Improved Mitral Regurgitation Outcomes Following Mitral Valve TEER

Approximately two-thirds of patients with secondary mitral regurgitation (SMR) and successful transcatheter edge-to-edge repair (TEER) of the mitral valve have an improved ratio of tricuspid annular plane systolic excursion to pulmonary artery systolic pressure (TAPSE/PASP), which is strongly and independently associated with mortality, according to a study in JACC: Cardiovascular Imaging.

Researchers conducted a retrospective multicenter analysis of patients receiving mitral valve TEER with the MitraClip system (Abbott Vascular) from December 2009 to February 2021 at 13 European centers. All participants had a complete echocardiographic evaluation at baseline and short-term follow-up (30 to 180 days) and received a successful mitral valve TEER procedure (defined as residual mitral regurgitation [MR] ≤2+ at discharge).

The participants were stratified based on changes in TAPSE/PASP between baseline and the echocardiographic reassessment in 2 groups: those with improved TAPSE/PASP (responders) and those with unchanged or worsened TAPSE/PASP (nonresponders).

Short-term follow-up was the time from mitral valve TEER to echocardiographic reassessment, and long-term follow-up was the time from that reassessment to the end of follow-up. All-cause mortality was assessed at long-term follow-up.

A total of 501 patients were included, 331 responders (mean age, 72.1 [SD, 10.1] years; 74% men) and 170 nonresponders (mean age, 73.2 [SD, 9.5] years; 62% men). The median time from baseline to short-term echocardiographic reassessment was 89 days (IQR, 43-159 days).

Of the nonresponders, 55% had no right ventricular (RV) dysfunction (TAPSE >15 mm), and 45% had a TAPSE/PASP of more than 0.36 mm/mm Hg at the short-term follow-up.

Responders were younger, more likely to be men, and less likely to have a history of cardiac procedure vs nonresponders. Responders also had larger left ventricular and left atrial dimensions, higher PASP, and lower TAPSE and TAPSE/PASP compared with nonresponders. No prior cardiac surgery, low baseline TAPSE, high baseline PASP, tricuspid regurgitation of 2+ or greater at baseline, and low postprocedural mitral mean gradient were independently associated with TAPSE/ PASP improvement after mitral valve TEER.

The baseline PASP, TAPSE, and degree of tricuspid regurgitation were the only independent predictors of TAPSE/PASP changes after patients with previous cardiac procedures were excluded.

The median follow-up for clinical outcomes was 584 days (IQR, 191-1243 days). All-cause mortality was lower in cumulative incidence among responders vs nonresponders (31.5% vs 44.9%, respectively; P =.002). An increase in TAPSE/PASP was associated with a reduced mortality risk on a continuous level (hazard ratio [HR], 0.34 per unit [95% CI, 0.18-0.65]; P =.001).

Multivariable analysis demonstrated that changes in TAPSE/PASP (responders vs nonresponders) were significantly associated with mortality (HR, 0.65 [95% CI, 0.42-0.92], P =.017), and changes in TAPSE or PASP alone were not.

Study limitations include the retrospective, observational, single-arm design, and unknown biases may affect the findings. In addition, a core laboratory for assessing echocardiographic images is not used, and a complete echocardiographic evaluation of RV function is not available for a majority of patients. Another potential limitation is selection bias owing to the exclusion of patients who died before the short-term echocardiographic reassessment or who are without complete echocardiographic data at baseline and follow-up.

“Changes in RV-PA coupling after M-TEER [mitral valve TEER] might have a strong impact on clinical outcome and seem to be affected by several clinical and procedural variables,” the study authors wrote. “Further larger and randomized studies are needed to confirm our results and identify patients who may obtain RV reverse remodeling after SMR correction.”

Disclosure: Some of the study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.