Mitral Regurgitation: Early Intervention Reduces One-Year Risks

The clinical challenge of mitral regurgitation: between hospital burden and interventional urgency

Mitral regurgitation (MR) is currently the second most common valvular disease requiring surgical or transcatheter intervention. With an estimated prevalence of 10 to 15% for moderate to severe forms, this pathology places a heavy burden on healthcare systems. While MR is particularly prevalent in patients over 75 years of age, its prognosis depends closely on early management. A lack of treatment correlates with a major degradation in quality of life and excess mortality, making the therapeutic decision complex when faced with a patient profile that is often elderly and polypathological.

The objective of this retrospective study is to precisely quantify the burden of MI based on national hospital discharge data. The authors seek to phenotype patients — through their demographic characteristics and comorbidities — while evaluating healthcare resource utilization (HCRU) and the costs associated with different care pathways. The study tests the hypothesis that a better understanding of hospitalization patterns and treatment disparities will optimize resource allocation and identify levers for earlier interventions, which are essential for improving long-term prognosis.

Methodology of the retrospective analysis

This study is based on the analysis of national hospital discharge records (SDO) in Italy, covering a population of approximately 60 million residents. The researchers adopted a retrospective design to evaluate the hospital burden of mitral regurgitation (MR) across the entire territory.

• Study population: Adults (≥18 years) hospitalized with a primary diagnosis of mitral insufficiency (ICD-9-CM code 424.0) between January 1 and December 31, 2018. The index event is defined by the first hospitalization during this period.
• Exclusion criteria: To isolate new incident cases, a 2-year look-back period was applied. Patients with a history of hospitalization for MI, endocarditis, congenital or rheumatic heart disease were excluded.
• Excluded interventions: Cases involving mitral valve replacement or combined procedures during the index event (other heart valves, coronary artery bypass grafting [CABG], or lung surgery) were excluded.
• Segmentation: The cohort was divided according to etiology: degenerative mitral regurgitation (DMR) or functional mitral regurgitation (FMR).
• Resource analysis: The study quantified healthcare resource utilization (HCRU), including lengths of stay, the nature of interventions (surgical vs. transcatheter), and associated costs.

Analysis of care pathways and clinical outcomes

The study, based on national hospital discharge data (SDO) in Italy for the year 2018, analyzed a cohort of adult patients (≥18 years) hospitalized with a primary diagnosis of mitral regurgitation (MR), identified by the ICD-9-CM code 424.0. The results highlight major disparities in therapeutic management and clinical outcomes at one year.

Treatment profiles and demographic disparities

The analysis reveals that a significant proportion of patients hospitalized for MR did not receive any interventional treatment (surgical or transcatheter). This lack of intervention is particularly marked in two specific subgroups:

• Elderly patients: a direct correlation is observed between advancing age and the probability of receiving no invasive treatment.
• Women: data indicate lower access to procedures compared to the male population.

One-year clinical results

The 12-month prognosis differs radically depending on the therapeutic strategy adopted. Patients who remained untreated show significantly degraded health indicators compared to the treated groups (surgery or edge-to-edge repair):

Economic impact and healthcare resource utilization (HCRU)

The study highlights an economic paradox between the initial cost of the intervention and the long-term financial burden. While the initial costs associated with surgical and transcatheter procedures are higher during the index event, untreated patients generate higher healthcare consumption over time. This increased economic burden on the healthcare system is directly linked to the higher frequency of rehospitalizations and the management of complications resulting from the natural progression of uncorrected mitral regurgitation.

Therapeutic Inertia with Measurable Consequences

This study based on Italian national data (SDO) reveals a concerning gap between diagnosis and intervention: a significant proportion of patients hospitalized for mitral regurgitation (MR), particularly women and elderly subjects, are discharged from the hospital without interventional treatment. Clinically, this conservative choice results in a poor prognosis at one year. The results unambiguously show that untreated patients experience higher mortality and more frequent re-interventions than those who underwent surgical or transcatheter repair.

The economic analysis of the study provides crucial insight for the practitioner and the decision-maker. While the initial cost of surgical or transcatheter interventions is higher, untreated patients generate a much greater consumption of healthcare resources over the long term. This expenditure is driven by iterative rehospitalisations and the management of complications. For the clinician, this means that 'medical' management alone is not a cost-saving option, but a postponement of costs associated with a loss of opportunity for the patient.

The limitations of this work lie primarily in the use of ICD-9 CM codes, which do not always allow for a perfect etiological distinction between degenerative (DMR) and functional (FMR) MI. However, the statistical power associated with a population of 60 million inhabitants highlights a field reality: the need for early intervention and structured post-hospitalization follow-up to break the cycle of readmissions.

This retrospective Italian study highlights a major paradox: while the prevalence of moderate to severe mitral regurgitation (MR) reaches 10 to 15%, a large proportion of patients — predominantly women and seniors — does not benefit from any curative intervention. This lack of management results in increased mortality at one year and an explosion of long-term costs driven by iterative rehospitalizations for complications.

In concrete terms, for the practitioner:

• Target populations at risk of undertreatment: Increase vigilance during the assessment of female patients and elderly subjects, who are statistically less likely to be referred for valve correction (surgical or transcatheter) despite an initial hospitalization for MI.
• Anticipate the medico-economic benefit: While the initial interventional cost is high, it is offset by the drastic reduction in readmissions for heart failure at 12 months compared to conservative treatment alone.
• Optimize interventional timing: The study demonstrates that early intervention is the key to improving the vital prognosis and reducing subsequent recourse to emergency care.

Technical lexicon of the study

Mitral Regurgitation (MR): Dysfunction of the mitral valve causing abnormal systolic reflux of blood from the left ventricle to the left atrium.

DMR (Degenerative Mitral Regurgitation): Primary etiology of MR resulting from a structural anatomical abnormality of the valvular apparatus, of genetic or degenerative origin, leading to leaflet prolapse.

FMR (Functional Mitral Regurgitation): Secondary etiology of MI related to ventricular or atrial dilation leading to cardiac remodeling and malcoaptation of the valve leaflets.

Coaptation: Mechanism of closure and joining of the mitral valve leaflets during systole; its insufficiency is at the heart of the regurgitation process.

Mitral valve apparatus: Complete anatomical structure including the leaflets, the mitral annulus, the chordae tendineae and the papillary muscles, whose integrity ensures ventricular-atrial sealing.

ICD-9 CM: International Classification of Diseases system (9th revision) used in this study to precisely identify diagnoses (code 424.0) and hospital procedures.

PASCAL System: Medical device used for transcatheter edge-to-edge repair (TEER) of mitral leaflets, mentioned as an alternative to conventional surgical techniques.

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