Outcomes of patients with severe mitral regurgitation treated with transcatheter mitral valve implantation or medical therapy

Funding Acknowledgements

Type of funding sources: None.

Background

Patients with severe mitral regurgitation (MR) unsuitable for standard therapy (i.e., open-heart surgery and transcatheter edge-to-edge repair [TEER]), often remain on medical therapy (MT) alone. Transcatheter mitral valve implantation (TMVI) may represent an alternative treatment option for these patients.

Purpose

We aimed to investigate differences in anatomical baseline characteristics and echocardiographic outcomes between MR patients unsuitable for standard therapy, that were either treated with TMVI or remained on MT.

Methods

Between 05/2016-02/2021, 121 high-risk patients with severe MR were evaluated for TMVI. Clinical, echocardiographic and functional outcomes between the subgroups of patients treated with TMVI and MT were compared. The primary combined endpoint was all-cause death or heart failure (HF) hospitalization at 1 year. Subgroup analyses were performed to define specific patient subsets favouring either TMVI or MT.

Results

At baseline, there were no differences between the TMVI group (n = 38) and the MT group (n = 44) regarding age (all TMVI vs. MT: 77.0 years [IQR 72.9, 80.1] vs. 79.0 [IQR 76.0, 81.7], p = 0.13), gender (42.1% female vs. 56.8% female, p = 0.27) and estimated surgical risk (EuroSCORE II 4.4% [IQR 2.8, 13.6] vs. 6.4 [IQR 3.4, 10.1], p = 0.72). Patients undergoing TMVI were more frequently treated for secondary MR (68.4%), while primary MR was the most prevalent MR etiology in patients remaining on medical therapy (50.0%). Left ventricular (LV) end-diastolic diameters (LVEDD) were larger and LV ejection fraction (LVEF) was lower in the TMVI group (LVEDD 58.0mm [IQR 51.4, 65.0], LVEF 37.0% [IQR 31.4, 51.2]) compared to the MT group (LVEDD 52.0mm [IQR 46.2, 58.8], LVEF 54.5% [IQR 40.8, 60.0]) (p = 0.02 for LVEDD, p < 0.001 for LVEF). MR was effectively reduced to ≤ mild MR in all patients undergoing TMVI. In the MT group, MR remained severe in 90% of patients after 1 year. The primary composite endpoint occurred numerically more often in the MT group (72.2%) compared to the TMVI group (51.6%, p = 0.061). Regarding the primary endpoint, the subgroups of patients with LVEF 30-49% (HR 0.28 [95%-CI 0.11-0.67], p = 0.004), effective regurgitant orifice area (EROA) <0.4 cm2 (HR 0.30 [95%-CI 0.13-0.71], p = 0.006), tricuspid annular plane systolic excursion (TAPSE) ≥17mm (HR 0.27 [95%-CI 0.11-0.67], p = 0.005) and New York Heart Association functional class III (HR 0.38 [95%-CI 0.18-0.81], p = 0.012) were more likely to benefit from TMVI compared to MT.

Conclusions

In patients with severe MR unsuitable for standard therapy, TMVI represents a reasonable therapeutic alternative yielding effective elimination of MR. While most patients eligible for TMVI suffer from secondary MR, the majority of patients remaining on MT has primary MR. The primary endpoint occurred numerically, yet not statistically, more often in patients on MT. Baseline echocardiography was able to identify subgroups of patients with beneficial outcome after TMVI.

Impact of the cardio-hepatic syndrome on outcomes after transcatheter mitral valve edge-to-edge repair

Background

The prognostic value of impaired liver function in the presence of moderate-to-severe and severe mitral regurgitation (MR), also called cardio-hepatic syndrome (CHS), for outcomes in patients undergoing transcatheter edge-to-edge repair (TEER) has not been studied yet.

Purpose

In this work, we aimed at identifying the prognostic impact of the CHS on two-year all-cause mortality in patients undergoing TEER compared to established risk factors. Furthermore, we evaluated the change in hepatic function after TEER.

Methods

Hepatic function was assessed by laboratory parameters of liver function (bilirubin, gamma glutamyl transferase [GGT], alkaline phosphatase [AP], aspartate and alanine aminotransferase [AST and ALT]). We defined CHS as elevation of at least two out of three laboratory parameters of hepatic cholestasis (bilirubin, GGT, AP). The impact of CHS on two-year mortality was evaluated using a proportional hazards Cox model. The change in hepatic function after TEER was evaluated by repeat laboratory testing at follow-up.

Results

We included 1083 patients who underwent TEER for highly symptomatic primary or secondary MR at four high volume academic European centers between 2008 and 2019. In 66.4% of patients, we observed elevated levels of either bilirubin, GGT or AP. CHS was present in 23% of patients and showed strong association with a reduced two-year survival (52.9% vs. 87.0% in patients without CHS, p<0.01). In a multivariate Cox regression model, CHS was identified as a strong and independent predictor of increased two-year mortality (hazard ratio 1.49, p=0.03). In patients with successful MR reduction ≤2+ (90.7% of patients), parameters of hepatic function significantly improved from baseline to follow-up (−0.2 mg/dl for bilirubin; −21 U/l for GGT, respectively, p<0.01), while they did not in case of residual postprocedural MR >2+.

Conclusions

CHS can be observed in up to 25% of patients undergoing TEER and is associated with impaired two-year survival rates. Successful TEER is associated with decreased levels of hepatic enzymes at follow-up evaluation.

Funding Acknowledgement

Type of funding sources: None. Cardio-hepatic syndrome TEER

Long-Term survival and functional status in patients with elevated mitral valve pressure gradient after transcatheter mitral valve repair

Background

A growing number of patients are currently treated for severe mitral regurgitation (MR) using a transcatheter mitral valve repair (TMVr). In clinical routine, the potential risk of elevated post-procedural mitral valve pressure gradient (MPG) may prohibit optimal MR reduction driven by the avoidance of additional clip implantations. Thus, the unfavorable impact on survival and functional outcome of increased MPG in patients undergoing TMVr is currently debatable.

Methods

In this single-center, prospective study, survival and functional outcome of 780 consecutive patients with severe MR undergoing TMVr between September 2008 and January 2020 were investigated. After exclusion of patients with unsuccessful procedure and those lost to follow-up, data of 676 patients with a median follow-up time of 5.26 (5.11, 5.51) years were analyzed. MPG was determined by transthoracic echocardiography at discharge and considered elevated in excess of 4.5 mmHg. Kaplan-Meier analysis as well as multivariable Cox regression models were performed for the impact on elevated MPG on 5-year outcomes for the subgroups of functional MR (FMR) and degenerative MR (DMR). The primary outcome measure was a combined endpoint of death or rehospitalization for congestive heart failure.

Results

Among 676 patients undergoing TMVr (mean age 74.6±8.5 years, 59.0% male, median STS Score 3.9 [interquartile range 2.5; 6.0]), 179 (26.4%) patients had elevated MPG >4.5 mmHg. FMR was present in 426 (63.0%) patients. In the overall patient cohort, Kaplan-Meier and Cox Regression analyses could not demonstrate significant differences for the combined endpoint (p=0.99). In contrast, subgroup analysis according to MR etiology indicated a significant adverse influence of elevated MPG on the combined endpoint as well as functional outcome in patients with DMR, but not with FMR (Figure 1). After adjustment, multivariate Cox Regression analysis showed an inferior prognosis in patients with DMR and elevated MVPG >4.5 mmHg (hazard ratio 1.79 [1.17, 2.72], p=0.0069, Figure 2).

Conclusions

TMVr-patients with DMR and measurable elevated post-procedural MVPG face an inferior prognosis and reduced functional outcomes compared to patients with FMR.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Association of left atrial volume index with outcomes after transcatheter mitral valve repair for secondary mitral regurgitation: results from the EuroSMR registry

Background

The benefit of transcatheter edge-to-edge mitral valve repair (TMVr) in heart failure patients with secondary mitral regurgitation (SMR) shows large heterogeneity. A potential explanation might be the burden and chronicity of left-ventricular backward failure which is reflected by left atrial (LA) size.

Purpose

To investigate the role of LA volume index (LAVi) in real-world SMR patients undergoing TMVr.

Methods

SMR patients in a European multicenter registry were evaluated. Outcomes were evaluated according to LAVi at baseline. Main analysis was performed for all-cause mortality; residual mitral regurgitation, improvement of NYHA class and heart failure hospitalization were analyzed for patients available.

Results

823 included patients were divided according to LAVi into quintiles (≤42, 43–52, 53–62, 63–78, ≥79). A higher hazard for mortality occurred in the four upper quintiles compared to the lower quintile (HR [95% CI] 1.61 [1.08–2.4], 1.65 [1.11–2.46], 1.52 [1.02–2.26] and 1.35 [0.89–2.05]). The incidence of all-cause mortality per 100 patient-years was 14.6, 23, 23.9, 21.7 and 19.5, respectively. Consequently, a cut-off of 42ml/m2 was adopted, which was associated with a significantly higher hazard for mortality after a mean of 589 days (HR 1.54 [95%-CI 1.1–2.1], p=0.01). Technical success rate (postprocedural MR ≤2+) was higher in large LAVi group (95% vs. 91%, p=0.045). The endpoints of heart failure hospitalization, improvement of NYHA class were not different among groups. Multivariable Cox regression analysis including age, EF<30%, diabetes mellitus and NTproBNP showed LAVi >42ml/m2 to be an independent predictor of mortality.

Conclusion

LA dilatation defined by LAVi>42 ml/m2 was associated with higher mortality hazard in SMR patients undergoing TMVr after multivariable adjustment. Our findings warrant further study on whether timely TMVr intervention in patients with SMR and small LAVi can modify outcome.

Funding Acknowledgement

Type of funding sources: None.

Interventional treatment of para-valvular leaks after prosthetic valve replacement with plug devices -first results from a prospective registry

Background

Interventional closure of symptomatic paravalvular leaks (PVL) after surgical or interventional valve replacement by plug implantation has emerged as an alternative to surgical correction, which is associated with high morbitity and mortality rates. To date, data on procedural efficacy and clinical outcome after transcatheter closure with plugs is sparse, especially prospective data are missing.

Methods

We analysed data from a multi-center prospective registry on interventional PVL closure with plug devices.

Results

Between 06/2012 and 04/2020 55 interventions were performed with different numbers of plugs (maximal 4) in 51 patients at 9 hospitals. Interventions were performed in 15 women and 36 men at high surgical risk for repeat surgery. 48% of procedures were performed for mitral PVLs and 52% procedures were performed for aortic PVLs. Mean age of the population treated was 69±13 years and mean log. Euro-Score I was 22.5±14.2%. Patients were treated by implantation of Amplatzer Vascular Plug III (80%) and Occlutec occluders (9%). Aortic PVLs were treated using a retrograde transfemoral access, mitral PVLs were treated using either a transseptal (25/26) or transapical access (1/26) with 3-dimensional transesophageal echocardiographic and fluoroscopic guidance. Indication for PVL closure was previous surgery (n=39), high-risk patients (n=24), heart failure (n=22), age (n=20) and hemolysis (n=12). 40 patients had NYHA class III/IV at admission. Interventional closure of PVL was completely successful in 40 procedures (73%), partially successful in 7 procedures (13%) and failed in 7 procedures (13%). NYHA class I/II after PVL closure was achieved in 75% patients. However, 8 out of 12 patients with hemolysis as indication still hemolyzed at discharge. Complications occurred in 16% of patients. In-hospital mortality rate was 4% of procedures (2/51). After hospital discharge no death occurred during 30-day follow-up.

Conclusions

In this prospective interventional PVL registry inclusion rate was lower than expected. There was an equal distribution of aortal and mitral PVLs. At least partial success could be achieved in 86% of patients, with significant functional improvement in most patients. In this high risk population hospital mortaliy was low (4%), indicating that interventional PVL treatment should be the treatment of choice, when discussed by a heart team.

Funding Acknowledgement

Type of funding sources: None.

Impact of tricuspid regurgitation and its postprocedural reduction on long term outcome in patients undergoing percutaneous mitral valve edge to edge repair

Background

Prevalence of functional tricuspid valve regurgitation (TR) in the adult population is high and mostly considered as a consequence of left-sided heart failure. In patients with moderate-to-severe and severe mitral regurgitation (MR), relevant concomitant TR is found in about 30–50%. For many years the concept of a reduction of secondary TR after mitral valve surgery has been widely accepted. However, more recently, compelling data have shown that surgically untreated functional TR can persist or even worsen despite the correction of the associated left-sided lesion.

In line with previous research, studies have indicated that preexisting concomitant TR is an independent predictor for adverse outcome in patients undergoing percutaneous mitral valve Edge-to-Edge Repair (pMVR).

Purpose

This study intends to determine the extent to which the severity of tricuspid regurgitation, measured six months after pMVR, impacts the outcome.

Methods

Between September 2008 and July 2018, 805 consecutive patients with moderate-to-severe or severe MR underwent pVMR therapy with the MitraClip device at our center. We exclude patients with missing date of follow-up (n=54) and patients with missing values for baseline tricuspid regurgitation (n=93). We analyze, therefore, data of 658 patients with a median follow-up time of 4.93 (4.2, 4.99) years. Severity of TR was evaluated at baseline and six months after pMVR.

Results

Among 658 high-risk patients (mean age 75.4±8.7 years, 59.7% male, median STS Score 3.9 [2.4, 6.1]), 248 patients were suffering from no/mild (37.6%), 213 from moderate (32.6%) and 197 patients from severe (29.9%) TR. Functional MR was present in 429 (65.5%) patients. Procedural success was achieved in the majority of patients (no/mild TR 90.3%, moderate TR 91.1%, severe TR 90.4%). Overall, mortality rates up to two-year follow-up were highest for patients with severe TR (no/mild TR 30.2%, moderate TR 37.6%, severe TR 42.6%, p=0.023). The risk for overall mortality (Kaplan-Meier analysis, p=0.0027, Figure 1) was related to increasing TR severity. However, Kaplan-Meier analysis showed no relevant differences for the combined endpoint of death and rehospitalization (p=0.058). Interestingly, in a pairwise comparison, the risk for patients with pre-existing severe TR and postprocedural reduction to mild or moderate TR (n=17) was reduced for the combined endpoint (p=0.021) compared to patients with persistent severe TR (n=28).

Conclusion

Moderate and severe TR in high-risk patients undergoing pMVR is associated with an increased risk for overall mortality. While preliminary, the presented data suggest a favorable outcome in patients with a postprocedural reduction in the severity of TR. The results of this study indicate the importance of developing new therapeutic strategies in high-risk patients with combined MR and TR, probably leading to concomitant tricuspid valve interventions.

Figure 1

Funding Acknowledgement

Type of funding source: None

Acute hemodynamic changes and long term prognostic impact of pulmonary hypertension in patients undergoing percutaneous mitral valve edge to edge repair

Background

Pulmonary hypertension (PH) due to left heart disease is the most common form of PH. Published literature suggests increased perisurgical mortality in patients undergoing surgical repair in the setting of preexisting PH. The data on the impact of preexisting PH on clinical outcomes after percutaneous Mitral Valve Edge-to-Edge Repair (pMVR) is limited to observational studies and rely mostly on echocardiographic data.

Purpose

The aim of the current study is to evaluate the influence of preexisting PH in patients undergoing pMVR analyzing periprocedural invasive right heart catheterization data.

Methods

Between September 2008 and July 2018, a total of 911 patients with moderate-to-severe or severe mitral regurgitation (MR) underwent pMVR at our center. This analysis includes 331 patients with a complete data set for pre- and postprocedural right heart catheterization and echocardiographic assessment as well as available follow-up information after the implantation. Patients are divided according to the etiology of PH. The combined primary endpoint consists of all-cause mortality and rehospitalization for heart failure. Furthermore, a sub-analysis is performed for all patients with preexisting post-capillary PH. Patients with post-capillary PH are divided into two groups based on a postprocedural decrease of pulmonary artery wedge pressure (mPAWP) below the threshold of 15mmHg. Univariate and multivariate Cox regression analyses are performed to assess the influence on long-term outcome.

Results

Of all 331 patients (57.7% [n= 191] male) undergoing pMVR, 195 (62.1%) had functional MR. Median ejection fraction was 40.5% (29.3, 54.0). Patients were followed-up for a maximum of 4.41 years and the median follow-up time was 1.98 years. Preexisting PH (mean pulmonary artery pressure ≥25 mmHg) was found in 236 (71.1%) patients: 49 patients had pre-capillary PH (≤15 mmHg), 187 had post-capillary PH (pcPH; n=183; mPAWP >15 mmHg). In Kaplan-Meier analysis, no statistically significant difference could be found in overall mortality in patients without or with PH, irrespective of etiology (p=0.43). However, in patients suffering from post-capillary PH, patients with a postprocedural reduction of mPAWP below the threshold of 15mmHg showed a significantly lower risk for overall long-term mortality compared to patients without a relevant mPAWP reduction (p=0.018). Multivariate analysis revealed acute postprocedural decrease of mPAWP below 15mmHg in patients with post-capillary PH to have a significant influence on mortality (HR 2.81 [1.35, 5.86]; p=0.006; Figure 1).

Conclusion

In contrast to previously published findings, the present results were not able to show a significant impact of PH, disregarding its etiology, on outcome. Nevertheless, a postprocedural decrease of mPAWP below 15mmHg in patients with post-capillary PH is associated with a favorable outcome.

Figure 1

Funding Acknowledgement

Type of funding source: None

Early results of a real-world series with two transapical transcatheter mitral valve replacement devices

Aims

Transcatheter mitral valve replacement (TMVR) with dedicated devices promises to fill the treatment gap between open-heart surgery and edge-to-edge repair for patients with severe mitral regurgitation (MR). We herein present a single-centre experience of a TMVR series with two transapical devices.

Methods and results

A total of 11 patients were treated with the Tendyne™ (N = 7) or the Tiara™ TMVR systems (N = 4) from 2016 to 2020 either as compassionate-use procedures or as commercial implants. Clinical and echocardiographic data were collected at baseline, discharge and follow-up and are presented in accordance with the Mitral Valve Academic Research Consortium (MVARC) definitions.

The study cohort [age 77 years (73, 84); 27.3% male] presented with primary (N = 4), secondary (N = 5) or mixed (N = 2) MR etiology. Patients were symptomatic (all NYHA III/IV) and at high surgical risk [logEuroSCORE II 8.1% (4.0, 17.4)]. Rates of impaired RV function (72.7%), severe pulmonary hypertension (27.3%), moderate or severe tricuspid regurgitation (63.6%) and prior aortic valve replacement (63.6%) were high. Severe mitral annulus calcification was present in two patients. Technical success was achieved in all patients. In 90.9% (N = 10) MR was completely eliminated (i.e. no or trace MR). Procedural and 30-day mortality were 0.0%. At follow-up NYHA class was I/II in the majority of patients. Overall mortality after 3 and 6 months was 10.0% and 22.2%.

Conclusions

TMVR was performed successfully in these selected patients with complete elimination of MR in the majority of patients. Short-term mortality was low and most patients experienced persisting functional improvement.

Graphic abstract

Electronic supplementary material

The online version of this article (10.1007/s00392-020-01757-z) contains supplementary material, which is available to authorized users.

1385Combined tricuspid and mitral vs. isolated mitral valve repair for severe mitral and tricuspid regurgitation: An analysis from TriValve and TRAMI registries

Background

Edge-to-edge repair has been shown to be a successful therapeutic option for patients with severe mitral regurgitation (MR). Lately, it has also been emerging as a treatment perspective for severe tricuspid regurgitation (TR) in patients at high-risk for cardiac surgery. In patients, with both severe MR and TR the best treatment strategy for patients at high risk for surgery is unknown.

Purpose and methods

We retrospectively analyzed data from the international multicentre TriValve (Transcatheter Tricuspid Valve Therapies) registry and from the German multicentre TRAMI (Transcatheter Mitral Valve Interventions) registry. All patients included into the analysis had both severe MR and TR. Patients from the TRAMI registry (n=106) were treated with edge-to-edge repair in mitral position only. In patients from the TriValve registry (n=122), both valves were treated concomitantly in compassionate and/or off-label use. We sought to compare baseline characteristics, procedural data and 1-year mortality in both treatment groups.

Results

228 patients (77±8 years; 44.3% female) were included into the analysis. All patients showed significant dyspnea on exposure (NYHA III or IV 93.9%). Kidney function (eGFR 42 ml/min/1,72m2) and the proportion of patients with significant pulmonary hypertension (59.0%) and COPD (23.7%) did not differ between the groups, but the proportion of patients with LV-EF <30% (34.9% vs. 18.0%, p<0.001) were higher in the TRAMI cohort.

At discharge, MR was comparably reduced in both groups (MR ≤ I° 75.9% vs. 77.3%, p=0.67). While all patients in both registries had significant TR at baseline, the percentage of patients with TR≥3+ at discharge was reduced to 18.6% in TriValve by the placement of 2±1 tricuspid clips/patient. The rate of in-hospital adverse events and the time of hospitalization did not differ in both cohorts. At 1-year, overall all-cause mortality was 34.0% in the TRAMI cohort and 16.4% in the TriValve cohort (p=0.0002, see figure; after adjustment for LVEF <30%: p=0.049). The rate of patients with NYHA ≤ II at 1 year did not differ between both cohorts (69.4% vs. 67.0%, p=0.54).

1-year mortality TriValve vs. TRAMI

Conclusion

Transcatheter mitral and tricuspid valve repair can result in a significant clinical improvement at 1 year. The concomitant treatment of both valve regurgitations may result in an improved survival, which needs to be confirmed in dedicated prospective trials.

P4730Underweight is associated with unfavourable short- and long-term outcomes after MitraClip therapy: a body mass index derived subgroup analysis of the German Transcatheter Mitral Valve Interventions (

Background

Underweight and obesity represent classical risk factors for patients undergoing cardiac surgery or interventional treatment. The multicentre German Transcatheter Mitral Valve Interventions (TRAMI) registry comprises a large and prospectively enrolled real-world cohort of patients treated by MitraClip implantation.

Aims

The current analysis examines the impact of underweight, overweight and obesity on intra-hospital, short and long-term outcomes in patients treated by MitraClip therapy.

Methods and results

From 08/2010 until 07/2013, 799 patients (age 75.3±8.6 years, male gender 60.7%, median logistic EuroSCORE 20% [12; 31], functional mitral regurgitation (MR): 69.3%) were prospectively enrolled into the multicentre, industry-independent German Transcatheter Mitral Valve Interventions registry. Patients were stratified according to body mass index (BMI) into four groups: BMI<20 kg/m2 (underweight, n=49), BMI 20.0 to <25.0 kg/m2 (normal weight, n=293), BMI 25.0 to <30.0 kg/m2 (overweight, n=296) and BMI≥30 kg/m2 (obese, n=132). Procedure and radiation time were comparable among all groups. Significant increased rates of procedural failure (12.2% vs. 2.1 [normal weight], p<0.001), transfusion/bleeding (20.8% vs. normal weight: 5.6%, obesity: 7.0%, p<0.01), sepsis or multiorgan failure and low cardiac output failure were found for underweight patients only. Kaplan-Meier survival curves demonstrated inferior survival for underweight patients, but comparable outcomes for all other patients (global log rank test, p<0.01). Multivariable Cox-regression analysis (adjusted for age, gender, creatinine≥1.5mg/dl, diabetes, left ventricular ejection fraction<30% and chronic obstructive pulmonary disease) confirmed underweight (as compared to normal weight) as an independent risk factor of death (hazard ratio [HR]: 1.58, 95%-confidence interval (CI): 1.01–2.46, p=0.044) and overweight as protective against death (HR: 0.71; 95%-CI: 0.55–0.93; p=0.011).

Conclusion

Underweight patients are exposed to increased rates of procedural failure, bleeding and low cardiac output as well as increased short- and long-term mortality rates when undergoing MitraClip implantation and should therefore be carefully discussed within the heart team.

Acknowledgement/Funding

The TRAMI registry has been supported by proprietary means of IHF. Additional funding is provided by “Deutsche Herzstiftung” and a grant from Abbott.

Homocysteine concentration in coronary artery disease: Influence of three common single nucleotide polymorphisms

BACKGROUND AND AIMS

Whether single nucleotide polymorphisms (SNPs) of homocysteine metabolism enzymes influence the rate of cardiovascular (CV) events in coronary artery disease (CAD) patients remains controversial.

METHODS AND RESULTS

In this analysis, 1126 subjects from the AtheroGene study with CAD and 332 control subjects without known CAD were included. The following SNPs were investigated: methylentetrahydrofolate reductase (MTHFR-C667T), methionin synthetase (MS-D919G), and cystathionin beta synthetase (CBS-I278T). The endpoint was the combination of cardiovascular death, stroke, and non-fatal myocardial infarction (N = 286). The median follow-up time was 6.4 years. Kaplan-Meier curve analysis showed an increasing event rate with rising homocysteine levels (p < 0.001) in CAD patients. Further, in Cox-Regression analysis homocysteine was a predictor of the endpoint with a hazard ratio (HR) of 6.5 (95% CI: 2.9-14.6, p < 0.001) in the adjusted model including cardiovascular risk factors. Of the three SNPs, homozygous MTHFR SNP increased homocysteine levels significantly in patients with CAD and individuals without CAD (both p < 0.001). The SNPs in MS and CBS were not related to relevant changes in homocysteine levels in CAD patients or controls. The different SNPs of MTHFR, MS, and CBS were not related to an increased event rate.

CONCLUSION

Homocysteine level is a strong predictor of CV events. Subjects with and without CAD and SNPs in the enzyme MTHFR had increased homocysteine levels. This was not observed for MS and CBS SNPs. Although MTHFR SNPs alter homocysteine levels in patients and controls, these polymorphisms had no impact on prognosis in CAD patients.