Elsevier

International Journal of Cardiology

Volume 344, 1 December 2021, Pages 141-146
International Journal of Cardiology

Early symptomatic benefit indicates long-term prognosis after transcatheter mitral valve edge-to-edge repair in functional and degenerative etiology

https://doi.org/10.1016/j.ijcard.2021.09.038Get rights and content

Highlights

  • •

    Mitral regurgitation is an well-established risk factor for adverse prognosis in HF.

  • •

    interventional therapy enables sustainable symptomatic improvement in nearly 75%.

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    Postprocedural change in NYHA-class might be a tool predict prognosis after TMVr.

Abstract

Background

Mitral regurgitation (MR) is common in patients with heart failure and constitutes an independent risk factor for adverse prognosis besides NYHA-class. The predictive value of dyspnea reduction after transcatheter mitral valve repair (TMVr) on outcome has not been investigated up to now.

Methods and results

We enrolled 627 consecutive patients (47.0% female, 57.4% functional MR; median follow-up 486 days[IQR 157/961]; survival status available in 96.8%; symptoms assessed in n = 556 at baseline / n = 406 at 1 month) treated with isolated percutaneous mitral valve edge-to-edge repair in our center from 06/2010–03/2018 (exclusion of combined forms of TMVr) in a monocentric retrospective analysis. Survival was 97.6% at discharge, 73.9% after 1, 54.5% after 3, 37.6% after 5 and 21.7% after 7-years. Before TMVr, NYHA-classes III/IV were found in 89.0%. Of these, 74.7% reported symptomatic relief (reduction in NYHA-class) one month after procedure (NYHA class recorded in 406 patients at 30 days). NYHA-classes III/IV were documented in 37.2% (p < 0.001) at 30 days and in 36.6% (p < 0.001) at 1 year without significant changes between the follow-ups. Dyspnea reduction was accompanied by significantly improved long-term survival (1 year, 89.1 vs 71.2%, p = 0.001, 2 years: 75.5 vs 58.7%, p = 0.039) and was identified as an independent predictor for lower mortality (1-year HR for increased mortality by missing symptomatic improvement 2.94 [95%CI 1.53–5.65], p = 0.001; long-term HR 1.95 [95%CI 1.29–2.94], p = 0.001) independently in both etiologies of MR.

Conclusion

TMVr by edge-to-edge therapy enables early and sustainable symptomatic improvement in nearly 75% of the symptomatic patients. The simple assessment of postinterventional changes in NYHA-class might serve as an independent predictor for mid- and long-term prognosis in both FMR and DMR.

Introduction

Mitral valve regurgitation (MR) is common in patients suffering from heart failure (HF) and has an age-dependent prevalence exceeding 10% in individuals older than 75 years in industrialized countries [1]. Percutaneous minimally invasive transcatheter mitral valve repair (TMVr) has become a frequently used treatment for patients at elevated surgical risk, and to date, “edge-to-edge”-therapy (e.g., MitraClip®, Abbott Vascular, Santa Clara, CA, USA) is the most established type of TMVr [2]. Defined by different pathomechanisms, functional (FMR) has to be discriminated from degenerative MR (DMR) [3]. Even though FMR is a consequence of concomitant HF, high-grade MR itself is an independent predictor for adverse individual prognosis in patients suffering from HF [4,5].

Recently, results of two large randomized prospective multicenter trials on the effect of an edge-to-edge repair for FMR have been published with in part divergent results: while the US COAPT-trial demonstrated a prognostic and symptomatic benefit by interventional in comparison to optimal medical treatment [6], the French MITRA-FR failed to show significant differences regarding re-hospitalization and mortality [7]. In the present study we aimed I) to assess symptomatic improvement over the follow-up period in our cohort and II) to detect potential prognostic implications of postprocedural changes in symptoms.

Section snippets

Methods

All patients consecutively treated with TMVr by edge-to-edge therapy in our center between 09th June 2010 and 08th March 2018 were screened. All included subjects were adults (≥18 years) with moderate to severe or severe MR despite optimal medical treatment for HF, including cardiac resynchronization therapy when indicated, in accordance to current guidelines [8]. In each patient, decision for transcatheter treatment was taken by an interdisciplinary Heart Team based on an individual risk

Enrolment and overall survival

Up to March 2018, 725 consecutive patients underwent percutaneous edge-to-edge-therapy in our center. Of those, 98 (13.1%) were excluded from the present study: 90 (12.4%) had undergone a primarily simultaneous combined treatment of edge-to-edge repair with an additional therapy with other forms of TMVr (e. g., interventional annuloplasty or chordal reconstruction), technical failure occurred in 8 patients (1.3%; resulting mitral stenosis by placement of the device, leading to abortion of clip

Discussion

MR is a common finding in patients with HF. The development of FMR (also referred to as secondary MR) is often accompanying left ventricular dysfunction. The underlying pathomechanism is multifactorial and FMR has been identified as an independent predictor for adverse prognosis in HF-patients [4], even under optimal contemporary medical therapy [16]. While FMR is more prevalent than DMR, the prognostic impact of mitral valve surgery is controversial for FMR-patients [5]. A survival benefit by

Conclusion

In this large retrospective monocentric analysis of consecutive patients undergoing TMVr by edge-to-edge repair, dyspnea relief at one month after procedure was sustained over later follow-ups and associated with better mid- and long-term survival in a cohort including both etiologies of MR, independently of age, sex and other factors. Thus, early stratification of symptomatic “responders” by NYHA-class reduction one month after TMVr might be an easy-to-obtain and viable tool to allow risk

Funding

This work is partially funded by the German Federal Ministry of Education and Research (BMBF 01EO1503).

Declaration of Competing Interest

FK: consultancy and lecture honoraria from Abbott, Cardiac Implants, Edwards Lifesciences.

ES: lecture honoraria from Edwards Lifesciences and Medtronic.

RSvB: consultancy and lecture honoraria from Abbott Structural Heart, Boehringer Ingelheim, Cardiac Dimensions, Edwards Lifesciences, GE Health Systems and Philips Healthcare.

All other authors state that there is no conflict of interest.

Acknowledgements

This work contains results that are part of the doctoral thesis of Sonja Born and Kevin Bachmann. Thomas Münzel is PI of the DZHK (German Center for Cardiovascular Research), Partner Site Rhine-Main, Mainz, Germany.

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    • 1

    M.G. and K.K. contributed equally and should both be considered as first authors.

    2

    All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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