonly observed in the elderly group than control group (45.44% vs P vs P vs P vs P vs P P vs P n Of the 680 elderly MR patients included in this study, 308 were denied surgery (45.29%), which was much higher than the rate of denial observed in the control group (45.29% vs P P vs P Two hundred and twenty seven patients in elderly group and 171 patients in the control group had primary indications for cardiac revascularization and their coronary angiography results differed from those of control group ( P 3.3 Factors associated with treatment decisions in elderly MR patients Clinical features of medication subgroup and surgery group were compared in univariate analysis and the results were presented in Table 4. In the multivariate analysis, the characteristics associated with increased probability of under-going surgery among elderly MR patients were severe regur-gitation and normal LVEF. The factors associated with de-creased probability of undergoing surgery were increased age, diabetes and EuroSCORE-II high risk stratification (Table 5). n 4 Discussion Valvular heart disease is a common disease that may greatly influence quality of life and survival in elderly patients. MR has been identified as the most frequently diagnosed valvular heart disease in elderly people in industrialized countries. [2] In this study, we observed that even under the current guidelines, the rate of surgery in elderly MR patients was far from that which would be expected, as many factors may influence treatment decisions. In this single-centre study, the rate of surgical intervention of mitral valve was only 60.31% in the included 1741 MR patients overall, and even lower in the elderly group (54.71%). This finding was consistent with a previous study conducted in Western countries. [6] [6] [7] Regurgitation degree was most strongly associated with the decision to operate. Although there has been controversy regarding the optimal timing of intervention in moderate MR patients, consensus suggests that valvular surgery should be advised in severe MR patients, as shown by the corresponding class I recommendation in the ACC/AHA guidelines. [4] [6] n [8] Another study showed that age was an important factor influencing treatment decisions in general MR patients. We would like to note that, in this study, age was an important influencing factor, even among elderly patients. As patients became older, their rate of surgery decreased (Figure1). Actually, only a moderate increase in the risk of surgery has been identified in patients <80 years old. [5] [9] LVEF was associated with decisions regarding the treatment of elderly and severe MR patients (Figure2). Low LVEF has been identified as a predictive factor for spontaneous mortality, [10] [11] [12] [13] EuroScore-II high risk, which indicates presence of various comorbidities, was in association with a decision not to operate. This decision may be understandable since having an increased EuroSCORE index had been found to have a negative impact on life expectancy, [14] [15] The presence of diabetes was also a factor that influenced treatment decisions in the elderly group. The relationship between diabetes and MR is under heat debate. On the one hand, diabetes can exert a bad influence on recovery after surgery and study showed diabetes predicted MR progression after MV repair. [16] [17] While degeneration has been identified as the most common aetiology of valvular disease in developed countries, [1,2] [2] [18] Ischaemic MR was another type of MR frequently observed in this Chinese cohort. The abnormal and dilated left ventricle caused by CHD or related MI (ischemic MR) leads to papillary muscle displacement, which in turn results in leaflet tethering with associated annular dilation. Among elderly patients, the prevalence of ischaemic MR was especially high at 18.24%. In this study, the prevalence rates of coronary heart disease, myocardial infarction history and atherosclerotic risk factors were higher in the elderly group, and these results were likely related to the higher incidence of ischaemic MR observed in the elderly group. Coronary artery disease may be associated with increased operative risk, but its weight in the decision to operate could hardly be objectively assessed since the performance of coronary angiography is also closely linked to the decision to operate. In this study, most MR patients combined with CHD underwent MV surgery with concomitant surgical revascularization, which was consistent with the principle of ACC/AHA guidelines about ischaemic MR surgery recommendations. In conclusion, many elderly patients with more advanced age, worse heart function and more comorbidities may not be able to undergo surgery in China. Novel technologies based on percutaneous intervention, such as Mitraclip, [19] [4] This study was meaningful in that it provided information regarding the diagnosis and treatment of elderly MR patients and to some extent remedied knowledge gaps in this field in China. However, the results of this study are not generalized to all of China. A prospective, multi-centre study should be conducted in the future to further explore survival and prognosis in elderly MR patients and provide a more precise view of treatment trends. Acknowledgments This work was supported by National Key Technology Support Program of China (2015BAI12B02). There was no conflict of interests to be declared. References 1 Iung B, Baron G, Butchart EG, et al Eur Heart J 2 Iung B, Vahanian A. Epidemiology of acquired valvular heart disease. Can J Cardiol 3 Green P, Rosner GF, Schwartz A. Valvular heart disease in older adults: evolving technology to meet the needs of aging patients. Aging Health 4 Nishimura RA, Otto CM, Bonow RO, et al J Am Coll Cardiol 5 Ambler G, Omar RZ, Royston P, et al Circulation 6 Mirabel M, Iung B, Baron G, et al Eur Heart J 7 Iung B, Cachier A, Baron G, et al Eur Heart J 8 Enriquez-Sarano M, Avierinos JF, Messika-Zeitoun D, et al N Engl J Med 9 D’Arcy JL, Coffey S, Loudon MA. Large-scale community echocardiographic screening reveals a major burden of undiagnosed valvular heart disease in older people: the OxVALVE Population Cohort Study. 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