Mitral Valve Anatomic Predictors of Hemodynamic Success With Transcatheter Mitral Valve Repair

Abstract

BackgroundMitral regurgitation is a heterogeneous disease. Determining which patients derive optimal outcomes from transcatheter edge‐to‐edge mitral valve repair (TMVR) remains challenging. We sought to determine whether baseline mitral valve anatomic characteristics are predictive of left atrial pressure (LAP) changes during TMVR with MitraClip.Methods and ResultsConsecutive patients with severe mitral regurgitation undergoing TMVR (n=112) underwent continuous intraprocedural LAP monitoring and retrospective echocardiographic analysis for specific mitral anatomic characteristics. Procedural success (optimal LAP reduction) was defined as ≥40% reduction in left atrial V‐wave pressure compared with baseline. Echocardiographic predictors of optimal LAP reduction and increased postprocedure mean diastolic gradient were evaluated. Mean age was 79±14 years, and 36 patients (32%) were women. Primary, mixed, and secondary mitral regurgitation were present in 78 patients (70%), 22 patients (20%), and 12 patients (10%), respectively. Baseline mean LAP and V‐wave were 22±6 and 38±13 mm Hg; after TMVR, these decreased to 19±5 and 27±10 mm Hg, respectively (P<0.0001 for both). Independent predictors of optimal LAP reduction were the presence of a flail scallop, mitral regurgitation localized to a single scallop, and high‐quality 3‐dimensional echocardiographic imaging. Independent predictors of elevated postprocedure mean diastolic gradient were elevated preprocedure mean diastolic gradient, mitral annular calcification, and implantation of multiple clips.ConclusionsMitral valve pathoanatomic features, including a flail leaflet and single jet, are predictive of optimal LAP reduction with TMVR. High‐quality 3‐dimensional imaging may help select patients with the highest likelihood of optimal hemodynamic results with TMVR. These data expand current knowledge about patient selection for TMVR and deserve further study in larger cohorts.

Left atrial hemodynamics and left ventricular remodeling –predictors of outcomes after Transcatheter mitral valve repair with the MitraClip device

“…. Similar to previous reports, a successful MitraClip procedure was associated with a significant acute decline in left atrial pressure immediately after the procedure (13.6 mm Hg vs. 18.2 mm Hg; P = 0.03) but with no significant change in LA volumes at 30 and 90‐days respectively. Toprak et al showed evidence for improvement in multiple left atrial volume parameters on 3D and speckle tracking on echocardiography at 12 months after a MitraClip procedure .…”

“…Left atrial pressure depends on three variables: LA preload, LA afterload, and mitral valve pathology. Of these three variables, flow dynamics through the mitral valve is the dominant variable.. 13 Similar to previous reports, a successful MitraClip procedure was associated with a significant acute decline in left atrial pressure immediately after the procedure (13.6 mm Hg vs. 18.2 mm Hg; P = 0.03) 14 but with no significant change in LA volumes at 30 and 90-days respectively.…”

Intraprocedural direct left atrial and wedge pressure correlation during transcatheter mitral valve repair: Results from a single center registry

“…A hemodynamic change, if any, can be a useful adjunct when color reduction is minimal or equivocal after implantation of a clip(s). 5,7,10,17 In our experience, improvement in hemodynamic parameters has been helpful in intraprocedural decision making when TEE color change was modest ( Figure 2). Direct LA pressure measurement has been shown in previous studies to improve…”

“…There is a growing need for non‐color (non‐TEE) based assessment after MitraClip implantation. A hemodynamic change, if any, can be a useful adjunct when color reduction is minimal or equivocal after implantation of a clip(s) . In our experience, improvement in hemodynamic parameters has been helpful in intraprocedural decision making when TEE color change was modest (Figure ).…”

MitraClip patient selection: inclusion and exclusion criteria for optimal outcomes

“…The Transcatheter Valve Therapy (TVT) registry data demonstrated that baseline MR degree grade impacts the success as defined by post-procedural MR ≤2 (OR per increasing grade: 0.66; 95% CI: 0.47 to 0.93; P=0.02). In addition, the presence of multiple jets of MR can negatively impact short-and long-term outcomes of MitraClip due to the high likelihood of requiring multiple clips to achieve an adequate reduction of MR (16). On the other hand, there are reports cautioning against a single clip strategy, suggesting increased risk of residual and recurrent MR (17).…”