Benefits of Early Surgery on Clinical Outcomes After Degenerative Mitral Valve Repair Tianyu Zhou, MD, Jun Li, MD, PhD, Hao Lai, MD, PhD, Kai Zhu, MD,

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Benefits of Early Surgery on Clinical Outcomes After Degenerative Mitral Valve Repair Tianyu Zhou, MD, Jun Li, MD, PhD, Hao Lai, MD, PhD, Kai Zhu, MD, PhD, Yongxin Sun, MD, Wenjun Ding, MD, Tao Hong, MD, Chunsheng Wang, MD The Annals of Thoracic Surgery Volume 106, Issue 4, Pages 1063-1070 (October 2018) DOI: 10.1016/j.athoracsur.2018.05.011 Copyright © 2018 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 (A) Trend in mitral valve repair: minimally invasive surgery (solid bars); median sternotomy (open bars). (B) Trend in New York Heart Association (NYHA) functional class: I (light gray); II (medium gray); III (dark gray); and IV (black). (C) Trend in proportion of atrial fibrillation. (D) Trends in preoperative left ventricular end-systolic dimension (LVESD) (circles), left ventricular end-diastolic dimension (LVEDD) (squares), left atrial dimension (LAD) (diamonds), and pulmonary artery systolic pressure (PASP) (triangles). (E) Trend in proportion of patients without any guideline-related indications. (F) Trends in repair techniques: leaflet resection (dashed line); chord reconstruction (broken line); and commissural closure (solid line). The Annals of Thoracic Surgery 2018 106, 1063-1070DOI: (10.1016/j.athoracsur.2018.05.011) Copyright © 2018 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Kaplan-Meier curve. (A) Overall survival. (B) Freedom from reoperation for mitral valve (MV). (C) Freedom from recurrent mitral regurgitation (MR). The Annals of Thoracic Surgery 2018 106, 1063-1070DOI: (10.1016/j.athoracsur.2018.05.011) Copyright © 2018 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Kaplan-Meier curve for recurrent mitral regurgitation (MR) stratified by predictive factors. (A) Left ventricular ejection fraction (LVEF) less than 60% (31% [solid line]); 60% or greater (12% [broken line]). (B) Left ventricular end-diastolic dimension (LVEDD) greater than 60 mm (29% [solid line]); 60 mm or less (6% [broken line]). (C) Isolated anterior leaflet lesion (18% [solid line]); posterior/bileaflet (14% [broken line]). (D) Residual mild MR in operating room (25% [solid line]; no residual MR (14% [broken line]). The Annals of Thoracic Surgery 2018 106, 1063-1070DOI: (10.1016/j.athoracsur.2018.05.011) Copyright © 2018 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Kaplan-Meier curve for recurrent mitral regurgitation (MR): early intervention group (broken line), and watchful waiting group (solid line). The Annals of Thoracic Surgery 2018 106, 1063-1070DOI: (10.1016/j.athoracsur.2018.05.011) Copyright © 2018 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Kaplan-Meier curve for recurrent mitral regurgitation (MR) in asymptomatic or mildly symptomatic patients (New York Heart Association class I–II): patients without left ventricular ejection fraction less than 60%, left ventricular end-systolic dimension greater than 40 mm, pulmonary hypertension, and atrial fibrillation (broken line); patients with any of the above indications (solid line). The Annals of Thoracic Surgery 2018 106, 1063-1070DOI: (10.1016/j.athoracsur.2018.05.011) Copyright © 2018 The Society of Thoracic Surgeons Terms and Conditions