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

Atrial fibrillation's role in MitraClip patient outcomes: a retrospective analysis of mortality and heart failure hospitalization in a single-centre cohort

OBJECTIVE

Atrial fibrillation (AF) is common in patients with mitral regurgitation (MR) undergoing transcatheter edge-to-edge repair (TEER) with MitraClip; however, its impact on procedural hemodynamics and clinical outcomes remains inadequately characterized.

METHODS

This retrospective single-center study analyzed 226 high-risk patients who underwent MitraClip implantation between 2010 and 2022. The primary endpoint was time to first heart failure hospitalization. Secondary endpoints included procedural hemodynamics and long-term mortality.

RESULTS

AF was observed in 46.9% of the patients and was associated with distinct hemodynamic features, including significantly elevated right (11 vs. 9 mmHg, P = 0.008) and left atrial pressures (17 vs. 15 mmHg, P = 0.023). Despite similar procedural success rates, patients with AF experienced markedly accelerated time to first HF hospitalization (median 48 vs. 106 weeks, P = 0.005). Tricuspid regurgitation at discharge emerged as the strongest predictor of early heart failure hospitalization (HR 1.393, 95% CI: 1.009-1.924, P = 0.044). One-year mortality (16.0% vs. 16.7%, P = 0.899) and long-term survival remained comparable between groups.

CONCLUSION

AF in TEER patients is characterized by elevated atrial filling pressures and substantially accelerated time to heart failure hospitalization, with tricuspid regurgitation at discharge predicting early events. Although these findings indicate the need for more intensive monitoring of patients with AF during the first post-procedural year, comparable survival rates suggest that AF alone should not preclude TEER in otherwise suitable candidates.

Impact of systolic dominant pulmonary venous flow morphology on outcomes after mitral transcatheter edge-to-edge repair

BACKGROUND

The prognostic significance of intraprocedural pulsed-wave Doppler analysis of pulmonary venous flow (PVF) during mitral transcatheter edge-to-edge repair (TEER) remains understudied. We aimed to investigate the prognostic value of systolic dominant-PVF (SD-PVF) morphology post-TEER.

METHODS

In a retrospective analysis from December 2019 to December 2022, patients undergoing mitral TEER were categorized into SD-PVF and systolic blunting (SB)-PVF groups based on post-TEER morphology. The primary endpoint was a composite of all-cause mortality or heart failure hospitalization at 1 year. We investigated the association of PVF morphology post-TEER with the primary endpoint at 1 year using Cox regression and compared the prognostic accuracy of PVF variables through receiver operating characteristic (ROC) curve analysis.

RESULTS

Among 187 patients (mean age 76.4 ± 10.5 years, 51.3% primary etiology), residual mitral regurgitation (MR) ≤mild was observed in 147 (82.4%) patients and 105 (56.2%) had SD-PVF post-TEER. Patients with SD-PVF had a lower incidence of >2+ residual MR after clip deployment, at 30 days (2.1% vs. 13.1%; p = 0.005) and at 1 year (1.4% vs. 9%; p = 0.08). SD-PVF post-TEER was independently associated with the primary endpoint (HR = 0.59, 95% CI = 0.39-0.87; p = 0.009). ROC curve analysis of the prognostic accuracy of SD-PVF demonstrated an AUC of 0.64 (95% CI = 0.54-0.73), comparable to other quantitative measures of PVF.

CONCLUSION

Assessing PVF morphology after clip deployment offers a simple prognostic tool for patients undergoing mitral TEER. Multicenter cohorts will be necessary to further investigate its prognostic value.

Echocardiographic Profiling Predicts Clinical Outcomes After Mitral Transcatheter Edge-to-Edge Repair

BACKGROUND

Prior studies investigating the impact of residual mitral regurgitation (MR), tricuspid regurgitation (TR), and elevated predischarge transmitral mean pressure gradient (TMPG) on outcomes after mitral transcatheter edge-to-edge repair (TEER) have assessed each parameter in isolation. We sought to examine the prognostic value of combining predischarge MR, TR, and TMPG to study long-term outcomes after TEER.

METHODS AND RESULTS

We reviewed the records of 291 patients who underwent successful mitral TEER at our institution between March 2014 and June 2022. Using well-established outcomes-related cutoffs for predischarge MR (≥moderate), TR (≥moderate), and TMPG (≥5 mm Hg), 3 echo profiles were developed based on the number of risk factors present (optimal: 0 risk factors, mixed: 1 risk factor, poor: ≥2 risk factors). Discrimination of the profiles for predicting the primary composite end point of all-cause mortality and heart failure hospitalization at 2 years was examined using Cox regression. Overall, mean age was 76.7±10.6 years, 43.3% were women, and 53% had primary MR. Two-year event-free survival was 61%. Predischarge TR≥moderate, MR≥moderate, and TMPG≥5 mm Hg were risk factors associated with the primary end point. Compared with the optimal profile, there was an incremental risk in 2-year event-rate with each worsening profile (optimal as reference; mixed profile: hazard ratio (HR), 2.87 [95% CI, 1.71-5.17], P<0.001; poor profile: HR, 3.76 [95% CI, 1.84-6.53], P<0.001). Echocardiographic profile was statistically associated with the 2-year mortality end point (optimal as reference; mixed profile: HR, 3.55 [95% CI, 1.81-5.96], P<0.001; poor profile: HR, 3.39 [95% CI, 2.56-7.33], P=0.02).

CONCLUSIONS

The echocardiographic profile integrating predischarge TR, MR, and TMPG presents a novel prognostic stratification tool for patients undergoing mitral TEER.