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Benito-González et al. Mini-invasive Surg 2020;4:67 I http://dx.doi.org/10.20517/2574-1225.2020.54 Page 7 of 9

are needed to assess its usefulness in patients undergoing other structural interventional procedures.

PMVR with MitraClip® has proven to persistently reduce MR with low rates of procedural complications in
[18]
patients at high surgical risk . Furthermore, observational registries have shown a significant improvement
[19]
in functional class, 6-minute walk test and quality of life . More recently, data from randomized controlled
trials suggest that there might be a survival benefit of MitraClip® compared to stand-alone medical therapy
in patients with functional MR [20-22] . Nevertheless, selection of patients in order to find those who will
benefit the most from PMVR and avoid futility is still extremely challenging. In this regard, pre-procedural
evaluation of frailty might help to identify those patients with very poor short-term prognosis and those
[23]
at a higher risk of non-cardiovascular mortality . Although there is extensive evidence of the prognosis
impact of frailty in cardiovascular disease, some aspects should be taken into account. First, frailty, in the
absence of advanced disability, is a potentially reversible and treatable condition, so that a pre-procedural
[24]
intervention could hypothetically improve the clinical prognosis of patients at high risk . Second, the
latest recommendations of the geriatric societies do not consider frailty as a contraindication to any
invasive treatment but, on the contrary, as an important assessment element to establish an individualized
[3]
plan of care . Therefore, frailty should be an additive point to address by the multidisciplinary Heart
Team when considering a potential candidate for MitraClip®, never a single tool for decision making.
Risk stratification of patients undergoing PMVR is currently based on non-dedicated scales developed in
[2]
the surgical field with a modest power of discrimination in this scenario . The implementation of frailty
[25]
scales might improve selection of patients . Finally, despite an worse prognosis, frail patients showed a
significant clinical improvement in the short-term and, therefore, this therapy might be considered for
symptomatic relief in the absence of other reliable alternatives, even in the absence of consistent survival
benefit.

Limitations
This study has some limitations. First of all, it is a single center small cohort of patients. Second, no
dedicated test has been included to assess physical frailty, such as pressure force or gait speed. Third, frailty
was not re-evaluated during follow up.

In conclusion, frailty was a frequent finding among patients undergoing PMVR. The presence of this
syndrome did not impact procedural success. Despite symptomatic improvement in this patient group after
PMVR, frailty was associated with an increase in adverse outcomes during follow-up. Further studies are
needed to validate our results, and to assess whether any intervention to improve this syndrome can modify
the prognosis of this patient group.

DECLARATIONS
Authors’ contributions
Made substantial contributions to conception and design of the study and performed data analysis and
interpretation: Benito-González T, Estévez-Loureiro R
Performed data acquisition, as well as provided administrative, technical, and material support: del Castillo
S, Minguito-Carazo C, Echarte-Morales J, Garrote-Coloma C
Drafted the paper: Benito-González T, Estévez-Loureiro R, Garrote-Coloma C
Reviewed critically: Fernández-Vázquez F
Gave final approval: Benito-González T, Estévez-Loureiro R, del Castillo S, Minguito-Carazo C, Echarte-
Morales J, Garrote-Coloma C, Fernández-Vázquez F

Availability of data and materials
Data of this work can be provided in case of formal request and under a legitimate cause.