Early surgery is recommended for mitral regurgitation.

Mitral regurgitation (MR), the systolic flow reversal from the left ventricle to the left atrium, is currently the most frequent valvular heart disease.1 Because MR affects predominantly patients ≥65 years of age,1 with age at surgery most often in the sixth decade,2 the observed prevalence will increase with the aging of the population. Thus, the number of US citizens affected by moderate or severe MR will almost double between 2000 and 2030, reaching almost 5 million by then.1 MR mechanism is classified as organic (intrinsic valve lesions) or functional (structurally normal mitral valve with MR caused by ventricular dysfunction).3 Indications of mitral surgery, the only current approved treatment of MR, are disputed because large clinical trials in MR have not been reported and outcome studies provide the best evidence available but require careful interpretation. The benefit of surgery is uncertain in functional MR and is not addressed here.4 However, we illustrate here that overwhelmingly coherent cumulative evidence obtained worldwide shows that early surgery should be the preferred management approach for organic MR. This approach differs from standard guidelines, and it is essential that its principles, rationales, and conduct be fully considered. Response by Gillam and Schwartz see p 804 Guidelines for the management of valve diseases mention class I versus class II indications as having agreed-on versus conflicting evidence/opinions.5 This classification is problematic for MR treatment because class I indications, based mostly on symptoms and overt left ventricular (LV) dysfunction, lead to the performance of rescue surgery (surgery for patients at considerable risk if unoperated) but do not result in optimal long-term outcomes for patients with organic MR.6,7 The concept of uniform surgical recommendations that supposedly apply equally to all centers is also problematic; recent studies have shown that the quality of …