Treatment and consequences of regurgitation during transcatheter valve therapies
Effects of preoperative tricuspid regurgitation on mitral regurgitation treatment with the MitraClip device in high-risk patients
Aims: Purpose of the study is to characterise high-risk patients with mitral regurgitation (MR) treated with the MitraClip device (Abbott Vascular, Abbott Park, IL, USA) and to assess the impact of preoperative TR≥3+ on the outcomes at mid-term follow-up after MitraClip treatment.
Methods and results: From November 2008 to March 2012, 106 consecutive patients with degenerative and functional moderate to severe or severe MR underwent MitraClip implantation at our institution. All the patients were assessed by a preoperative standardised protocol, which included TEE, angiography and evaluation of the surgical risk. The functional status was assessed by 6 MWT, while quality of life was evaluated by MLHFQ and SF-36 questionnaires. Short and mid-term outcomes of patients with and without concomitant TR≥3+ (TR group and no-TR group, respectively) were compared. Preoperative TR≥3+ was present in 21/106 patients (19.8%). Patients of the two groups were similar for age, comorbidities and expected surgical risk. Functional aetiology was present in 71.4% of the TR group and in 70.6% of the no-TR group (p=0.9). Preoperative echocardiography showed similar LVEDD (p=0.5) and LVEF (p=0.4). Patients of the TR group had worse quality of life (MLHFQ 44.7 vs. 36.9- p=0.04; SF-36 physical domain 30.4 vs. 36.6 –p=0.004). In-hospital mortality was 0% in TR group and 1.2% in no-TR group (p=0.6). Similar reduction of MR to ≤2+ before discharge was achieved in the two groups (TR group=90.5%, no-TR group=91.6%, p=0.8). At one-year follow-up, actuarial survival was 79.4±10.6% for TR group and 91.1±3.9% for no-TR group (p=0.5) while freedom from MR≥3+ was 67.7±12.1% for TR group and 85.1±5.1% for no-TR group (p=0.04). At last follow-up (mean 9.2 months, range 1-41 months), overall freedom from death, MR≥3+ and rehospitalisation for HF was 47.6% for TR group and 69% for no-TR group (p=0.06). Significant reduction in LV dimensions was observed at follow-up in no-TR group: LVEDD decreased from 66.1±9.4 mm to 62.9±9.1 (p=0.04); LVEDD did not significantly change in TR group (from 66.2±10.6 mm to 69.4±6.5; p=0.3). The presence of preoperative TR≥3+ was identified as predictor of recurrence of MR≥3+ (OR 3.75).
Conclusions: The presence of preoperative TR is associated with more impaired quality of life in MitraClip candidates. Moreover, in patients with significant TR, the recurrence of MR≥3+ and the incidence of composite outcome of death, MR recurrence and rehospitalisation for HF results were higher at mid-term follow-up. Reverse remodelling at follow-up is more likely to occur in patients without preoperative TR.
