Mitral valve repair for degenerative mitral regurgitation in patients with left ventricular systolic dysfunction: early and mid-term outcomes

Do Not Withhold Mitral Surgery from Patients with Poor Left Ventricular Function

Background and Objectives: Increasing reluctance to perform surgical mitral valve repair or replacement particularly in high-risk patients with poor left-ventricular function is trending. These patients are increasingly treated interventionally, e.g., by MitraClip, but often show only low to moderate improvement. The primary objective of the study was to investigate whether left ventricular ejection fraction (LVEF) influences postoperative mortality. Materials and Methods: The study included 903 patients undergoing mitral valve repair or replacement between 2009 and 2021. Statistical comparison was performed between patients with LVEF ≤ 30% and LVEF > 30%. Finally, statistical analysis was performed according to propensity score matching (1:3 PS matching). Results: No significant difference in in-hospital mortality was found before and after matching regarding LVEF ≤ 30% and LVEF > 30% (Pre: 10.8% vs. 15.1%, p = 0.241, after: 11.6% vs. 18.1%, p = 0.142). After PS matching, the 112 patients with LVEF ≤ 30% compared with 336 patients with LVEF > 30% showed a significantly higher preoperative NT-proBNP (p < 0.001), larger diameters at preoperative left ventricle and atrium (p < 0.001), lower preoperative TAPSE (p = 0.003) and PAP (p = 0.003), and more dilated cardiomyopathy and chronic kidney disease (p < 0.001, p = 0.045). Conclusions: The results of this study demonstrate that poor preoperative LVEF alone does not play a significant role in postoperative outcome and long-term mortality. Prognosis appears to be multifactorial. Poor preoperative LVEF is not a contraindication for surgery and does not justify primary interventional treatment accepting inferior hemodynamic results impeding outcome.

Coaptation Reserve Predicts Optimal Reduction in Mitral Regurgitation and Long-Term Survival With Transcatheter Edge-to-Edge Repair

BACKGROUND

Although transcatheter edge-to-edge repair (TEER) is effective and safe, there is a need for better prediction of optimal outcomes. We aimed to determine predictors of optimal reduction in mitral regurgitation (MR) and survival with TEER.

METHODS

We examined mitral anatomy and its change with TEER on outcomes in 183 patients (age, 82 [77-87] years; 53% women). Coaptation reserve was measured as the distance of continuous apposition of the A2 and P2 leaflet segments in 2-dimensional apical long-axis imaging at the site of the predominant jet of MR. Augmentation in coaptation was measured as the total amount of leaflet insertion. Addressable coaptation area was calculated using the physical boundaries of the TEER device.

RESULTS

Coaptation reserve, its augmentation, and addressable coaptation area were strong predictors of MR reduction (all P<0.001), as well as heart failure hospitalization and death. For patients with either mild or no residual MR, median values for coaptation reserve, its augmentation, and addressable coaptation area were 3.7 (2.8-4.5) mm, 7.3 (5.2-9.5) mm, and 59.0 (48.0-71.8) mm2, respectively. Receiver operating characteristic analyses determined the best values for optimal MR reduction as a coaptation reserve of >3.0 mm (P<0.001), addressable coaptation area of ≥52 mm2 (P<0.001), and coaptation augmentation of ≥4.7 mm (P<0.001). These values were associated with greater 2-year survival free of all-cause mortality and persisting even in analyses restricted to those with mild or no residual MR after TEER.

CONCLUSIONS

Coaptation reserve and its augmentation are simple, independent parameters that predict optimal MR reduction and better survival in patients undergoing TEER. These findings may have implications for patient selection and expanded use of the therapy.

Advances in Mitral Valve Repair for Degenerative Mitral Regurgitation: Philosophy, Technical Details, and Long-Term Results

Degenerative mitral valve disease represents the most common cause of mitral regurgitation in industrialized countries. When left untreated, patients with severe degenerative mitral regurgitation show a poor clinical outcome. Conversely, a timely and appropriate correction provides a restored life expectancy and a good quality of life. Therefore, in this scenario, surgical mitral valve repair represents the gold standard of treatment. This review aims to analyze the indications, timing, and contemporary surgical techniques of mitral valve repair for degenerative mitral regurgitation. Moreover, the value of heart team approach and centers of excellence for mitral valve repair are also deeply discussed.