Prognostic Value of Increased Mitral Valve Gradient After Transcatheter Edge-to-Edge Repair for Primary Mitral Regurgitation

Background The relationship between high postprocedural mean gradient (ppMG) and clinical events following mitral valve transcatheter edge‐to‐edge repair (MV‐TEER) in patients with degenerative mitral regurgitation (DMR) is still debated. Aim The purpose of this study was to evaluate the effect of elevated ppMG after MV‐TEER on clinical events in patients with DMR at 1‐year follow‐up. Methods The study included 371 patients with DMR treated with MV‐TEER enrolled in the “Multi‐center Italian Society of Interventional Cardiology (GISE) registry of trans‐catheter treatment of mitral valve regurgitation” (GIOTTO) registry. Patients were stratified in tertiles according to ppMG. Primary endpoint was a composite of all‐cause death and hospitalization due to heart failure at 1‐year follow‐up. Results Patients were stratified as follows: 187 with a ppMG ≤ 3 mmHg, 77 with a ppMG > 3/=4 mmHg, and 107 with a ppMG > 4 mmHg. Clinical follow‐up was available in all subjects. At multivariate analysis, neither a ppMG > 4 mmHg nor a ppMG ≥ 5 mmHg were independently associated with the outcome. Notably, the risk of elevated residual MR (rMR > 2+) was significantly higher in patients belonging to the highest tertile of ppMG (p = 0.009). The association of ppMG > 4 mmHg and rMR ≥ 2+ was strongly and independently associated with adverse events (hazard ratio: 1.98; 95% confidence interval: [1.10–3.58]). Conclusions In a real‐world cohort of patients suffering DMR and treated with MV‐TEER, isolated ppMG was not associated with the outcome at 1‐year follow‐up. A high proportion of patients showed both elevated ppMG and rMR and their combination appeared to be a strong predictor of adverse events.

Section: Discussionsupporting

confidence: 92%

Section: Introductionmentioning

confidence: 99%

Postprocedural trans‐mitral gradient in patients with degenerative mitral regurgitation undergoing mitral valve transcatheter edge‐to‐edge repair

Felice

Paolucci

Musto

et al. 2023

“…Neuss et al, described an association between transmitral pressure gradient >5 mmHg and all‐cause mortality but exclusively in the setting of residual MR of 2+ or more 16 . Toggweiler et al 17 also reported improved survival in patients with a postprocedural transmitral pressure gradient <3 mmHg and a <moderate residual MR. On the other hand, other studies showed no association between an elevated transmitral gradient and clinical outcomes 18–20 . Our study provides mechanistic insights to the association between post‐TEER mitral stenosis and clinical outcomes by documenting a lower rate of hemodynamic success in these patients (Figure 3).…”

Section: Discussionmentioning

confidence: 51%

Predictors of hemodynamic response to mitral transcatheter edge‐to‐edge repair

Samimi

Ponce

Alarouri

et al. 2023

Background: Improvement in left atrial pressure (LAP) during transcatheter edge-toedge repair (TEER) is associated with improved outcomes. We sought to investigate the predictors of optimal hemodynamic response to TEER. Methods:We identified patients who underwent TEER at Mayo Clinic between May 2014 and February 2022. Patients with missing LAP data, an aborted procedure, and those undergoing a concomitant tricuspid TEER were excluded. We performed a logistic regression analysis to identify predictors of optimal hemodynamic response to TEER (defined as LAP ≤ 15 mmHg).Results: A total of 473 patients were included (Mean age 78.5 ± 9.4 years, 67.2% males). Overall, 195 (41.2%) achieved an optimal hemodynamic response after TEER.Patients who did not achieve an optimal response had higher baseline LAP (20.0 [17][18][19][20][21][22][23][24][25] vs. 15.0 [12-18] mmHg, p < 0.001), higher prevalence of AF (68.3% vs. 55.9%, p = 0.006), functional MR (47.5% vs. 35.9%, p = 0.009), annular calcification (41% vs. 29.2%, p = 0.02), lower left ventricular EF (55% vs. 58%, p = 0.02), and more frequent postprocedural severe MR (11.9% vs. 5.1%, p = 0.02) and elevated mitral gradient >5 mmHg (30.6% vs. 14.4%, p < 0.001). In the multivariate logistic regression analysis, AF (OR = 0.58; 95% CI = 0.35-0.96; p = 0.03), baseline LAP (OR = 0.80; 95% CI = 0.75-0.84; p < 0.001) and postprocedural mitral gradient <5 mmHg (OR = 0.35; 95% CI = 0.19-0.65; p < 0.001), were independent predictors of achieving an optimal hemodynamic response. In the multivariate model, residual MR was not independently associated with optimal hemodynamic response.Conclusions: Optimal hemodynamic response is achieved in 4 in 10 patients undergoing TEER. AF, higher baseline LAP, and higher postprocedural mitral gradient were negative predictors of optimal hemodynamic response after TEER.

“…Similarly, in a recent study by Koell et al, an elevated post TEER MG ≥ 5 mmHg was associated with a composite endpoint of death or heart failure rehospitalization after 5 years in degenerative but not functional MR 9 . Contrary to these findings, Yoon et al showed that an elevated post‐TEER MG at discharge was not independently associated with adverse events 10 …”

Section: Discussionmentioning

confidence: 88%

The impact of baseline transmitral diastolic mean gradient on left atrial pressure reduction in patients undergoing transcatheter mitral valve edge‐to‐edge repair

Lugo-Fagundo

Pierre

Adedinsewo

et al. 2023

Background Elevated transmitral gradient post transcatheter mitral valve edge‐to‐edge repair (TEER) has been associated with worse outcomes. Whether an elevated baseline transmitral diastolic mean gradient (MG) ≥5 mmHg is associated with hemodynamic outcomes after TEER is unknown. Methods A total of 164 consecutive patients undergoing TEER at Mayo Clinic between June 2014 and May 2018 were analyzed in this retrospective study. Baseline demographics, as well as clinical, echocardiographic, and procedural data were obtained. Data on direct left atrial pressure (LAP) before and after TEER were recorded. Logistic regression models were constructed to evaluate the association between preprocedure transmitral diastolic mean gradient (pre‐MG) and (1) improvement in LAP following TEER, (2) postprocedure transmitral diastolic mean gradient (post‐MG). A decrease in LAP post TEER was considered an improvement in hemodynamic response. Pre‐MG was categorized as: ≥5 and <5 mmHg. Results Median age of the cohort was 81.5 years (Q1: 76.3, Q3: 87) and 34% were female. At baseline, median transmitral diastolic MG was 4 mmHg (Q1: 3, Q3: 5) and median LAP was 19 mmHg (Q1:16, Q3: 23.5). In a multivariable model, adjusted for age and sex, patients with pre‐MG ≥ 5 mmHg were less likely to see an improvement in LAP post TEER (adjusted odds ratio [aOR]: 0.22, 95% confidence interval [CI]: 0.09, 0.55; p = 0.001) and more likely to have elevated post‐MG (aOR; 7.08, 95% CI: 2.93, 17.13; p < 0.001). Conclusion Higher pre‐MG (≥5 mmHg) was associated with a lower reduction in LAP and higher residual transmitral gradient following TEER suggesting other potential contributors to increased LAP besides mitral regurgitation as a cause of elevated baseline MG.