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A Simplified Stepwise Approach to Echo Guidance during Percutaneous Mitral Valve Repair
Published on: October 16, 2021
Relation of Residual Mitral Regurgitation and Gradient Following Mitral Valve Transcatheter Edge-to-Edge Repair
Donika Mustafa1,2, Jennifer von Stein1,3,2, Lukas Stolz4,5
1Department of Cardiology, Heart Center, Faculty of Medicine, University of Cologne, Germany (D.M., J.S., H.G., S.B., R.P., V.M., P. von Stein).
Background:
Residual mitral regurgitation (rMR) ≤1+ has been associated with improved 1-year outcomes after mitral valve transcatheter edge-to-edge repair, regardless of the mean mitral pressure gradient (MPG). Prior evidence is limited to 30-day echocardiographic follow-up and patients treated with the MitraClip (Abbott Structural Heart). Whether rMR and MPG assessed at discharge are associated with outcomes after PASCAL mitral valve transcatheter edge-to-edge repair (Edwards Lifesciences) remains unknown.
Methods:
REPAIR (Registry of Pascal for Mitral Regurgitation) is an investigator-initiated, multicenter registry including all consecutive patients treated with PASCAL mitral valve transcatheter edge-to-edge repair. Based on discharge echocardiography, patients were stratified into 4 groups: optimal (rMR ≤1+, MPG <5 mm Hg), MPG-suboptimal (rMR ≤1+, MPG ≥5 mm Hg), rMR-suboptimal (rMR ≥2+, MPG <5 mm Hg), and dual-suboptimal (rMR ≥2+, MPG ≥5 mm Hg). The primary end point was 1-year mortality.
Results:
Among 2172 patients (median follow-up, 463 days [Q1-Q3, 357-815]), 59.4% were classified as optimal, 12.2% MPG-suboptimal, 21.3% rMR-suboptimal, and 7.0% dual-suboptimal. One-year mortality differed significantly across groups (P<0.001), with the lowest rate in the optimal (8.7% [95% CI, 6.8%-10.5%]) and highest in the dual-suboptimal group (20.1% [95% CI, 12.0%-27.4%]; PBonferroni <0.001). rMR ≤1+ was associated with lower 1-year mortality (hazard ratio, 0.54 [95% CI, 0.37-0.74]; P<0.001) and remained significant, independent of dichotomized (MPG, <5 versus ≥5 mm Hg) or continuous MPG. Dichotomized MPG was not significantly associated with 1-year mortality (hazard ratio, 0.73 [95% CI, 0.51-1.04]; P=0.078), whereas continuous MPG was (hazard ratio per mm Hg increase, 1.10 [95% CI, 1.00-1.21]; P=0.048) with a trend after adjusting for rMR ≤1+ (adjusted hazard ratio per mm Hg increase, 1.07 [95% CI, 0.98-1.18]; P=0.145). No interaction was observed between rMR ≤1+ and dichotomized/continuous MPG (both Pinteraction >0.450).
Conclusions:
Discharge rMR ≤1+ is independently associated with lower 1-year mortality after PASCAL mitral valve transcatheter edge-to-edge repair. Although MPG was not independently associated, modestly elevated gradients may be acceptable when rMR ≤1+ is achieved, but should still warrant clinical attention.
Registration:
URL: https://www.drks.de; Unique identifier: DRKS00033959.
Insights
Residual mitral regurgitation (rMR) ≤1+ after PASCAL transcatheter edge-to-edge repair is linked to better 1-year survival. Mildly elevated mitral pressure gradients (MPG) may be acceptable with optimal rMR, but warrant monitoring.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Cardiac Surgery
Background:
- Residual mitral regurgitation (rMR) ≤1+ is linked to improved outcomes post-transcatheter edge-to-edge repair (TEER).
- Previous studies focused on MitraClip and limited follow-up durations.
- The association of discharge rMR and mean mitral pressure gradient (MPG) with outcomes after PASCAL TEER is not well-established.
Purpose of the Study:
- To evaluate the association of discharge residual mitral regurgitation (rMR) and mean mitral pressure gradient (MPG) with 1-year mortality after PASCAL mitral valve transcatheter edge-to-edge repair (TEER).
Main Methods:
- The REPAIR registry analyzed 2172 patients undergoing PASCAL TEER.
- Patients were stratified into four groups based on discharge rMR (≤1+ vs. ≥2+) and MPG (<5 mmHg vs. ≥5 mmHg).
- The primary endpoint was 1-year mortality.
Main Results:
- One-year mortality varied significantly across groups (P<0.001), lowest in optimal (rMR ≤1+, MPG <5 mmHg) and highest in dual-suboptimal (rMR ≥2+, MPG ≥5 mmHg) groups.
- rMR ≤1+ was independently associated with lower 1-year mortality (HR 0.54; P<0.001).
- MPG was not independently associated with mortality when dichotomized (P=0.078), but continuous MPG showed association (HR 1.10 per mmHg; P=0.048), with a trend after adjusting for rMR (aHR 1.07; P=0.145).
Conclusions:
- Discharge rMR ≤1+ is an independent predictor of lower 1-year mortality following PASCAL TEER.
- While MPG was not independently associated, elevated gradients may be acceptable with optimal rMR but require clinical attention.
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