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Predictors pinpointed for recurrent mitral regurgitation, worse outcomes after MitraClip use

Circulation: Cardiovascular Interventions
Reuters Health - 10/03/2022 - Predictors of recurrent mitral regurgitation (MR) after a MitraClip procedure for primary or secondary MR were identified in a registry analysis.

"Transcatheter edge-to-edge repair (TEER) with the MitraClip system, which mimics a surgical Alferi's stitch, has been developed as a less invasive therapeutic option to treat MR," Dr. Atsushi Sugiura and Dr. Marc Ulrich Becher, both of University Hospital Bonn in Germany, told Reuters Health by email. "But the durability of the treatment remains a matter of debate."

"The main message is that a greater amount of residual MR is associated with recurrent MR during follow-up," they said. "Residual moderate MR as compared with mild MR was a strong predictor of recurrent MR, regardless of the baseline MR etiology."

"Combined with residual MR," they note, "suboptimal leaflet grasping and subsequent residual leaflet prolapse during the MitraClip procedure may progress over time, resulting in a loss of leaflet insertion or leaflet tear and, thereby, a recurrence of MR."

"In contrast," they added, "recurrent MR in patients with secondary MR at baseline are more likely to have increased left atrial volume and a functional cause of recurrent MR due to annular dilatation."

As reported in Circulation: Cardiovascular Interventions, Drs. Sugiura, Becher and colleagues analyzed data on 685 MitraClip recipients from the Heart Failure Network Rhineland registry from August 2010 to October 2018. All patients had a reduction in MR up to 2+.

Those with primary MR had a mean age of 79 and about 45% with or without recurrent MR were women; those with secondary MR had a mean age of 75 and about 22% of those with recurrent and 37% of those with nonrecurrent MR were women.

Overall, 61 patients developed recurrent MR within the first year.

Predictors of recurrent MR in primary MR patients were flail leaflet (hazard ratio, 3.68) and residual MR (MR grade 2+ vs. up to 1+: HR, 2.56); loss of leaflet insertion or leaflet tear were the predominant morphologies with recurrent MR in these patients.

In secondary MR patients, left atrial volume (per 10 mL increase: HR, 1.11) and residual MR (HR, 2.45) were independently associated with recurrent MR; more than half of those with recurrent MR did not show any disorder of the clip or leaflets.

Overall, patients with recurrent MR were more likely to experience unplanned heart failure hospitalization or heart failure symptoms with New York Heart Association scale III/IV than those without recurrent MR (54.1% vs. 37.8%) and to undergo a repeat mitral valve intervention (9.8% vs. 2.2%) during the follow-up.

In the landmark survival analysis, patients with recurrent MR also tended to have lower long-term survival (58.7% vs. 83.9%).

Summing up, the authors write, "Flail leaflet and residual MR were the predictors of recurrent MR in primary MR patients, while a larger left atrial volume and residual MR were associated with recurrent MR in secondary MR patients, which may be associated with long-term clinical outcomes of patients after MitraClip."

Dr. Mackram Eleid of Mayo Clinic in Rochester, Minnesota, coauthor of a related editorial, commented by email, "The findings emphasize the importance of careful patient selection to ensure appropriate anatomy for the procedure, as well as optimizing medical therapy first in patients with secondary MR prior to undergoing the procedure."

"Additionally," he said, "careful procedural technique is necessary to achieve the greatest possible reduction of MR during the TEER procedure to optimize subsequent outcomes."

SOURCE: https://bit.ly/3I2ygUg and https://bit.ly/3MKnhTo Circulation: Cardiovascular Interventions, online February 23, 2022.

By Marilynn Larkin

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