Elsevier

International Journal of Cardiology

Volume 323, 15 January 2021, Pages 208-212
International Journal of Cardiology

Disproportionate functional mitral regurgitation predicts a favourable response after MitraClip implant in patients with advanced heart failure. Real-world evidence of a new conceptual framework.

https://doi.org/10.1016/j.ijcard.2020.08.026Get rights and content

Highlights

  • Patient selection before Mitraclip implant is critical.

  • Predictors of Mitraclip outcomes are lacking.

  • Disproportionate mitral regurgitation identifies Mitraclip responders.

  • Regurgitant fraction >50% predicts better outcomes after Mitraclip.

  • TAPSE ≤14 mm is associated with worse outcomes after Mitralip implant.

Abstract

Introduction

Accurate predictors of good clinical response after MitraClip implant in patients with heart failure (HF) are still lacking. Aim of this study was to investigate the role of regurgitant fraction >50% as a marker of disproportionate functional mitral regurgitation (FMR) in identifying best responders to Mitraclip.

Methods and results

Data from 58 advanced HF patients (age 66 ± 8 years, 81% males, 63% NYHA class IV, LV ejection fraction (EF) 25.5 ± 5.5%) with disproportionate and proportionate FMR who underwent successful MitraClip implant were analyzed. After MitraClip all patient achieved mild (≤ 2+/4+) MR. During 12-month follow-up 18 patients (31%) had a major adverse cardiac event (MACE, i.e. cardiac death, urgent LVAD implant or heart transplantation, HF hospitalization). Disproportionate FMR (n = 48, 83%) was associated with a better clinical outcome (p = .003) while regurgitant volume and EROA were not. TAPSE ≤14 mm was associated with worse outcome (p = .018). At multivariable analysis only disproportionate MR and TAPSE ≤14 mm showed a significant association with MACE (p = .017 and p = .02, respectively). A reverse left ventricular remodeling (i.e., reduction on LV end-diastolic diameter and end-diastolic volume) was achieved only in the disproportionate FMR group.

Conclusions

In conclusion, disproportionate FMR assessed by regurgitant fraction and RV dysfunction assessed by TAPSE may help the selection of HF patients candidates for MitraClip therapy.

Section snippets

Background

MitraClip is an increasingly widespread therapeutic opportunity for functional mitral regurgitation (FMR) in patients with left ventricular (LV) dysfunction, though its efficacy in the reduction of mortality is still debated. In fact, the results from two randomized trial and a meta-analysis showed different results [[1], [2], [3]]. Nevertheless, the profoundly divergent results of MITRA-FR and COAPT trials may indicate that patient selection is crucial for clinical success. Although right

Methods

This was a single-center study that screened all consecutive patients undergoing MitraClip implant in the Cardiology Division of Città della Salute e della Scienza in Turin, from June 2016 to June 2018. Inclusion criteria were age ≥ 18 years, advanced chronic Heart Failure [9] with ejection fraction ≤35%, severe functional mitral regurgitation (as defined below). Exclusion criteria were organic mitral regurgitation, contraindication to transesophageal echocardiography and etiology of heart

Results

We analyzed data from 58 patients with advanced chronic HF (age 66 ± 8 years, 81% males, 63% NYHA class IV, median NTproBNP 4005, EF 25.5 ± 5.5%) who underwent successful MitraClip implant in the Cardiology division of Città della Salute e della Scienza University Hospital in Turin. Baseline characteristics of the population are listed in Table 1. All patient showed an EROA ≥30 mm2 before procedure. Mean trans-mitral gradient after MitraClip implant was 2.58 ± 1.02 mmHg. A regurgitant fraction

Discussion

Our results suggest that regurgitant fraction >50% as a marker of disproportionate FMR accurately identifies patients who may benefit from the MitraClip procedure. Notably EROA and regurgitant volume failed to predict events after MitraClip in the setting of severe FMR, partially due to selection of patients with severely altered lesion-related parameters (i.e., EROA ≥30 mm2). These results may improve the suggestions of a recent review of Pibarot [14] that proposed EROA ≥30 mm2 and regurgitant

Conclusions

In conclusion, disproportionate FMR assessed by regurgitant fraction >50%, and RV dysfunction assessed by TAPSE may help the selection of HF patients candidates for MitraClip therapy. A clinical benefit and reverse remodeling were possible even in presence of severe LV dilation and dysfunction in patients with regurgitant fraction >50%.

Declaration of Competing Interest

There are no conflicts of interest.

References (16)

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  • Transcatheter Repair of the Mitral Valve: Relevant Pathophysiology, Investigation, and Management

    2021, Canadian Journal of Cardiology
    Citation Excerpt :

    It is in the latter group that MitraClip is thought to be beneficial.45 This concept was assessed in 2 small studies with mixed results, and further evidence is needed.46,47 Additional studies showed that MV repair with the use of MitraClip induces reverse remodelling, most notably manifested by significant reduction in systolic and diastolic LV volumes as well as reduction in LA volume and improved echocardiographic LV strain parameters.

This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation

1

Division of Cardiac Surgery, Città della Salute e della Scienza University Hospital, Torino, Italy.

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