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Cabrucci F, Baudo M, Magouliotis DE, Yamashita Y, Kjelstrom S, Bacchi B, Bonacchi M, Dokollari A, Sicouri S, Ramlawi B. Mitral Valve Surgery After Failed Transcatheter Edge-to-Edge Repair: A Meta-Analysis. Can J Cardiol 2025; 41:813-828. [PMID: 39947459 DOI: 10.1016/j.cjca.2025.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2024] [Revised: 01/13/2025] [Accepted: 02/06/2025] [Indexed: 03/22/2025] Open
Abstract
BACKGROUND Transcatheter edge-to-edge repair (TEER) is increasingly used for mitral regurgitation (MR), particularly in high-risk patients. However, when TEER fails, patients often require mitral valve surgery, which remains challenging because of patients' compromised condition. This study aims to evaluate short- and long-term surgical outcomes following failed TEER. METHODS This meta-analysis included observational studies with reported outcomes of mitral valve surgery after failed TEER published until September 2024. Multivariable meta-regressions were performed to predict short- and long-term mortality. Kaplan-Meier function was reconstructed from individual studies. RESULTS Sixteen studies were included with a total sample of 892 patients. The mean age was 74.8 years (55% males), with most patients (87.8%) in New York Heart Association class III or IV before surgery. Pooled mean Society of Thoracic Surgeons (STS) predicted risk of mortality score before index TEER was 6.3%. Surgical indications were recurrent MR ≥3+ (93%), mitral stenosis (17%), and endocarditis (2.7%). The average time between TEER and surgery was 6.4 months. Mitral valve replacement was performed in 83.8% of cases. Thirty-day all-cause mortality was 12.2% but significantly lower for elective cases (2.5%). At a mean follow-up of 14.7 months, mortality was 28.3%. Preoperative incidence of coronary artery disease, lower left ventricle ejection fraction (LVEF), rate of concomitant procedures, and functional mitral regurgitation were predictors of short- and long-term outcomes. CONCLUSION Mitral valve surgery after failed TEER presents significant challenges, yet acceptable outcomes are achievable, particularly in elective cases. Complete treatment of concomitant lesions may improve outcomes in patients with preserved LVEF. Future research should stratify outcomes based on emergent vs elective surgery and MR etiology to guide tailored surgical strategies.
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Affiliation(s)
- Francesco Cabrucci
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania, USA.
| | - Massimo Baudo
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania, USA
| | - Dimitrios E Magouliotis
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania, USA. https://twitter.com/Takotsubo91
| | - Yoshiyuki Yamashita
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania, USA; Department of Cardiac Surgery, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania, USA
| | - Stephanie Kjelstrom
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania, USA
| | - Beatrice Bacchi
- Department of Cardiac Surgery, AOU Careggi University Hospital, Firenze, Italy
| | - Massimo Bonacchi
- Department of Cardiac Surgery, AOU Careggi University Hospital, Firenze, Italy
| | - Aleksander Dokollari
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania, USA; Department of Cardiac Surgery, St Boniface Hospital, University of Manitoba, Winnipeg, Canada. https://twitter.com/Dr_Dokollari
| | - Serge Sicouri
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania, USA
| | - Basel Ramlawi
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania, USA; Department of Cardiac Surgery, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania, USA. https://twitter.com/BaselRamlawiMD
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Baudo M, Cuko B, Ternacle J, Sicouri S, Busuttil O, Denti P, Godino C, De Vincentiis C, Ramlawi B, Leroux L, Modine T, Palloshi A, Maisano F. Transcatheter management of residual mitral regurgitation after transcatheter edge-to-edge repair: a systematic review. Cardiovasc Interv Ther 2025; 40:255-267. [PMID: 39838219 DOI: 10.1007/s12928-025-01091-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2024] [Accepted: 01/10/2025] [Indexed: 01/23/2025]
Abstract
BACKGROUND Treatment of residual mitral regurgitation (MR) with different percutaneous devices after transcatheter edge-to-edge repair (TEER) has been reported as an alternative option to reclipping or surgery. This review aims at describing the different transcatheter strategies available and their results when managing residual MR after TEER. METHODS A literature search was undertaken across Pubmed, ScienceDirect, SciELO, DOAJ, and Cochrane library databases, to identify article reporting patients with post-TEER residual MR managed by a transcatheter approach that did not involve only the implantation of new clips. RESULTS From 439 deduplicated studies, 24 articles ultimately met the inclusion criteria. Fifteen described an occluder device implantation, 12 with an Amplatzer and 3 with a Cardioform. The most feared complications were hemolysis and device embolization. Three cases of transcatheter annuloplasty were reported in patients with residual functional MR. An electrosurgical detachment of the TEER device from the anterior mitral leaflet (ELASTA-Clip) before mitral valve replacement was reported in 6 articles. CONCLUSIONS Transcatheter procedures addressing residual MR after TEER in carefully selected patients are feasible in experienced centers. Outcomes are promising despite some technical issues. Percutaneous strategies and related complications should be anticipated using multimodality imaging.
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Affiliation(s)
- Massimo Baudo
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, 100 E Lancaster Avenue, Wynnewood, PA, 19096, USA.
| | - Besart Cuko
- Department of Cardiology and Cardio-Vascular Surgery, Hôpital Cardiologique du Haut-Lévêque, Bordeaux University Hospital, Pessac, France
| | - Julien Ternacle
- Department of Cardiology and Cardio-Vascular Surgery, Hôpital Cardiologique du Haut-Lévêque, Bordeaux University Hospital, Pessac, France
| | - Serge Sicouri
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, 100 E Lancaster Avenue, Wynnewood, PA, 19096, USA
| | - Olivier Busuttil
- Department of Cardiology and Cardio-Vascular Surgery, Hôpital Cardiologique du Haut-Lévêque, Bordeaux University Hospital, Pessac, France
| | - Paolo Denti
- Heart Valve Center, IRCCS San Raffaele, Milan, Italy
| | - Cosmo Godino
- Heart Valve Center, IRCCS San Raffaele, Milan, Italy
| | | | - Basel Ramlawi
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, 100 E Lancaster Avenue, Wynnewood, PA, 19096, USA
- Department of Cardiac Surgery, Lankenau Heart Institute, Main Line Health, Wynnewood, PA, USA
| | - Lionel Leroux
- Department of Cardiology and Cardio-Vascular Surgery, Hôpital Cardiologique du Haut-Lévêque, Bordeaux University Hospital, Pessac, France
| | - Thomas Modine
- Department of Cardiology and Cardio-Vascular Surgery, Hôpital Cardiologique du Haut-Lévêque, Bordeaux University Hospital, Pessac, France
| | - Altin Palloshi
- Heart Valve Center, IRCCS San Raffaele, Milan, Italy
- Department of Interventional Cardiology, Istituto Clinico Città Studi, Milan, Italy
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Wagner CM, Schultz ML, Brescia AA, Wang Y, Fu W, Hawkins RB, Romano MA, Ailawadi G, Bolling SF, Michigan Mitral Research Group. Surgical outcomes of patients at prohibitive risk who are reconsidered for surgery. JTCVS OPEN 2023; 16:234-241. [PMID: 38204727 PMCID: PMC10775058 DOI: 10.1016/j.xjon.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/07/2023] [Accepted: 08/28/2023] [Indexed: 01/12/2024]
Abstract
Objectives Transcatheter treatment of advanced mitral and tricuspid valve disease is largely limited to patients at prohibitive surgical risk, although many are not candidates for transcatheter treatment. Here, we describe surgical outcomes of patients at prohibitive risk who were ineligible for transcatheter therapies to guide surgeons in management of this unique population. Methods Patients at prohibitive risk, defined per surgeon or cardiologist discretion, who were initially referred for a transcatheter mitral or tricuspid intervention in a multidisciplinary atrioventricular valve clinic, were identified from 2019 to 2022. Preoperative risk, operative outcomes, and long-term mortality were evaluated. Results A total of 337 patients at prohibitive risk were referred for evaluation in a multidisciplinary atrioventricular valve clinic. Of those, 161 underwent transcatheter therapy, 130 patients underwent continued medical management, and 45 were reevaluated and had high-risk surgery. Among surgical patients, 51% were women with a median age of 76 years (quartile 1-quartile 3, 65-81 years). Most patients presented in heart failure (83%; n = 37 out of 45), and 73% were in New York Heart Association functional class III or IV. Most patients (94%; n = 43) had a mitral valve intervention, of whom 56% (24 out of 43) had a mitral valve replacement. The 30-day mortality rate was 4% (2 out of 45) and major morbidity occurred in 33% (15 out of 45). By Kaplan-Meier analysis, 1-year survival was 86% ± 9%. Conclusions Select patients at prohibitive risk who were ineligible for transcatheter mitral or tricuspid valve intervention underwent surgery with overall low operative mortality and excellent 1-year survival. Patients a prohibitive risk whose anatomy is not amenable to transcatheter devices should be reconsidered for surgery.
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Affiliation(s)
| | - Megan L. Schultz
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | | | - Yoyo Wang
- University of Michigan Medical School, Ann Arbor, Mich
| | - Whitney Fu
- Department of General Surgery, University of Michigan, Ann Arbor, Mich
| | - Robert B. Hawkins
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Matthew A. Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Steven F. Bolling
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Michigan Mitral Research Group
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
- University of Michigan Medical School, Ann Arbor, Mich
- Department of General Surgery, University of Michigan, Ann Arbor, Mich
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