Background .– Type (undersizing annuloplasty–UA- vs. mitral valve replacement–MVR-) and outcome of surgical treatment of functional mitral regurgitation (FMR) are still debated.

Objectives .– Early and mid-term outcome of patients operated for symptomatic severe FMR; Comparison of respective results of UA and MVR.

Methods .– Inclusion criteria:

– severe FMR due to either ischemic or non-ischemic cardiac disease;

– heart failure symptoms despite optimal medical treatment;

– LVEF < 40%.

Primary endpoints:

– in-hospital mortality;

– late CV mortality.

Secondary endpoints:

– evolution of LVEF after surgery;

– recurrence of MR.

Results .– Fifty-nine consecutive patients included between 1997 and 2011, mean age = 65 ± 10, ischemic disease in 41 (70%), heart failure symptoms in all, LVEF = 36 ± 6%, ERO = 41 ± 17 mm ² . Surgical procedures included 12UA and 47 MVR with only eight (13%) concomitant CABG. MVR and UA groups were comparable for age, ischemic etiology, LVEF, ERO and sPAP (all P > 0.5). In-hospital mortality: 3.3% overall, 8.3% in UA group and 2.1% in MVR group ( P = 0.36). Eight-year survival free from CV death: 58 ± 13% in the total population, 60 ± 18% in the UA group and 72 ± 10% in the MVR group ( P = 0.48). By multivariable analysis, older age (1.22 [1.05–1.42], P = 0.008) and LV end-diastolic diameter (1.25 [1.05–1.49], P = 0.01) independently predicted late mortality with borderline effect of pre-op LVEF (1.1[0.99–1.2], P = 0.08) whereas type of surgery did not (1.7 [0,38–7.55], P = 0.48). LVEF did not change between preop and late FU echo in the MVR group (36 ± 6% vs. 36 ± 10%, P = 0.68) but tended to decrease in the UA group (37 ± 5.8% vs. 31 ± 12%, P = 0.1). In the UA group, 50% of patients experienced recurrence of significant MR (mean postop ERO = 19 ± 4 mm ² ) whereas no patients in the MVR group presented with postop MR.

Conclusions .– Despite severe clinical and echocardiographic presentation, surgical treatment of FMR can be performed with an acceptable operative risk and mid-term survival. MVR is a reasonable approach, which does not expose patients to MR recurrence, particularly frequent after UA.