Prognostic Impact of Heart Failure History in Patients with Secondary Mitral Regurgitation Treated by MitraClip

doi:10.1016/j.amjcard.2020.08.037

The American Journal of Cardiology

Volume 135, 15 November 2020, Pages 120-127

https://doi.org/10.1016/j.amjcard.2020.08.037 Get rights and content

The aim of this study was to investigate the prognostic role of heart failure (HF) history in patients with secondary mitral regurgitation (SMR) underwent MitraClip. We retrospectively analyzed 186 patients with SMR undergoing MitraClip at 4 centres. HF history was defined as number or days of HF hospitalizations in the 12-month before MitraClip, or as time from last HF hospitalization to MitraClip, or time between first SMR diagnosis and MitraClip. More severe symptoms were observed in patients with >1 HF hospitalization compared with those with ≤1 HF hospitalizations, in those with ≥10 days versus <10 days of HF hospitalization and in those with shortest time from the last HF hospitalization. No significant differences were observed for procedural data in the population stratified according to the different definitions. In variables related with HF history, only the number of HF hospitalizations before MitraClip was associated with an increased risk of clinical events (hazard ratio 1.59; 95% confidence interval [1.09 to 2.12]; p = 0.015), whereas days of previous HF hospitalization, time from last HF hospitalization and from first diagnosis of SMR do not impact on prognosis. A significant decrease in the number and days of HF hospitalizations was observed in the 12-month after MitraClip compared with the 12-month before. In conclusion, in variables related with HF history, recurrence (>1) of HF hospitalizations before MitraClip was the most powerful predictor of prognosis. Latency of intervention did not affect outcomes.

Section snippets

Methods

We retrospectively analysed 186 patients with significant SMR undergoing MitraClip between October 2010 and October 2018 at 4 European centres (Civil Hospitals of Brescia, University Hospital of Zurich and Hospital Puerta de Hierro-Majadahonda of Madrid and Hospital of Leon). For the purpose of the present analysis only SMR patients whose number and time of HF hospitalizations during the 12-month period before the intervention have been included.

A local multidisciplinary Heart Team discussed

Results

Patients with more than 1 hospitalization during the 12-month interval before the procedure were more likely to be males and to have advanced symptoms compared with those with no-hospitalizations or 1 hospitalization (Table 1).

More advanced NYHA class and higher left ventricular end-diastolic diameter were noted in patients with ≥10 days versus <10 days of HF hospitalization during the 12-month period before MitraClip (Supplementary Table 1).

Shorter time between the last HF hospitalization and

Discussion

MitraClip is the most widespread device to treat SMR in HF patients. Data from many registries1, 2, 3^,6, 7, 8, 9, 10, 11^,¹⁸^,¹⁹ and 2 recent randomized trials⁴^,⁵^,²⁰ support its use in carefully selected patients with significant SMR despite maximum GDMT, at an early stage of HF.²¹ Several parameters have been identified to drive patient selection, such as SMR severity (i.e., effective regurgitant orifice area),²² symptoms (i.e., NYHA class),6, 7, 8, 9 biomarkers (i.e., NT-proBNP),¹¹

Authors contribution

Marianna Adamo: conceptualization, methodology, formal analysis, writing original draft.

Mara Gavazzoni: conceptualization, methodology, formal analysis, writing (review and editing).

Assunta Castiello: formal analysis, resources, data curation.

Rodrigo Estevez-Loureiro: writing (review and editing), resources, data curation.

Maurizio Taramasso: writing (review and editing), resources, data curation.

Laura Lupi: writing (review and editing), resources, data curation.

Luca Branca: formal analysis,

Declaration of Interests

The authors declare that they have no known competing financial interests or personal relations that could have appeared to influence the work reported in this study.

Disclosures

M. Metra received consulting honoraria for participation to steering committees or advisory boards or for speeches from Abbott, Amgen, Astra-Zeneca, Bayer, Edwards Ther., Fresenius, Novartis, Servier. F. Maisano received grant and/or research support from Abbott, Medtronic, Edwards Lifesciences, Biotronik, Boston Scientific Corporation, NVT, Terumo; consulting fees and honoraria from Abbott, Medtronic, Edwards Lifesciences, Swissvortex, Perifect, Xeltis, Transseptal solutions, Cardiovalve,

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Cited by (1)

Changes in Right Ventricular–to–Pulmonary Artery Coupling After Transcatheter Edge-to-Edge Repair in Secondary Mitral Regurgitation
2022, JACC: Cardiovascular Imaging
Citation Excerpt :
The main findings of the present study are the following: 1) two-thirds of patients with SMR undergoing successful M-TEER improved their RV-PA coupling; 2) patients with lower TAPSE, higher PASP, and TR ≥2+ at baseline were more likely to improve their TAPSE/PASP ratio after M-TEER; 3) previous cardiac surgery and high postprocedural mitral mean gradient after M-TEER were associated with a lower probability of improving TAPSE/PASP; and 4) improvement in TAPSE/PASP after M-TEER was associated with better outcomes. Several parameters have been identified as predictors of clinical outcome in patients with SMR undergoing M-TEER and are currently used for patient selection before percutaneous SMR correction.28-32 TAPSE/PASP is a noninvasive measurement of RV-PA coupling12 and has been shown to have better prognostic value than each parameter alone in patients with HF.12-16
Preprocedural right ventricular–to–pulmonary artery (RV-PA) coupling is a major predictor of outcome in patients with secondary mitral regurgitation (SMR) undergoing transcatheter edge-to-edge mitral valve repair (M-TEER). However, clinical significance of changes in RV-PA coupling after M-TEER is unknown.
The aim of this study was to evaluate changes in RV-PA coupling after M-TEER, their prognostic value, and predictors of improvement.
This was a retrospective observational study, including patients undergoing successful M-TEER (residual mitral regurgitation ≤2+ at discharge) for SMR at 13 European centers and with complete echocardiographic data at baseline and short-term follow-up (30-180 days). RV-PA coupling was assessed with the use of echocardiography as the ratio of tricuspid annular plane systolic excursion to pulmonary artery systolic pressure (TAPSE/PASP). All-cause death was assessed at the longest available follow-up starting from the time of the echocardiographic reassessment.
Among 501 patients included, 331 (66%) improved their TAPSE/PASP after M-TEER (responders) at short-term follow-up (median: 89 days; IQR: 43-159 days), whereas 170 (34%) did not (nonresponders). Lack of previous cardiac surgery, low postprocedural mitral mean gradient, low baseline TAPSE, high baseline PASP, and baseline tricuspid regurgitation were independently associated with TAPSE/PASP improvement after M-TEER. Compared with nonresponders, responders had lower New York Heart Association functional class and less heart failure hospitalizations at short-term follow-up. Improvement in TAPSE/PASP was independently associated with reduced risk of mortality at long-term follow-up (584 days; IQR: 191-1,243 days) (HR: 0.65 [95% CI: 0.42-0.92]; P = 0.017).
In patients with SMR, improvement in TAPSE/PASP after successful M-TEER is predicted by baseline clinical and echocardiographic variables and postprocedural mitral gradient, and is associated with a better outcome.

: Funding: No funding was received for this study.

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Prognostic Impact of Heart Failure History in Patients with Secondary Mitral Regurgitation Treated by MitraClip

Section snippets

Methods

Results

Discussion

Authors contribution

Declaration of Interests

Disclosures

Int J Cardiol

Am Heart J

Am Heart J

Int J Cardiol

JACC Hear Fail

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

JACC Cardiovasc Interv

J Am Coll Cardiol

J Am Coll Cardiol