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.☆
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)
- et al.
Prognostic impact of MitraClip in patients with left ventricular dysfunction and functional mitral valve regurgitation: a comprehensive meta-analysis of RCTs and adjusted observational studies
Int. J. Cardiol.
(2019) - et al.
Improving selection of Mitraclip candidates in advanced chronic heart failure: look right to predict right
J. Card. Fail.
(2019) - et al.
Proportionate and disproportionate functional mitral regurgitation: a new conceptual framework that reconciles the results of the MITRA-FR and COAPT trials
JACC Cardiovasc. Imaging
(2019) - et al.
A unifying concept for the quantitative assessment of secondary mitral regurgitation
J. Am. Coll. Cardiol.
(2019) - et al.
Recommendations for noninvasive evaluation of native valvular regurgitation: a report from the American Society of Echocardiography
J. Am. Soc. Echocardiogr.
(2017) - et al.
Percutaneous mitral valve repair: the last chance for symptoms improvement in advanced refractory chronic heart failure?
Int. J. Cardiol.
(2017) - et al.
Percutaneous repair or medical treatment for secondary mitral regurgitation
N. Engl. J. Med.
(2018) - et al.
Transcatheter mitral-valve repair in patients with heart failure
N. Engl. J. Med.
(2018)
Cited by (4)
Transcatheter Repair of the Mitral Valve: Relevant Pathophysiology, Investigation, and Management
2021, Canadian Journal of CardiologyCitation 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.
Learning from Controversy and Revisiting the Randomized Trials of Secondary Mitral Regurgitation
2022, Reviews in Cardiovascular Medicine
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This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation
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Division of Cardiac Surgery, Città della Salute e della Scienza University Hospital, Torino, Italy.