Pulmonary Hypertension in Transcatheter Mitral Valve Repair for Secondary Mitral Regurgitation: The COAPT Trial

J Am Coll Cardiol. 2020 Dec 1;76(22):2595-2606. doi: 10.1016/j.jacc.2020.09.609.

Abstract

Background: Pulmonary hypertension worsens prognosis in patients with heart failure (HF) and secondary mitral regurgitation (SMR).

Objectives: This study sought to determine whether baseline pulmonary hypertension influences outcomes of transcatheter mitral valve repair (TMVr) in patients with HF with SMR.

Methods: In the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation) trial, 614 patients with HF with moderate-to-severe or severe SMR were randomized to TMVr with the MitraClip plus guideline-directed medical therapy (GDMT) (n = 302) versus GDMT alone (n = 312). Baseline pulmonary artery systolic pressure (PASP) estimated from echocardiography was categorized as substantially increased (≥50 mm Hg) versus not substantially increased (<50 mm Hg).

Results: Among 528 patients, 184 (82 TMVr, 102 GDMT) had PASP of ≥50 mm Hg (mean: 59.1 ± 8.8 mm Hg) and 344 (171 TMVr, 173 GDMT) had PASP of <50 mm Hg (mean: 36.3 ± 8.1 mm Hg). Patients with PASP of ≥50 mm Hg had higher 2-year rates of death or HF hospitalization (HFH) compared to those with PASP of <50 mm Hg (68.8% vs. 49.1%; adjusted hazard ratio: 1.52; 95% confidence interval: 1.17 to 1.97; p = 0.002). Rates of death or HFH were reduced by TMVr versus GDMT alone, irrespective of baseline PASP (pinteraction = 0.45). TMVr reduced PASP from baseline to 30 days to a greater than GDMT alone (adjusted least squares mean: -4.0 vs. -0.9 mm Hg; p = 0.006), a change that was associated with reduced risk of death or HFH between 30 days and 2 years (adjusted hazard ratio: 0.91 per -5 mm Hg PASP; 95% confidence interval: 0.86 to 0.96; p = 0.0009).

Conclusions: Elevated PASP is associated with a worse prognosis in patients with HF with severe SMR. TMVr with the MitraClip reduced 30-day PASP and 2-year rates of death or HFH compared with GDMT alone, irrespective of PASP.

Keywords: heart failure; mitral regurgitation; mitral valve repair; pulmonary hypertension; transcatheter.

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Cardiac Catheterization / methods*
  • Echocardiography / methods
  • Female
  • Heart Failure* / etiology
  • Heart Failure* / physiopathology
  • Heart Valve Prosthesis Implantation* / adverse effects
  • Heart Valve Prosthesis Implantation* / methods
  • Humans
  • Hypertension, Pulmonary* / etiology
  • Hypertension, Pulmonary* / physiopathology
  • Male
  • Middle Aged
  • Mitral Valve Insufficiency* / complications
  • Mitral Valve Insufficiency* / diagnosis
  • Mitral Valve Insufficiency* / physiopathology
  • Mitral Valve Insufficiency* / surgery
  • Mitral Valve* / diagnostic imaging
  • Mitral Valve* / pathology
  • Mitral Valve* / surgery
  • Postoperative Complications* / diagnosis
  • Postoperative Complications* / mortality
  • Prognosis
  • Risk Assessment / methods
  • Risk Assessment / statistics & numerical data
  • Risk Factors
  • Severity of Illness Index
  • Treatment Outcome