Transcatheter Edge-to-Edge Repair for Atrial Secondary Mitral Regurgitation

Tanaka, Tetsu; Sugiura, Akira; Öztürk, Can; Vogelhuber, Johanna; Tabata, Noriaki; Wilde, Nihal; Zimmer, Sebastian; Nickenig, Georg; Weber, Marcel

doi:10.1016/j.jcin.2022.06.005

Cited by 22 publications

(11 citation statements)

References 23 publications

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“…[14][15][16][23][24][25][26][27] Meanwhile, three studies with a total of 192 and 694 individuals reported long-term postprocedural MR ≤ 2 outcomes in both groups. 16,26,27 No statistical significance in regard to the rates of postprocedural MR ≤ 2 was observed in short-term (RR, 1.00 [95% CI, 0.95-1.06]; p = 0.90, I 2 = 53%) or long-term follow-up (RR, 1.08 [95% CI, 0.89-1.32]; p = 0.44, I 2 = 22%; Figure 2). Similarly, there was no statistical difference in short-or long-term outcomes of postprocedural NYHA ≤ 2 between the two groups (RR, 1.09 [95% CI, 0.93-1.29], p = 0.28, I 2 = 0% for short term and RR, 1.07 [95% CI, 0.86-1.34], p = 0.52, I 2 = 0% for long term; Figure 3).…”

Section: Results Of Individual Studies and Synthesis Of Resultsmentioning

confidence: 99%

“…A total of eight studies had data available for short‐term outcomes of postprocedural MR ≤ 2 in both AFMR and VFMR groups, with a total of 539 and 3486 individuals, respectively 14–16,23–27 . Meanwhile, three studies with a total of 192 and 694 individuals reported long‐term postprocedural MR ≤ 2 outcomes in both groups 16,26,27 .…”

Section: Resultsmentioning

confidence: 99%

“…Similar to what was observed in the COAPT and MITRA‐FR trials, clinical outcomes may differ depending on the degree of left atrial remodeling. Tanaka et al reported that severe left atrial dilation coupled with a low leaflet‐to‐annulus‐index, that is, the ratio of the sum of anterior and posterior leaflets lengths to the anteroposterior length of the mitral annulus, was associated with a low incidence of MR reduction, which they attribute to a mismatch between leaflet remodeling and annulus dilatation 16 . It may be wise to consider stratifying left atrium morphology when conducting future prospective studies.…”

Section: Discussionmentioning

confidence: 99%

“…11,13 Likewise, many studies do not distinguish between AFMR and VFMR; therefore, clinical outcomes of TEER may be conflicting due to differences in the underlying etiology between the two entities. In recent years, observational studies investigating the efficacy of TEER in patients specifically with AFMR have displayed positive outcomes, [14][15][16] yet the relatively small number of patients in each study calls for a meta-analysis to elucidate uncertainties. Herein, we conducted a systematic review and metaanalysis of the existing literature on procedural success and clinical outcomes of TEER for AFMR, including comparison with VFMR.…”

Section: Introductionmentioning

confidence: 99%

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Outcomes of transcatheter edge‐to‐edge repair for atrial functional mitral regurgitation: A meta‐analysis of observational studies

Hamada,

Ueyama,

Aikawa

et al. 2023

Cathet Cardio Intervent

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BackgroundTranscatheter edge‐to‐edge repair (TEER) may have potential benefits in the treatment of atrial functional mitral regurgitation (AFMR), but robust evidence is currently lacking. We conducted a systematic review and meta‐analysis to investigate the clinical outcomes of TEER for AFMR, including comparisons to ventricular functional MR (VFMR).MethodsMEDLINE and EMBASE were searched through January 2023 to identify studies eligible for analysis. The primary outcome was postprocedural MR severity. Postprocedural New York Heart Association (NYHA) functional class classification and all‐cause mortality were also evaluated. Outcomes were stratified into short term (postprocedure to 6 months) and long term (6 months to 2 years).ResultsA total of eight observational studies met the inclusion criteria, enrolling 539 AFMR and 3486 VFMR patients. Postprocedural MR grade ≤2 in the AFMR group was observed in 93.7% (454/491 patients; 95% confidence interval (CI), 91.1%–96.2%, I2 = 24.3%) and 97.1% (89/93 patients; 95% CI, 92.9%–100%, I2 = 26.4%) in short‐ and long‐term follow‐up, respectively. There was no difference in the rates of postprocedural MR grade ≤2 between AFMR and VFMR either in short‐term (risk ratio [RR], 1.00 [95% CI, 0.95–1.06]; p = 0.90; I2 = 53%) or long‐term follow‐up (RR, 1.08 [95% CI, 0.89–1.32]; p = 0.44; I2 = 22%). Similarly, no difference was observed between AFMR and VFMR in the rates of postprocedural NYHA class ≤2 or all‐cause mortality.ConclusionTEER provides similar clinical outcomes for AFMR and VFMR. A high rate of MR grade ≤2 was observed in patients at both short‐ and long‐term follow‐ups. Further prospective studies with TEER versus medical therapy and/or rhythm control for AFMR are warranted.

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Section: Results Of Individual Studies and Synthesis Of Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Outcomes of transcatheter edge‐to‐edge repair for atrial functional mitral regurgitation: A meta‐analysis of observational studies

Hamada,

Ueyama,

Aikawa

et al. 2023

Cathet Cardio Intervent

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“…[3][4][5] Conversely, the most consistently reported predictors of worse outcomes include secondary MR, atrial fibrillation, low leaflet-to-annulus index, large left atrial volume index, severe tricuspid regurgitation, and pulmonary hypertension. [5][6][7][8][9] In a recent study that stratified patients undergoing TEER based on residual MR and mean left atrial pressure (LAP), 1-year survival was superior among patients with optimal reduction in MR and normal postprocedural LAP. 10 Intraprocedural transesophageal echocardiography (TEE) derived pulmonary vein (PV) Doppler is emerging as a useful adjunct to assess MR reduction during the procedure, and few studies thus far have investigated the impact of changes in PV Doppler on outcomes after mitral TEER.…”

Section: Introductionmentioning

confidence: 99%

Intraprocedural Doppler and Invasive Hemodynamic Profiling Predict Clinical Outcomes After Mitral TEER

Zaid

Wessly

Hatab

et al. 2023

Preprint

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Background: Whether intraprocedural changes in left atrial pressure and Doppler Echocardiographic parameters are synergistic in predicting outcomes after mitral transcatheter edge-to-edge repair (TEER) is not currently known. We sought to evaluate real-time changes in invasive hemodynamics and non-invasive Doppler to develop intraprocedural profiles and assess their impact on clinical outcomes after TEER for MR. Methods: Intraprocedural changes in hemodynamics and Doppler flow with transesophageal echocardiography were assessed in 181 patients with significant MR (51.9% primary MR) undergoing TEER between 2014 and 2022. Independent predictors of the primary composite endpoint of 1-year mortality and heart failure hospitalization (HFH) were identified using multivariable Cox-regression. With receiver operating characteristic curve-derived thresholds for the predictors of the primary end-point, patients were stratified into hemodynamic profiles based on the number of predictors present, and their impact on outcomes was examined. Results: Median follow-up was 21.3 months (IQR:11.3-36.5), with 1-year mortality and HFH rates of 19.3% and 12.7%, respectively. Residual mean left atrial pressure (mLAP) [HR=1.073/mmHg (1.03-1.12)], a lesser degree of MR reduction [HR=0.65/grade (0.45-0.93)], and lesser increment in PV systolic time velocity integral (S-VTI) [HR=0.95/cm (0.91-0.99)] were independent predictors of 1-year mortality/HFH. MR reduction by <3 grades (33.1%), S-VTI increment ≤8cm (33.9%), and residual mLAP >15mmHg (43.6%) were the most predictive thresholds. Optimal profile (0 predictors), Mixed (1 predictor) and Poor profile (>2 predictors) were present in 28.7%, 39.2% and 32.0% of cases respectively. Two-year cumulative event-free survival was 60.1% overall, and higher in patients with optimal profile compared to mixed/poor groups (84.7% vs 55.5% vs 43.3%, P<0.001). There was an incremental risk of mortality/HFH with each profile overall [HR=1.75/profile (1.34-2.29)], and within primary MR [HR=1.64/profile (1.15-2.36)] and secondary MR [HR=1.77/profile (1.17-2.68)] cohorts. There was also an incremental risk of mortality alone with each profile [HR=1.65/profile (1.22-2.22)]. Hemodynamic profile was an independent predictor of 1-year mortality [HR=1.98/profile (1.21-3.25)] after TEER, along with baseline tricuspid regurgitation severity [HR=1.55/grade (1.10-2.19)], and post-procedural transmitral mean gradient>5mmHg [HR=2.32 (1.17-4.61)]. Conclusion: Intraprocedural hemodynamic profiling integrating changes in invasive hemodynamics and non-invasive doppler provide prognostic information in patients undergoing TEER and may provide real-time intraprocedural guidance to optimize long-term clinical outcomes.

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Clinical Outcomes of Mitral Valve Surgery in Atrial Functional Mitral Regurgitation in the REVEAL-AFMR Registry

Kagiyama,

Kaneko,

Amano

et al. 2024

JAMA Netw Open

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ImportanceThe characteristics and treatment strategies of atrial functional mitral regurgitation (AFMR) are poorly understood.ObjectiveTo investigate the prevalence, clinical characteristics, and outcomes of mitral valve (MV) surgery in AFMR.Design, Setting, and ParticipantsThis retrospective cohort study, called the Real-World Observational Study for Investigating the Prevalence and Therapeutic Options for Atrial Functional Mitral Regurgitation (REVEAL-AFMR), was conducted across 26 Japanese centers (17 university hospitals, 1 national center, 3 public hospitals, and 5 private hospitals). All transthoracic echocardiography procedures performed from January 1 to December 31, 2019, were reviewed to enroll adult patients (aged ≥20 years) with moderate or severe AFMR, defined by preserved left ventricular function, a dilated left atrium, and an absence of degenerative valvular changes. Data were analyzed from May 8, 2023, to May 16, 2024.ExposuresMitral valve surgery, with or without tricuspid valve intervention.Main Outcomes and MeasuresThe primary composite outcome included heart failure hospitalization and all-cause mortality.ResultsIn 177 235 patients who underwent echocardiography, 8867 had moderate or severe MR. Within this group, 1007 (11.4%) were diagnosed with AFMR (mean [SD] age, 77.8 [9.5] years; 55.7% female), of whom 807 (80.1%) had atrial fibrillation. Of these patients, 113 underwent MV surgery, with 92 (81.4%) receiving concurrent tricuspid valve surgery. Patients who underwent surgery were younger but had more severe MR (57.5% [n = 65] vs 9.4% [n = 84]; P &lt; .001), a larger mean (SD) left atrial volume index (152.5 [97.8] mL/m2 vs 87.7 [53.1] mL/m2; P &lt; .001), and a higher prevalence of heart failure (according to the New York Heart Association class III [marked limitation of physical activity] or class IV [symptoms of heart failure at rest], 26.5% [n = 30] vs 9.3% [n = 83]; P &lt; .001) than those who remained under medical therapy. During a median follow-up of 1050 days (IQR, 741-1188 days), 286 patients (28.4%) experienced the primary outcome. Despite a more severe disease status, only the surgical group showed a decrease in natriuretic peptide levels at follow-up and had a significantly lower rate of the primary outcome (3-year event rates were 18.3% vs 33.3%; log-rank, P = .03). Statistical adjustments did not alter these findings.Conclusions and RelevanceThe findings of this cohort study suggest that in patients with AFMR, who were typically older and predominantly had atrial fibrillation, MV surgery was associated with lower rates of adverse clinical outcomes. Future studies are warranted to investigate a possible causal relationship to better regulate cardiovascular medicine.

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Transcatheter Edge-to-Edge Repair for Atrial Secondary Mitral Regurgitation

Cited by 22 publications

References 23 publications

Outcomes of transcatheter edge‐to‐edge repair for atrial functional mitral regurgitation: A meta‐analysis of observational studies

Outcomes of transcatheter edge‐to‐edge repair for atrial functional mitral regurgitation: A meta‐analysis of observational studies

Intraprocedural Doppler and Invasive Hemodynamic Profiling Predict Clinical Outcomes After Mitral TEER

Clinical Outcomes of Mitral Valve Surgery in Atrial Functional Mitral Regurgitation in the REVEAL-AFMR Registry

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