Outcomes of urgent/emergent transcatheter mitral valve repair (MitraClip): A single center experience

Abstract

Objectives To describe the outcomes of urgent/emergent transcatheter edge‐to‐edge mitral valve repair (TMVr) and compare the clinical, echocardiographic, and procedural characteristics of survivors and nonsurvivors. Background TMVr is a treatment strategy for select patients with severe primary or secondary mitral regurgitation. However, knowledge regarding outcomes for urgent/emergent TMVr is limited. Methods All urgent or emergent TMVr procedures using MitraClip performed at the University of Washington Medical Center between January 2018 and March 2019 were identified and clinical, echocardiographic, hemodynamic, procedural, and outcomes data were obtained by chart review. Outcomes included all‐cause mortality, hospital mortality, procedural success, periprocedural complications, and hospital readmission. Results Of the 20 patients who underwent urgent/emergent TMVr, eight were treated for cardiogenic shock (CS), four for acute decompensated heart failure (ADHF) with hypoxemic respiratory failure requiring mechanical ventilation, and eight for ADHF with failure of inpatient medical therapy. Mechanical circulatory support (MCS) was used in six patients; preceding TMVr in three patients and immediately post‐TMVr in three patients. Overall, 30‐day mortality and hospital readmission rates were 21 and 13%, respectively. Over a median 153 days (IQR 20–491) of follow‐up, 10 patients (50%) died. Preprocedure CS, new or ongoing MCS post‐TMVr, refractory respiratory failure post‐TMVr, and acute kidney injury post‐TMVr were associated with mortality. Conclusions In a single‐center retrospective analysis, urgent/emergent TMVr in high‐risk patients with ADHF or CS was associated with high short‐term mortality and periprocedural complications. Prospective studies are warranted to inform patient selection and periprocedural management for urgent/emergent TMVr.

Percutaneous mitral valve repair with MitraClip device in hemodynamically unstable patients: A systematic review

“…Subsequently, 168 full texts were reviewed to assess eligibility criteria, of which 141 were excluded due to reference to the MitraClip implant in stable patients. Finally, 40 publications, 13‐52 describing a total of 250 critically ill patients treated with MitraClip, were included (Figure 1). We identified 23 studies that refer to a single clinical case, 21‐34,36‐39,46,47,50‐52 14 small case series ( n ≤ 20), 13‐18,35,41‐45,48,49 two larger single center series ( n = 29 and n = 27) 19,40 and one multicenter study ( n = 44) 20 .…”

“…Hemodynamic support was required in the majority of the patients, with vasoactive drugs in 173 (68.1%) patients, and additional mechanical circulatory support in 104 (41%) patients. Intra‐aortic balloon pump was the most frequent (81.7%, n = 85 patients) device used for mechanical circulatory support, followed by Impella® (9.6%, n = 10) 18,19,42,47,48,52 and extracorporeal membrane oxygenation (8.7%, n = 9) 15,18,20,21,37,45‐47 . Regarding echocardiographic data, MR was quantified as severe (Grade 4) in 91.1% of the patients at baseline, with 13.1% related to a papillary muscle rupture in the context of acute STEMI.…”

“…Pre‐ and immediately post‐procedure MR grade compared by a paired analysis revealed a mean improvement of 2.3 ± 0.6 grades ( p < .001). In‐hospital mortality occurred in 32 patients (12.6%) 13,14,17‐20,35,40‐42,44,45 (Table 2). The cause of death was reported in only eight cases, being: gastrointestinal bleeding, 44 nosocomial pneumonia, 44 cardiac amyloidosis, 44 sepsis, 30 multiorgan failure, 13 severe biventricular dysfunction, 14 posterior leaflet tear as described above, 17 and ventilator‐associated pneumonia 35 .…”

“…Finally, 40 publications, 13‐52 describing a total of 250 critically ill patients treated with MitraClip, were included (Figure 1). We identified 23 studies that refer to a single clinical case, 21‐34,36‐39,46,47,50‐52 14 small case series ( n ≤ 20), 13‐18,35,41‐45,48,49 two larger single center series ( n = 29 and n = 27) 19,40 and one multicenter study ( n = 44) 20 . In our center, a total of 103 MitraClip procedures were performed to December 2020, and four (3.9%) patients fulfilled the inclusion criteria.…”

“…The cause of death was reported in only eight cases, being: gastrointestinal bleeding, 44 nosocomial pneumonia, 44 cardiac amyloidosis, 44 sepsis, 30 multiorgan failure, 13 severe biventricular dysfunction, 14 posterior leaflet tear as described above, 17 and ventilator-associated pneumonia. 35 Other non-fatal in-hospital complications were: cerebrovascular accident (n = 4), 14,23,34,42 major bleeding (n = 3), 42,45 major vascular complication (n = 2), 42 atrioventricular block requiring permanent pacemaker implantation (n = 1), 21 afterload mismatch immediately post procedure with acute transient impairment of ventricular function (n = 1), 38 single-leaflet detachment requiring a second procedure during the same hospitalization (n = 1), 19 cardiac tamponade (n = 1) 45 and a minor vascular access site complication consisting of a hematoma treated by manual compression (n = 1). 17 Kaplan-Meier curves estimated an overall mortality rate of 39.1% at 12-month follow-up (Figure 4).…”