Acute Reduction in Left Ventricular Function Following Transcatheter Mitral Edge‐to‐Edge Repair

Abstract

Background Little is known about the impact of transcatheter mitral valve edge‐to‐edge repair on changes in left ventricular ejection fraction (LVEF) and the effect of an acute reduction in LVEF on prognosis. We aimed to assess changes in LVEF after transcatheter mitral valve edge‐to‐edge repair for both primary and secondary mitral regurgitation (PMR and SMR, respectively), identify rates and predictors of LVEF reduction, and estimate its impact on prognosis. Methods and Results In this international multicenter registry, patients with both PMR and SMR undergoing transcatheter mitral valve edge‐to‐edge repair were included. We assessed rates of acute LVEF reduction (LVEFR), defined as an acute relative decrease of >15% in LVEF, its impact on all‐cause mortality, major adverse cardiac event (composite end point of all‐cause death, mitral valve surgery, and residual mitral regurgitation grade ≥2), and LVEF at 12 months, as well as predictors for LVEFR. Of 2534 patients included (727 with PMR, and 1807 with SMR), 469 (18.5%) developed LVEFR. Patients with PMR were older (79.0±9.2 versus 71.8±8.9 years; P <0.001) and had higher mean LVEF (54.8±14.0% versus 32.7±10.4%; P <0.001) at baseline. After 6 to 12 months (median, 9.9 months; interquartile range, 7.8–11.9 months), LVEF was significantly lower in patients with PMR (53.0% versus 56.0%; P <0.001) but not in patients with SMR. The 1‐year mortality was higher in patients with PMR with LVEFR (16.9% versus 9.7%; P <0.001) but not in those with SMR ( P =0.236). LVEF at baseline (odds ratio, 1.03 [95% CI, 1.01–1.05]; P =0.002) was predictive of LVEFR for patients with PMR, but not those with SMR ( P =0.092). Conclusions Reduction in LVEF is not uncommon after transcatheter mitral valve edge‐to‐edge repair and is correlated with worsened prognosis in patients with PMR but not patients with SMR. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT05311163.

Transcatheter Structural Heart Interventions in the Acute Setting: An Emerging Indication

“…Finally, the immediate resolution of MR may not always result in a clinical benefit. In particular, the underrecognized afterload mismatch, which is defined as the acute impairment of LV systolic function as a consequence of increased afterload after correction of the regurgitation, has been described in the literature after TEER and is linked to worse outcomes [ 69 , 70 ]. This could be a dreadful complication in an already deteriorating LV, and although there is no clear evidence of LV ejection fraction drop in the aforementioned studies, it should be more extensively studied, especially as in the setting of CS, the medical therapy may have masked this observation.…”

Transcatheter Mitral Valve Intervention: Current and Future Role of Multimodality Imaging for Device Selection and Periprocedural Guidance

“…A feared complication is MR aggravation that can be potentially related to acute LV dysfunction, leaflet or chordal damage, loss of leaflet insertion (LLI) and partial leaflet detachment (PLD). While some of these factors may be predictable, others, such as iatrogenic leaflet or chordal damage, are considered avoidable complications that may result from technical errors during the procedure, such as multiple grasping attempts or navigating into non-chordal free areas [73].…”

Cardiological Challenges Related to Long-Term Mechanical Circulatory Support for Advanced Heart Failure in Patients with Chronic Non-Ischemic Cardiomyopathy

“…These observations are of particular practical relevance because they question the reliability of conventional ECHO-derived LVEF and LVEDD to be used as parameters for decision making in the management of HTx candidates with non-ischemic DCM. From a pathophysiological point of view, the lack of predictive value revealed by LVEF and LVEDD is quite understandable because in the end stage of DCM-related HF they usually present mitral valve regurgitation (MR) related to the dilation of the mitral valve ring, which reduces the validity of LVEF for quantification of the LV systolic function, whereas the progressive reduction in LV compliance limits further LV dilation, corresponding to a progressive increase in LV filling pressures [52][53][54]. In a recent study, the new occurrence or worsening of MR in patients with DCM appeared independently predictive for their outcome, and the prognostic value of MR was incomparably higher than that of LVEF or LVEDD [55].…”

“…The alteration of LV diastolic function and intraventricular synchronicity, the increase in total pulmonary vascular resistance, and the reduction in the CO and progressive alteration of right-sided heart geometry and function with the new appearance or rapid aggravation of preexistent TR were found to be important short-term prognostic markers [50][51][52]. Given that with the aggravation of HF, which was primarily initiated by left-sided heart dysfunction, the prognostic relevance of the secondary hemodynamic overload-induced morphological and functional right-sided heart alterations increases pro-gressively; it is not surprising that for the short-term prediction of advanced DCM-related HF worsening, certain ECHO-derived right-sided heart parameters were often found to be even more reliable than many left-sided heart parameters [50,51,62].…”