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

OBJECTIVES: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.