Recurrence of Functional Versus Organic Mitral Regurgitation After Transcatheter Mitral Valve Repair: Implications from Three-Dimensional Echocardiographic Analysis of Mitral Valve Geometry and Left Ventricular Dilation for a Point of No Return

Abstract

Background: MitraClip implantation has become the standard transcatheter mitral valve repair (TMVR) technique for severe mitral regurgitation (MR). However, approximately one third of patients have poor outcomes, with MR recurrence at follow-up. The aim of this study was to investigate whether quantitative analysis of mitral valve (MV) geometry on three-dimensional (3D) echocardiography can identify geometric parameters associated with the recurrence of severe functional MR (FMR) versus organic MR (OMR) at 6-month follow-up after TMVR using the MitraClip.Methods: Sixty-one patients with severe FMR (n = 45) or OMR (n = 16) who underwent transesophageal 3D echocardiography before and 6 months after TMVR were retrospectively analyzed. MV geometry was quantified using 3D echocardiography software. Vena contracta area (VCA) at 6-month follow-up was used to define two outcome groups: patients with good results with VCA < 0.6 cm 2 (MR < 0.6) and those with MR recurrence with VCA $ 0.6 cm 2 (MR $ 0.6).Results: MR recurrence was found in 34% of all study patients (21 of 61). In patients with FMR, significant differences between MR < 0.6 and MR $ 0.6 were found at baseline for tenting index (1.13 vs 1.23, P = .004), tenting volume (2.8 vs 4.0 ml, P = .04), indexed left ventricular (LV) end-diastolic volume (68.0 vs 99.9 ml/m 2 , P = .001), and VCA (0.71 vs 1.00 cm 2 , P = .003); no significant parameters of MR recurrence were found in patients with OMR. Multivariate analysis identified indexed LV enddiastolic volume as the strongest independent determinant of MR recurrence. Receiver operating characteristic analysis identified a tenting index of 1.185 (area under the curve 0.79) and indexed LV end-diastolic volume of 88 ml/m 2 (area under the curve 0.76) to best discriminate between MR < 0.6 and MR $ 0.6.Conclusions: MR recurrence after TMVR in patients with FMR is associated with advanced LV dilation and MV tenting before TMVR, which provides clinical implications for a point of no return beyond which progressive LV dilation with MV geometry dilation and tethering cannot be effectively prevented by TMVR. In contrast, no significant determinants of MR recurrence and progressive MV annular dilation could be identified in patients with OMR.

Transcatheter Edge-to-Edge Repair in Proportionate Versus Disproportionate Functional Mitral Regurgitation

“…Although evidence for mechanisms behind delayed FMR deterioration is limited, several anatomic predictors, including LVEDV, may play a key role. 25,26 This sobering reality contrasts with the excellent 1-and 2-year echocardiographic data from the COAPT trial showing maintained MR reduction over time, although patient-level FMR follow-up has not been published to date. Several studies have reported discharge and 12-month FMR grade but did not perform pairwise comparisons of postprocedural versus 12-month FMR grade, [27][28][29][30] precluding reliable insights on durable effects of TEER on FMR reduction.…”

Research Opportunities in the Treatment of Mitral Valve Prolapse

“…Multicenter, randomized clinical TEER trials with standardized follow-up intervals and echocardio-graphic core laboratory-adjudicated outcomes improved our understanding of the timing and mechanisms of recurrent MR associated with this procedure, 62 , 63 notwithstanding limitations of almost universal short-term follow-up periods, 60 , 63 as well as the constant evolution of the transcatheter device arena. National TEER registries only include site-reported, short-term outcomes.…”

Mitral valve leaflet stiffness predicts residual mitral regurgitation after transcatheter edge‐to‐edge mitral valve repair

“…Patients’ baseline characteristics and several echocardiographic parameters, including mitral valve (MV) features, have been reported to predict the success of TMVR and post‐procedural survival in patients with FMR 2,5,7 . Several parameters assessed by three‐dimensional (3D) transesophageal echocardiography (TEE) have also been shown to be helpful in predicting outcomes after TMVR 8–10 . We aimed to determine the MV leaflet features and 3D‐TEE parameters that affect residual regurgitation after TMVR in patients with FMR.…”

“…2,5,7 Several parameters assessed by threedimensional (3D) transesophageal echocardiography (TEE) have also been shown to be helpful in predicting outcomes after TMVR. [8][9][10] We aimed to determine the MV leaflet features and 3D-TEE parameters that affect residual regurgitation after TMVR in patients with FMR.…”