Risk for Increased Mean Diastolic Gradient after Transcatheter Edge-to-Edge Mitral Valve Repair: A Quantitative Three-Dimensional Transesophageal Echocardiographic Analysis

doi:10.1016/j.echo.2021.01.018

Journal of the American Society of Echocardiography

Volume 34, Issue 6, June 2021, Pages 595-603.e2

https://doi.org/10.1016/j.echo.2021.01.018 Get rights and content

Highlights

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MVA < 4.0 cm² is associated with high risk for increased MG after TMVr.
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Risk for increased MG after TMVr is increased in patients with MAC-LC ≥ 6 mm.
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Baseline MVA > 6.0 cm² is associated with low risk for increased MG after TMVr.

Background

Iatrogenic mitral stenosis is a known limitation of transcatheter edge-to-edge mitral valve repair (TMVr), but determinants of increased postprocedural mean diastolic gradient (MG) are not well defined. The aim of this study was to determine correlates of increased post-TMVr MG or aborted clip implantation due to increased MG.

Methods

Procedural three-dimensional transesophageal echocardiographic (TEE) data sets of 112 patients who underwent TMVr were retrospectively analyzed. Three-dimensional TEE mitral valve area (MVA) planimetry and mitral annular calcification (MAC) were quantified using multiplanar reconstruction. When MAC extension into the mitral leaflets was present, MAC with leaflet calcification (MAC-LC) length was recorded as the maximum distance from the mitral annulus to the most distal leaflet calcification. Increased MG after TMVr, measured on intraprocedural TEE imaging, was defined as ≥5 mm Hg or aborted clip implantation due to increased MG.

Results

Baseline MVA was 5.9 ± 1.7 cm², baseline MG was 2.1 ± 1.2 mm Hg, and MAC-LC length was 4.0 ± 4.5 mm. Thirty-two patients (29%) had increased post-TMVr MG. Risk for increased post-TMVr MG was 86%, 28%, and 14% in patients with baseline MVA < 4.0, 4.0 to 6.0, and >6.0 cm², respectively (P < .001). In patients with baseline MVA 4.0 to 6.0 cm², concurrent baseline MG ≥ 4 mm Hg or MAC-LC ≥ 6 mm was associated with higher risk for increased post-TMVr MG (53% vs 12%, P = .002). In patients with baseline MVA < 4.0 and >6.0 cm², the risk for increased post-TMVr MG was similar in the presence or absence of baseline MG ≥ 4 mm Hg or MAC-LC ≥ 6 mm (P > .05 for both).

Conclusions

Patients with baseline three-dimensional TEE MVA < 4.0 cm² are at high risk for increased post-TMVr MG. Additionally, patients with borderline MVA (4.0–6.0 cm²) and concurrent MAC-LC length ≥ 6 mm or baseline MG ≥ 4 mm Hg are at moderate risk for increased MG after TMVr.

Section snippets

Patients

This study was approved by the Mayo Clinic institutional review board. We retrospectively identified 118 consecutive patients with moderate to severe or severe MR who underwent TMVr with the MitraClip (Abbott Vascular, Santa Clara, CA) between May 1, 2015, and August 1, 2019, at our institution with raw 3D transesophageal echocardiographic (TEE) data sets. Six patients were excluded from the analysis because of poor 3D TEE image quality, and the remaining 112 patients were included in the

Baseline Characteristics

Baseline clinical characteristics are listed in Table 1. Mean Society of Thoracic Surgeons mortality score was 6.9 ± 5.0%, and 97 patients (87%) had New York Heart Association functional class III or IV symptoms before TMVr. Primary MR was present in 68 patients (61%), and secondary or mixed MR was present in 44 patients (39%). Thirty-two patients (29%) had increased post-TMVr MG or aborted clip implantation. Aborted clip implantation occurred in six patients (5%); in one patient, clip

Discussion

TMVr is an established therapy that offers a potential therapeutic option for patients with significant MR at high or prohibitive risk for conventional open mitral valve surgery. Data support its use in select patients with primary and secondary MR.4, 5, 6 Expert consensus24, 25, 26 suggests that baseline MVA > 4.0 cm² and MG < 4 mm Hg are important to avoid iatrogenic mitral stenosis after TMVr, but supporting data are limited. We evaluated preprocedural predictors of increased post-TMVr MG or

Conclusion

We found that patients with baseline MVA < 4.0 cm² and MG ≥ 4 mm Hg are at high risk for increased MG after TMVr, but there is also modest risk for elevated post-TMVr MG even in patients with intermediate MVA 4.0 to 6.0 cm². In patients with baseline MVA of 4.0 to 6.0 cm², MAC-LC length ≥ 6 mm or baseline MG ≥ 4 mm Hg identifies patients at moderate risk for increased MG after TMVr. Patients with baseline MVA > 6.0 cm² are at low risk for increased MG after TMVr regardless of the presence of

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Cardiac computed tomography-based assessment of mitral annular calcification in patients undergoing mitral transcatheter edge-to-edge repair
2024, Journal of Cardiovascular Computed Tomography
The role of assessment of mitral annular calcification (MAC) using cardiac computed tomography (CCT) in mitral transcatheter edge-to-edge repair (TEER) remains unclear. The aim of this study was to investigate the association of MAC assessed by CCT with procedural and clinical outcomes in patients undergoing TEER.
We retrospectively analyzed 275 patients who underwent pre-procedural CCT prior TEER. Mitral calcium volume (MCV) and MAC score were measured by CCT. Functional procedural success was defined as residual mitral regurgitation of ≤2+ with mean transmitral gradient of <5 mmHg at discharge. All-cause mortality within two years after TEER was collected.
MAC was present in 115 of 275 patients (41.8 %). The median MCV was 198 mm³ (interquartile range [IQR]: 84 to 863 mm³), and the median MAC score was 3 (IQR: 2 to 4). Higher MCV and MAC score were inversely related to the rate of functional procedural success, independently of anatomical features of mitral valve. Patients with moderate/severe MAC, defined as MAC score of ≥4, had a lower rate of functional procedural success than those without MAC (56.1 % vs. 81.3 %; p = 0.002). Moreover, higher MCV and MAC score were associated with a higher risk of all-cause mortality within two years, irrespective of baseline characteristics and functional procedural success.
The presence and burden of MAC assessed by CCT were associated with procedural and clinical outcomes in patients undergoing TEER. The CCT-based assessment of MAC may improve patient selection for TEER.
1-Year Outcomes With a Fourth-Generation Mitral TEER Device: Maturity Comes With Experience
2023, JACC: Cardiovascular Interventions
Transcatheter edge-to-edge repair in mitral regurgitation: A comparison of device systems and recommendations for tailored device selection. A systematic review and meta-analysis
2023, Progress in Cardiovascular Diseases
Mitral valve transcatheter edge-to-edge repair (M-TEER) is a minimally invasive method for the treatment of mitral regurgitation (MR) in patients with prohibitive surgical risks. The traditionally used device, MitraClip, showed both safety and effectiveness in M-TEER. PASCAL is a newer device that has emerged as another feasible option to be used in this procedure.
We searched for observational studies that compared PASCAL to MitraClip devices in M-TEER. The electronic databases searched for relevant studies were PubMed/MEDLINE, Scopus, and Embase. The primary outcomes were technical success and the grade of MR at follow-up. Secondary outcomes included all-cause mortality, bleeding, device success and reintervention.
Technical success (PASCAL: 96.5% vs MitraClip: 97.6%, p = 0.24) and MR ≤ 2 at 30-day follow-up (PASCAL: 89.4vs MitraClip 89.9%, p = 0.51) were comparable between both groups. Both devices showed similar outcomes including all-cause mortality (RR: 0.68 [0.34, 1.38]; P = 0.28), major bleeding (RR: 1.87 [0.68, 5.10]; P = 0.22) and reintervention (RR: 1.02 [0.33, 3.16]; P = 0.97). Device success was more frequent with PASCAL device (PASCAL: 86% vs MitraClip 68.5%; P = 0.44), however, the results did not reach statistical significance.
Clinical outcomes of PASCAL were comparable to those of MitraClip with no significant difference in safety and effectiveness. The choice between MitraClip and PASCAL devices should be guided by various factors, including mitral valve anatomy, etiology of regurgitation, and device-specific characteristics.
Transmitral Gradients Following Transcatheter Edge-to-Edge Repair: Are Mean Gradients Meaningful?
2022, JACC: Cardiovascular Interventions
Echocardiographic Variables Associated with Transvalvular Gradient After a Transcatheter Edge-To-Edge Mitral Valve Repair
2022, Journal of the American Society of Echocardiography
Citation Excerpt :
Several other studies and reports have demonstrated the accuracy and superiority of 3D analysis to assess MVA in patients with MS24,25 or before interventional repair.9,26,27 Although MVA3D < 4 cm2 has been related to TMG after TMVr and linked to procedural success,18,28,29 specific comparison of anatomic MVAs obtained by different methods and their impact on TMG has not been reported to our knowledge. MVA is correlated with BSA,30 and the use of indexed values has potential interest.
Transcatheter edge-to-edge mitral valve repair may lead to a reduction in mitral valve area (MVA) and elevated mean transmitral gradient (TMG). The objectives of this study were to assess the value of baseline MVA by different imaging methods and to explore the associations between MVA indexed to body surface area or left ventricular forward stroke volume and postprocedural TMG.
Preprocedural echocardiographic images from 76 consecutive patients were retrospectively reviewed. MVA planimetry from two-dimensional (2D) transthoracic echocardiography (MVA_TTE), 2D transesophageal echocardiography in the transgastric view (MVA_{2D TEE}), and three-dimensional (3D) transesophageal echocardiography (MVA_3D) were measured. Postprocedural TMGs were assessed at 1 to 3 months and all-cause mortality at 1 year.
Postprocedural mean TMG > 5 mm Hg was associated with a 3.42-fold (95% confidence interval [CI], 1.08–10.87; P = .04) increased risk for 1-year all-cause mortality. Patients with postprocedural TMG > 5 mm Hg (25% [19 of 76]) had significantly smaller preprocedural MVA_3D (3.9 ± 0.8 vs 5.2 ± 1.3 cm², P < .01) and MVA_TTE (4.9 ± 1.1 vs 5.8 ± 1.5 cm², P = .01) compared with patients without elevated TMG. No significant difference was found for MVA_{2D TEE} (P = .20). The best threshold values for MVA_3D and MVA_TTE to be associated with postprocedural TMG > 5 mm Hg were, respectively, 3.9 cm² (area under the curve [AUC] = 0.80; 95% CI, 0.66–0.94; sensitivity 62%, specificity 87%) and 4.6 cm² (AUC = 0.68; 95% CI, 0.54–0.82; sensitivity 53%, specificity 80%). MVA_3D indexed to body surface area and to stroke volume showed overall the best associations with postprocedural mean TMG > 5 mm Hg, with optimal thresholds, respectively, of 2.5 cm²/m² (AUC = 0.88; 95% CI, 0.77–0.98; sensitivity 92%, specificity 74%) and 95 cm²/L (AUC = 0.87; 95% CI, 0.77–0.97; sensitivity 85%, specificity 82%).
Elevated TMG following transcatheter edge-to-edge mitral valve repair was associated with increased mortality. The present results indicate that MVA_3D, MVA_3D indexed to body surface area, and MVA_3D indexed to stroke volume may be considered potential predictors of postprocedural TMG > 5 mm Hg and could help optimize patient selection, while the use of 2D methods for valve area were poorly associated with TMG.
Implications of Mitral Annular Calcification on Outcomes Following Mitral Transcatheter Edge-to-Edge Repair
2024, Circulation: Cardiovascular Interventions

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: Conflicts of interest: None.

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Clinical InvestigationEchocardiography and Percutaneous Mitral Valve InterventionsRisk for Increased Mean Diastolic Gradient after Transcatheter Edge-to-Edge Mitral Valve Repair: A Quantitative Three-Dimensional Transesophageal Echocardiographic Analysis

Highlights

Background

Methods

Results

Conclusions

Section snippets

Patients

Baseline Characteristics

Discussion

Conclusion

Lancet

Lancet

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

JACC Cardiovasc Interv

JACC Cardiovasc Interv

J Cardiol

J Am Soc Echocardiogr

J Am Soc of Echocardiogr

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Soc Echocardiogr

Clinical Investigation
Echocardiography and Percutaneous Mitral Valve Interventions
Risk for Increased Mean Diastolic Gradient after Transcatheter Edge-to-Edge Mitral Valve Repair: A Quantitative Three-Dimensional Transesophageal Echocardiographic Analysis