Impact of Transcatheter or Surgical Mitral Repair on Arrhythmic Burden in Patients With Mitral Valve Prolapse

Arrhythmic mitral valve prolapse (AMVP) is associated with malignant ventricular arrhythmias, yet the impact of surgical repair versus transcatheter edge-to-edge repair (TEER) on arrhythmic outcomes remains unclear. We evaluated ventricular arrhythmia occurrence and premature ventricular contraction (PVC) burden following mitral repair in patients with and without AMVP.

We conducted a retrospective cohort study of 1911 patients who underwent surgical mitral valve repair or TEER between 2004 and 2024 at a single institution. AMVP was defined per EHRA/ESC criteria, requiring mitral valve prolapse with frequent (≥5% PVC burden) or complex ventricular arrhythmias and no alternative arrhythmic substrate. Outcomes included non-sustained ventricular tachycardia (NSVT), ventricular tachycardia (VT), implantable cardioverter-defibrillator (ICD) implantation, mortality, and changes in PVC burden in patients with pre- and post-procedural rhythm monitoring.

Among 154 patients with AMVP, 109 (71%) underwent surgical repair and 45 (29%) underwent TEER. Following surgical repair, patients with AMVP had similar rates of NSVT (18% vs 13%), VT (3.7% vs 3.6%), and ICD implantation (3.7% vs 3.7%) compared with non-AMVP patients. In contrast, after TEER, patients with AMVP experienced significantly higher NSVT (33% vs 7%, P < 0.01), VT (12% vs 2.6%, P = 0.01), and ICD implantation (4.7% vs 0%, P = 0.02). PVC burden decreased after surgical repair (1.1% to 0.5%, P < 0.001) but remained unchanged after TEER. Mortality was higher in AMVP but not statistically significant.

Surgical mitral repair is associated with reduced arrhythmic burden in AMVP, whereas TEER is associated with persistently elevated ventricular arrhythmias. These findings support phenotype-guided repair strategies and underscore the need for prospective studies comparing arrhythmic outcomes across repair modalities.