Clinical Investigation
Valvular Heart Disease
Recurrence of Functional Versus Organic Mitral Regurgitation After Transcatheter Mitral Valve Repair: Implications from Three-Dimensional Echocardiographic Analysis of Mitral Valve Geometry and Left Ventricular Dilation for a Point of No Return

https://doi.org/10.1016/j.echo.2021.02.017Get rights and content

Highlights

  • Recurrence of FMR is determined by LV dilation before MitraClip implantation.

  • In patients with FMR, a point of no return of MV tethering exists.

  • Remodeling after MitraClip placement is markedly different between FMR and OMR.

  • Recurrence of OMR after MitraClip implantation could not be predicted.

  • MV remodeling after MitraClip placement can be comprehensively analyzed by 3D echo.

Background

MitraClip implantation has become the standard transcatheter mitral valve repair (TMVR) technique for severe mitral regurgitation (MR). However, approximately one third of patients have poor outcomes, with MR recurrence at follow-up. The aim of this study was to investigate whether quantitative analysis of mitral valve (MV) geometry on three-dimensional (3D) echocardiography can identify geometric parameters associated with the recurrence of severe functional MR (FMR) versus organic MR (OMR) at 6-month follow-up after TMVR using the MitraClip.

Methods

Sixty-one patients with severe FMR (n = 45) or OMR (n = 16) who underwent transesophageal 3D echocardiography before and 6 months after TMVR were retrospectively analyzed. MV geometry was quantified using 3D echocardiography software. Vena contracta area (VCA) at 6-month follow-up was used to define two outcome groups: patients with good results with VCA < 0.6 cm2 (MR < 0.6) and those with MR recurrence with VCA ≥ 0.6 cm2 (MR ≥ 0.6).

Results

MR recurrence was found in 34% of all study patients (21 of 61). In patients with FMR, significant differences between MR < 0.6 and MR ≥ 0.6 were found at baseline for tenting index (1.13 vs 1.23, P = .004), tenting volume (2.8 vs 4.0 ml, P = .04), indexed left ventricular (LV) end-diastolic volume (68.0 vs 99.9 ml/m2, P = .001), and VCA (0.71 vs 1.00 cm2, P = .003); no significant parameters of MR recurrence were found in patients with OMR. Multivariate analysis identified indexed LV end-diastolic volume as the strongest independent determinant of MR recurrence. Receiver operating characteristic analysis identified a tenting index of 1.185 (area under the curve 0.79) and indexed LV end-diastolic volume of 88 ml/m2 (area under the curve 0.76) to best discriminate between MR < 0.6 and MR ≥ 0.6.

Conclusions

MR recurrence after TMVR in patients with FMR is associated with advanced LV dilation and MV tenting before TMVR, which provides clinical implications for a point of no return beyond which progressive LV dilation with MV geometry dilation and tethering cannot be effectively prevented by TMVR. In contrast, no significant determinants of MR recurrence and progressive MV annular dilation could be identified in patients with OMR.

Section snippets

Study Design and Objectives

Of 133 consecutive patients who underwent TMVR using the MitraClip (Abbott Laboratories, Abbott Park, IL) for the treatment of FMR and OMR between March 2009 and February 2014, 61 patients (45 with FMR, 16 with OMR) who had complete 3D echocardiographic data sets acquired within 7 days before TMVR and at 6-month follow-up were retrospectively analyzed. The percentages of patients with FMR (73.8%) and OMR (26.2%) in our study group were similar to the ratio in the total group of 133 consecutive

Results

Intraprocedural MR grading of color Doppler jet size before and after TMVR showed satisfactory MR reduction in all 61 patients (grade 2.75 vs 1.53, with MR reduction to grade < 2 in 38 patients and from grade 3 to grade 2 in 23 patients) independent of MR mechanism (FMR, 2.69 vs 1.52; OMR, 2.93 vs 1.53; Table 1).

Discussion

To the best of our knowledge, this is the first study to comprehensively analyze the association of 3D echocardiographic MV geometry in concert with LV size and function on MR recurrence and MV remodeling after TMVR and the differences between patients with FMR and those with OMR. In all, 34% of patients (21 of 61) had MR recurrence at follow-up, which is in line with the reported 34% of patients (26 of 76) with MR > 2+ at 1 year after TMVR in the EVEREST study,4 but the rates were higher

Conclusion

Comprehensive 3D echocardiographic analysis of MV geometry and two-dimensional echocardiographic LV size and function revealed MR recurrence in patients with FMR to be strongly associated with advanced LV dilation and MV tethering at baseline, with LVEDVi being the strongest independent determinant. In patients with OMR, however, no significant determinants of MR recurrence could be identified despite associations with progressive MV annular dilation, leaflet enlargement, and prolapse size.

Acknowledgments

We wish to acknowledge Mirjam Frank, MD, and Börge Schmidt, MD, PhD, Institute of Medical Informatics, Biometry and Epidemiology of University Essen, Germany, for their support in statistical analyses.

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      Citation Excerpt :

      Previously, de Bonis et al.24 also reported favorable initial procedural results (MR ≤ 1+) but a decay toward MR ≥ 2+ after 1 year (paired data) that continued throughout 4 years of follow-up. Although evidence for mechanisms behind delayed FMR deterioration is limited, several anatomic predictors, including LVEDV, may play a key role.25,26 This sobering reality contrasts with the excellent 1- and 2-year echocardiographic data from the COAPT trial showing maintained MR reduction over time, although patient-level FMR follow-up has not been published to date.

    Conflicts of Interest: The authors declare that there are no conflicts of interest or funding for this article.

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