New Research Paper
Structural
Impact of Mitral Regurgitation Etiology on Mitral Surgery After Transcatheter Edge-to-Edge Repair: From the CUTTING-EDGE Registry

https://doi.org/10.1016/j.jcin.2023.02.029Get rights and content

Abstract

Background

Although >150,000 mitral TEER procedures have been performed worldwide, the impact of MR etiology on MV surgery after TEER remains unknown.

Objectives

The authors sought to compare outcomes of mitral valve (MV) surgery after failed transcatheter edge-to-edge repair (TEER) stratified by mitral regurgitation (MR) etiology.

Methods

Data from the CUTTING-EDGE registry were retrospectively analyzed. Surgeries were stratified by MR etiology: primary (PMR) and secondary (SMR). MVARC (Mitral Valve Academic Research Consortium) outcomes at 30 days and 1 year were evaluated. Median follow-up was 9.1 months (IQR: 1.1-25.8 months) after surgery.

Results

From July 2009 to July 2020, 330 patients underwent MV surgery after TEER, of which 47% had PMR and 53.0% had SMR. Mean age was 73.8 ± 10.1 years, median STS risk at initial TEER was 4.0% (IQR: 2.2%-7.3%). Compared with PMR, SMR had a higher EuroSCORE, more comorbidities, lower LVEF pre-TEER and presurgery (all P < 0.05). SMR patients had more aborted TEER (25.7% vs 16.3%; P = 0.043), more surgery for mitral stenosis after TEER (19.4% vs 9.0%; P = 0.008), and fewer MV repairs (4.0% vs 11.0%; P = 0.019). Thirty-day mortality was numerically higher in SMR (20.4% vs 12.7%; P = 0.072), with an observed-to-expected ratio of 3.6 (95% CI: 1.9-5.3) overall, 2.6 (95% CI: 1.2-4.0) in PMR, and 4.6 (95% CI: 2.6-6.6) in SMR. SMR had significantly higher 1-year mortality (38.3% vs 23.2%; P = 0.019). On Kaplan-Meier analysis, the actuarial estimates of cumulative survival were significantly lower in SMR at 1 and 3 years.

Conclusions

The risk of MV surgery after TEER is nontrivial, with higher mortality after surgery, especially in SMR patients. These findings provide valuable data for further research to improve these outcomes.

Section snippets

Data Source

The CUTTING-EDGE registry is a multicenter, international registry of patients who underwent MV surgery after TEER.4 Patients who underwent MV surgery between July 2009 and July 2020 after TEER were included across 34 centers worldwide. Anonymized data were obtained from each institution's electronic health records and transmitted to a central site for data management and statistical analyses. Because all institutions contributed cases after obtaining local institutional review board approvals,

Baseline Clinical, Procedural and Echocardiographic Characteristics at Index TEER

A total of 330 patients underwent MV surgery following TEER in the CUTTING-EDGE registry during the study period, of which 155 patients (47%) had PMR and 175 patients (53%) SMR. Temporal trends in annual MV surgery cases stratified by MR etiology are illustrated in Figure 1. The mean age at the time of index TEER procedure was 73.8 ± 10.1 years, and 42.7% were female (Table 1). Median STS risk score was 4.0% (IQR: 2.2%-7.3%), 48.0% were deemed high or extreme surgical risk by the local heart

Discussion

This analysis from the CUTTING-EDGE registry examined the impact of initial MR etiology on MV surgery outcomes after a failed TEER procedure, and has several key findings (Central Illustration). First, compared with PMR, SMR patients exhibited a significantly higher 1-year mortality and a lower cumulative survival at 3 years after surgery, despite no differences in the scenario of TEER failure and timing of surgery. We can speculate that this was mainly due to the greater comorbidity burden in

Conclusions

In this report from the international CUTTING-EDGE registry, patients with SMR undergoing MV surgery for TEER failure had more operations for mitral stenosis, with fewer MV repair and worse prognosis compared with those with PMR. Our findings are hypothesis generating and will provide further insights into patients after TEER who may require MV surgery in the future.

WHAT IS KNOWN? Although mitral TEER is widely performed in patients with severe primary and secondary MR, the impact of MR

Funding Support and Author Disclosures

Dr Bhadra has received travel compensation from Edwards Lifesciences. Dr Tagliari has received research support from the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior. Dr Leurent has been a consultant and physician proctor for and has received speaker honoraria from Abbott. Dr Asgar has been a consultant for Medtronic, Abbott, Edwards Lifesciences, and W. L. Gore & Associates; and has received research grants from Abbott. Dr Leroux has been a physician proctor for Medtronic and

Acknowledgments

The authors thank all the coinvestigators for their participation and involvement in the CUTTING-EDGE registry. The names are listed in the Supplemental Appendix.

References (26)

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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 Zaid and Avvedimento contributed equally to this work.

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