Transcatheter MitraClip repair alters mitral annular geometry – device induced annular remodeling on three-dimensional echocardiography predicts therapeutic response

Abstract

BackgroundEchocardiography (echo) is widely used to guide therapeutic decision-making for patients being considered for MitraClip. Relative utility of two- (2D) and three-dimensional (3D) echo predictors of MitraClip response, and impact of MitraClip on mitral annular geometry, are uncertain.MethodsThe study population comprised patients with advanced (> moderate) MR undergoing MitraClip. Mitral annular geometry was quantified on pre-procedural 2D transthoracic echocardiography (TTE) and intra-procedural 3D transesophageal echocardiography (TEE); 3D TEE was used to measure MitraClip induced changes in annular geometry. Optimal MitraClip response was defined as ≤mild MR on follow-up (mean 2.7 ± 2.5 months) post-procedure TTE.ResultsEighty patients with advanced MR underwent MitraClip; 41% had optimal response (≤mild MR). Responders had smaller pre-procedural global left ventricular (LV) end-diastolic size and mitral annular diameter on 2D TTE (both p ≤ 0.01), paralleling smaller annular area and circumference on 3D TEE (both p = 0.001). Mitral annular size yielded good diagnostic performance for optimal MitraClip response (AUC 0.72, p < 0.01). In multivariate analysis, sub-optimal MitraClip response was independently associated with larger pre-procedural mitral annular area on 3D TEE (OR 1.93 per cm2/m2 [CI 1.19–3.13], p = 0.007) and global LV end-diastolic volume on 2D TTE (OR 1.29 per 10 ml/m2 [CI 1.02–1.63], p = 0.03). Substitution of 2D TTE derived mitral annular diameter for 3D TEE data demonstrated a lesser association between pre-procedural annular size (OR 5.36 per cm/m2 [CI 0.95–30.19], p = 0.06) and sub-optimal MitraClip response. Matched pre- and post-procedural TEE analyses demonstrated MitraClip to acutely decrease mitral annular area and circumference (all p < 0.001) as well as mitral tenting height, area, and volume (all p < 0.05): Magnitude of MitraClip induced reductions in mitral annular circumference on intra-procedural 3D TEE was greater among patients with, compared to those without, sub-optimal MitraClip response (>mild MR) on followup TTE (p = 0.017); greater magnitude of device-induced annular reduction remained associated with sub-optimal MitraClip response even when normalized for pre-procedure annular circumference (p = 0.028).ConclusionsMitraClip alters mitral annular geometry as quantified by intra-procedural 3D TEE. Pre-procedural mitral annular dilation and magnitude of device-induced reduction in mitral annular size on 3D TEE are each associated with sub-optimal therapeutic response to MitraClip.

Acute changes in mitral valve geometry after percutaneous valve repair with MitraClip XTR by three‐dimensional echocardiography

“…Previous studies have already suggested that AP diameter at baseline, 28 post‐procedural reduction in AP diameter 7 and ventricular chamber size 33 might be possible determinants of MitraClip effectiveness.…”

3D echocardiography in mitral valve prolapse

“…Kim et al used 3D TEE to measure TEER-induced changes in annular geometry. They confirmed that suboptimal response (residual MR grade >mild) was associated with larger pre-procedural MA area on 3D TEE, and found that the magnitude of reductions in MA circumference by intra-procedural 3D TEE was greater among patients with, compared to those without, suboptimal response on follow-up TTE ( 124 ).…”

The impact of transcatheter edge-to-edge repair on mitral valve annular geometry

“…Furthermore, the authors did not find an association between change in annular measurements and degree of mitral regurgitation reduced [24]. Conversely, Kim et al [25] found that the magnitude of reduction in annular circumference was greater among patients with suboptimal MitraClip response (>mild mitral regurgitation) at 2.7 AE 2.5 months follow-up (P ¼ 0.017). Otherwise, their results were consistent with others, reinforcing that MitraClip significantly reduced annular area, circumference and anterior-posterior diameter (all P < 0.001) acutely [25].…”

“…Conversely, Kim et al [25] found that the magnitude of reduction in annular circumference was greater among patients with suboptimal MitraClip response (>mild mitral regurgitation) at 2.7 AE 2.5 months follow-up (P ¼ 0.017). Otherwise, their results were consistent with others, reinforcing that MitraClip significantly reduced annular area, circumference and anterior-posterior diameter (all P < 0.001) acutely [25]. Most recently, Caballero et al validated model of functional mitral regurgitation.…”