Mitral regurgitation (MR) is the most frequent valvular disease in developed countries. The degenerative aetiology predominates in primary MR, therefore its management represents an important public health issue (Figure 1). It has been observed both in Europe and in the USA that there is an underuse of surgery in patients with MR when indicated. This occurs with the frequent finding that risk evaluation is not adequate, leading to undertreatment of the sickest patients while conversely lower risk patients are often overtreated. The search for an improvement of risk stratification in patients with degenerative MR was the aim of the study published by Grigioni et al. in this issue of the journal. The goal was to define a score to predict early and late mortality. The authors should be congratulated for putting together what is the largest study ever published on degenerative MR since it included >3000 patients. The patient population comes from two registries: the MIDA Flail registry (2472 patients) was used as a derivation cohort for the score, and the MIDA BNP registry (1194 patients) served as the validation cohort. Besides its size, one of the strengths of the study is that it included patients from several countries, suggesting a good representation of the presentation of patients with degenerative MR and practices worldwide. Among the potential limitations of the present study we should take into account the fact that the inclusion period covers more than two decades, which may lead to significant changes in practices as regards both diagnosis and management. Although no specific information was given about co-morbidities, the patient population seems to be at relatively low risk since EuroSCORE II ranged from 1 to a maximum of 2.48, mean age was 66 years, a large proportion of patients were asymptomatic, and mean left ventricular ejection fraction was 64%. Thus it is likely that the high-risk patients currently treated using percutaneous device are under-represented here. We also lack precision as regards the methods used for grading the severity of MR; however, it was assessed using an integrative approach in experienced teams. In addition, most patients had flail leaflets which usually results in severe MR. The MIDA score was derived from the derivation cohort by weighing clinical and echocardiographic parameters which are in the guidelines: age >_65 years, left atrium diameter >_55 mm, left ventricular ejection fraction >_60%, left ventricular end-diastolic diameter >_40 mm, heart failure symptoms, atrial fibrillation, and right ventricular systolic pressure >_50 mmHg. All criteria corresponding to recommendations for surgery in guidelines were strongly associated with outcome, and this is a further proof of the validity of guidelines and of the relevance of the proposed thresholds. The positive aspects of this score are that it includes both clinical and echo variables taking into account all criteria together with a weight which is proportional to their prognostic impact. The MIDA score is simple, thus it may be expected to be user-friendly which may facilitate its use in practice. The score showed a good discrimination and also a good calibration, with a C index of 0.78 and 0.81, respectively. Finally it appears that the MIDA score adds incremental value in comparison with the guideline-provided prognostic markers and the EuroSCORE II for predicting 1and 5-year mortality. The fact that the MIDA score has a good predictive performance of 1-year mortality in medically treated patients is an important contribution in decision-making since it allows for a better assessment of the respective outcomes of operated and medically treated patients. The predictive value of the MIDA score in operated patients further highlights the prognostic impact of the consequences of MR on the left ventricle, left atrium, and pulmonary pressures. This is a further

中文翻译：

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预测退行性二尖瓣关闭不全的结果：向前迈进了一步，但仍有很长的路要走！

二尖瓣关闭不全（MR）是发达国家最常见的瓣膜疾病。退行性病因在原发性 MR 中占主导地位，因此其管理代表了一个重要的公共卫生问题（图 1）。在欧洲和美国都观察到，当有指征时，MR 患者的手术使用不足。出现这种情况的原因是经常发现风险评估不充分，导致对病情最严重的患者治疗不足，而相反，风险较低的患者往往治疗过度。Grigioni 等人发表的研究的目的是寻求改善退行性 MR 患者的风险分层。在本期杂志中。目标是定义一个分数来预测早期和晚期死亡率。应该祝贺作者整合了有史以来最大的关于退行性 MR 的研究，因为它包括 >3000 名患者。患者群体来自两个登记处：MIDA Flail 登记处（2472 名患者）用作评分的推导队列，而 MIDA BNP 登记处（1194 名患者）用作验证队列。除了规模之外，该研究的优势之一是它包括来自多个国家的患者，这表明它很好地代表了全球退行性 MR 患者的表现和实践。在本研究的潜在局限性中，我们应该考虑到纳入期超过二十年的事实，这可能导致诊断和管理实践的重大变化。虽然没有提供关于合并症的具体信息，但患者群体的风险似乎相对较低，因为 EuroSCORE II 的范围从 1 到最大值 2.48，平均年龄为 66 岁，大部分患者无症状，平均左心室射血分数为 64%。因此，目前使用经皮装置治疗的高危患者可能在此处的代表性不足。我们在用于对 MR 的严重程度进行分级的方法方面也缺乏精确性；然而，它是在经验丰富的团队中使用综合方法进行评估的。此外，大多数患者有连枷传单，这通常会导致严重的 MR。MIDA 评分来自推导队列，通过权衡指南中的临床和超声心动图参数：年龄 >_65 岁，左心房直径 >_55 毫米，左心室射血分数 >_60%，左心室舒张末期直径 >_40 mm，心力衰竭症状，心房颤动，右心室收缩压 >_50 mmHg。指南中与手术建议相对应的所有标准都与结果密切相关，这进一步证明了指南的有效性和拟议阈值的相关性。该评分的积极方面是它包括临床和回声变量，同时考虑了所有标准以及与其预后影响成正比的权重。MIDA 分数很简单，因此可以预期它是用户友好的，这可以促进其在实践中的使用。该分数显示出良好的辨别力和良好的校准，C 指数分别为 0.78 和 0.81。最后，与指南提供的预后标志物和 EuroSCORE II 相比，MIDA 评分似乎增加了预测 1 年和 5 年死亡率的增量值。MIDA 评分对接受药物治疗的患者的 1 年死亡率具有良好的预测性能这一事实是对决策的重要贡献，因为它允许更好地评估手术和接受药物治疗的患者各自的结果。MIDA 评分在手术患者中的预测价值进一步突出了 MR 对左心室、左心房和肺压后果的预后影响。这是进一步 MIDA 评分对接受药物治疗的患者的 1 年死亡率具有良好的预测性能这一事实是决策的重要贡献，因为它允许更好地评估手术和接受药物治疗的患者各自的结果。MIDA 评分在手术患者中的预测价值进一步突出了 MR 对左心室、左心房和肺压后果的预后影响。这是进一步 MIDA 评分对接受药物治疗的患者的 1 年死亡率具有良好的预测性能这一事实是决策的重要贡献，因为它允许更好地评估手术和接受药物治疗的患者各自的结果。MIDA 评分在手术患者中的预测价值进一步突出了 MR 对左心室、左心房和肺压后果的预后影响。这是进一步 左心房和肺压。这是进一步 左心房和肺压。这是进一步