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CORRESPONDENCE cardiovascular deaths), whereas 82 remained asymptomatic (compensated cohort). The indication for surgical referral was development of symptoms in 90% of patients. The mean time to clinical event in the decompensated cohort was 12.6±16.8 months, and the mean follow-up time in the compensated cohort was 33.8±23.9 months.

Clinical and most imaging variables were similar among cohorts (decompensated vs compensated: age 64.1 vs 60.6 years, LV ejection fraction 66% vs 67%, LV end-diastolic volume 100.1 vs 92.1 mL/m2, prevalence of replacement fibrosis 34% vs 31%). Patients in the decompensated cohort had more severe MR (regurgitant fraction 47% vs 38%; P< 0.001), larger left atrial size (83.4 vs 67.9 ml/m2; P< 0.001), and higher ECV (median ECV 28.1% vs 27.1%; P< 0.001). Prevalence of elevated ECV (ECV≥ 30%, threshold selected a priori based upon normal …