Risk Stratification of Percutaneous Edge-to-Edge Repair by MitraClip in Patients with Mitral Regurgitation

Prognostic value of baseline RV dysfunction using TAPSE and TAPSE to PASP ratio in patients undergoing mitra-clip: a systematic review and meta-analysis

Mitra-clip is an established therapy for high-risk surgical candidates who are refractory to optimal medical treatment. Reports have shown that right ventricular dysfunction (RVD) has been associated with increased morbidity and mortality in heart failure (HF) patients. Our goal of this systematic review/meta-analysis is to assess the prognosis of baseline RV function markers including TAPSE (tricuspid annular plane systolic excursion) and TAPSE:PASP (pulmonary artery systolic pressure) ratio after Mitra-clip. MEDLINE and EMBASE were searched from inception to December 20th, 2023, for studies discussing the prognostic outcome of pre-existing RVD in Mitra-clip patients. Definition of RV dysfunction was reported as an abnormal TAPSE (< 15-16 mm) or RV-PA (right ventricle-pulmonary artery) uncoupling expressed as abnormal TAPSE:PASP ratio (< 0.30-0.37 mm/mmHg). We included all original research studies (excluding reviews, meta-analysis, commentaries/editorials, and animal studies) that assessed the prognostic utility of TAPSE and TAPSE:PASP ratio in patients with MR undergoing Mitra-clip. Reviewers independently screened the studies and extracted the pertinent data. Odds ratios (OR) were calculated using a random-effects model. Twelve reports enrolling 3526 patients were included. Mean age ranged from 70 to 81 years and 61.1% patients were male. Primary, secondary, and mixed MR were reported in 36.9%, 61.4%, and 1.8% respectively. Mean LVEF ranged from 27% to 57.1% and 93.7% of patients had MR grade ≥ 3 + (at least moderate to severe MR). Patients with RVD had a reduction in the overall survival (OS) after Mitra-clip at 6 months (81.8% vs 90.5%, OR = 0.45 [0.35-0.58]; P < 0.001), 1-year (71.1% vs 85.7%, OR = 0.40 [0.33-0.48]; P < 0.001), and 2-year (60.3% vs 76.8%, OR = 0.37 [0.31-0.45]; P < 0.001) compared to normal RV group. Likewise, HF re-admission free survival was minimized among RVD patients at 6 months (76.8% vs 88.1%, OR = 0.47 [0.34-0.65]; P < 0.001), 1-year (64.5% vs 81.3%, OR = 0.44 [0.35-0.55]; P < 0.001), and 2-year (58.2% vs 78.9%, OR = 0.41 [0.30-0.56]; P < 0.001) compared to normal RV group. Decreased TAPSE: PASP was associated with lower OS at 6-month (OR = 0.46 [0.31-0.68]; P < 0.001), 1-year (OR = 0.37 [0.29-0.47]; P < 0.001), and 2-year (OR = 0.35 [0.25-0.47]; P < 0.001) and reduced HF re-admission free survival at 6-month ((OR = 0.44 [0.31-0.62]; P < 0.001), 1-year (OR = 0.41[0.31-0.54]; P < 0.001), and 2-year (OR = 0.41 [0.31-0.58]; P < 0.001) after Mitra-clip. Furthermore, decreased TAPSE negatively impacted the OS and HF re-admission at 6-month (OR = 0.40 [0.21-0.77]; P = 0.006), and 1-year (OR = 0.50 [0.31-0.80]; P = 0.004) and increased HF re-admission rate at 6-month (OR = 0.27 [0.13-0.56]; P = 0.0005), and 1-year (OR = 0.30 [0.15-0.58]; P = 0.0004). Pre-existing RVD as expressed by TAPSE < 15-16 mm or TAPSE:PASP ratio < 0.30-0.37 mmHg reduced the OS and HF readmission free survival after Mitra-clip.

The Prognostic Value of Pulmonary Hypertension in Patients with Mitral Regurgitation Undergoing Mitral Valve Transcatheter Edge-to-Edge Repair: A Systematic Review and Meta-Analysis

Background: Pulmonary hypertension (PH) is associated with the outcomes of mitral valve transcatheter edge-to-edge repair (M-TEER) in patients with severe mitral regurgitation (MR). However, the prognosis of baseline PH on MR patients after M-TEER has been controversial. This meta-analysis aimed to determine the prognostic value of PH with early and late outcomes after M-TEER with MitraClip. Methods: We systematically searched PubMed/MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL) and Web of Science for studies. The results of the meta-analysis are summarized as the hazard ratio (HR), odds ratios (ORs) or mean difference (MD) and 95% confidence interval (CI). Results: A total of 20 publications were included in the systematic review, of which six were observational cohort studies including 5684 patients. The pooled incidence estimate of all-cause mortality was more common in severe PH than in patients who were non-PH. On pooled multivariate analysis, baseline PH was associated with late (≥1-year) all-cause mortality (HR = 1.61, 95% CI [1.23-2.11]) and the combined outcome of late HF rehospitalization and all-cause mortality (HR = 1.33, 95% CI [1.15-1.53]) after M-TEER. The level of SPAP significantly decreased after MitraClip in MR patients with PH (MD = -12.33 mmHg, 95% CI [-14.08--10.58]). Conclusions: Baseline PH had a worse prognosis of early (≥30-day) cardiac mortality, late all-cause mortality as well as the composite outcome of HF rehospitalization and all-cause mortality after M-TEER compared to non-PH patients. Future studies are needed to prove these findings.