New Research Paper
Structural
Impact of Transcatheter Edge-to-Edge Mitral Valve Repair on Guideline-Directed Medical Therapy Uptitration

https://doi.org/10.1016/j.jcin.2023.01.362Get rights and content

Abstract

Background

Guideline-directed medical therapy (GDMT) optimization is mandatory before transcatheter edge-to-edge mitral valve repair (M-TEER) in patients with secondary mitral regurgitation (SMR) and heart failure (HF) with reduced ejection fraction (HFrEF). However, the effect of M-TEER on GDMT is unknown.

Objectives

The authors sought to evaluate frequency, prognostic implications and predictors of GDMT uptitration after M-TEER in patients with SMR and HFrEF.

Methods

This is a retrospective analysis of prospectively collected data from the EuroSMR Registry. The primary events were all-cause death and the composite of all-cause death or HF hospitalization.

Results

Among the 1,641 EuroSMR patients, 810 had full datasets regarding GDMT and were included in this study. GDMT uptitration occurred in 307 patients (38%) after M-TEER. Proportion of patients receiving angiotensin-converting enzyme inhibitors/angiotensin receptor blockers/angiotensin receptor-neprilysin inhibitors, beta-blockers, and mineralocorticoid receptor antagonists was 78%, 89%, and 62% before M-TEER and 84%, 91%, and 66% 6 months after M-TEER (all P < 0.001). Patients with GDMT uptitration had a lower risk of all-cause death (adjusted HR: 0.62; 95% CI: 0.41-0.93; P = 0.020) and of all-cause death or HF hospitalization (adjusted HR: 0.54; 95% CI: 0.38-0.76; P < 0.001) compared with those without. Degree of MR reduction between baseline and 6-month follow-up was an independent predictor of GDMT uptitration after M-TEER (adjusted OR: 1.71; 95% CI: 1.08-2.71; P = 0.022).

Conclusions

GDMT uptitration after M-TEER occurred in a considerable proportion of patients with SMR and HFrEF and is independently associated with lower rates for mortality and HF hospitalizations. A greater decrease in MR was associated with increased likelihood for GDMT uptitration.

Section snippets

Study population

This is a retrospective analysis of prospectively collected data on patients with SMR who underwent M-TEER between November 2008 and January 2021 at 11 high-volume European centers included in the EuroSMR Registry. Patients received GDMT according to local judgment and expertise, and were considered eligible for M-TEER after a multidisciplinary heart team discussion. All patients gave their consent after explanation of the benefits and risks of the procedure. The study complied with the

Results

During the study period, a total of 1,641 patients underwent M-TEER for SMR, 1,159 of whom had HFrEF. After excluding patients without data regarding GDMT at both baseline and 6-month follow-up, 810 patients were finally included into this analysis (Supplemental Figure 1). Before M-TEER, 798 patients (98.5%) received GDMT, of whom 633 (78%) received ACE inhibitor/ARB/ARNI, 723 (89%) beta-blockers, and 499 (62%) MRA (Figure 1A). GDMT was largely underdosed with >50% target doses of ACE

Discussion

The main findings of this analysis of EuroSMR, the largest observational study of M-TEER in patients with SMR, are the following: 1) more than one-third of patients undergoing M-TEER underwent uptitration of GDMT after M-TEER, which consisted of the initiation or increase in dose of either ACE inhibitor/ARB/ARNI and/or beta-blockers and/or MRA after the procedure; 2) uptitration of GDMT after M-TEER was independently associated with a lower risk of all-cause death and of all-cause death or HF

Conclusions

More than one-third of patients with HFrEF and SMR undergoing M-TEER received GDMT uptitration at 6 months after the procedure. GDMT uptitration after M-TEER was independently associated with a reduced risk of clinical events. Greater decrease in MR severity was a major factor associated with GDMT uptitration after M-TEER.

WHAT IS KNOWN? GDMT is recommended before M-TEER because it may improve SMR. However, whether treatment of SMR may enable further GDMT uptitration is unknown.

WHAT IS NEW?

Funding Support and Author Disclosures

Dr Adamo has received speaker fees from Abbott Vascular and Medtronic. Dr Baldus has received lecture fees and research support from Abbott and Edwards Lifesciences. Dr Kalbacher has received speaker honoraria from Abbott; and has received travel expenses and proctor fees from Edwards Lifesciences. Dr Lurz has received institutional research grants from Edwards Lifesciences and Abbott Vascular. Dr Petronio has been a consultant for Abbott Vascular, Boston Scientific, and Medtronic. Dr von

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Lars Søndergaard, MD, served as Guest Editor-in-Chief and David Muller, MD, served as Guest Editor of this paper.

The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.

Drs Adamo and Tomasoni contributed equally to this work as first authors.

Dr Hausleiter and Prof Metra contributed equally to this work as senior authors.

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